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Rapid Analysis of Mental Services (RAMS) An overview of correlates of high service utilisation in South-East Metropolitan Melbourne
A/Prof Fabrizio Carinci Director, Centre for Health Systems Research February 2003
Rapid Analysis of Mental Services (RAMS) A phase - Approch
we’ve got new questions for Mental Health Services… 1. explore correlates of high demand and utilisation of health services both at the individual and organisational level 2. build user interfaces that would allow to simplify and automate the procedure of rapid analysis of mental services
Rapid Analysis of Mental Services (RAMS) SD phase - Scaling down operational data
Database Team
MIHSR Medical Informatics Leader
(B.Cesnik)
MIHSR Database manager
(D.Anderson)
SH Database manager
(R.Thornton)
Clinical Experts
(S.Damodaran,A.Yontchev)
Rapid Analysis of Mental Services (RAMS) QT Phase (Question Time)
Population Health Research Team
Clinical Leader
(P.Talman)
Epidemiologist
(E.Villanueva)
Statistician
(F.Carinci)
Clinical Experts
(S.Damodaran,A.Yontchev)
Main clinical question: Identification of individual and structural characteristics associated to an increased rate of “events” in terms of the following outcome indicators: a. abnormal length of stay b. readmissions c. excessive utilisation of mental services (“frequent flyers”) Population: Southern Health mental health catchment area Time of observation: 1/10/1999 - 30/9/2002
Rapid Analysis of Mental Services (RAMS) OD Phase - Outcomes Definition
Analysis of the Literature
Analyst/Statistician
(F.Carinci)
Epidemiologist
(E.Villanueva)
1.HIGHLOS (TTLOS>45) Total 3-year LOS per subject > 45 days (75%) 2.HIGHCONT (N_CONT>100) More than 100 Contacts during the last 3-years (75%) 3.REVOLVE (N_ADM>3)
“Revolving Door patient”
No.Admissions >3 during the last 3 years 4.EARLREHOSP
Rehospitalisation within 28 days 5.ADMLOS (TLOS>28) Single Admission Episode longer than 28 days 6.READM
Readmission 7. NLS (LOS>28) “New Long Stay” Consecutive in-hospital presence > 28 days
Rapid Analysis of Mental Services (RAMS) ADM Phase - Analytical Data Management
admission event contacts separation time
RAMS Outcomes Datasets (SHCN Mental Services, 1/10/1999-30/9/2002)
Outcomes
”Excessive Cumulative LOS”
HIGHLOS (TTLOS>45) Cum. 3yrs LOS per subject higher than 45 days (75%)
”High number of Contacts”
HIGHCONT (N_CONT>100) More than 100 Contacts during the last 3 yrs (75%)
“Revolving Door Patients”
REVOLVE (N_ADM>3) Four or more Admissions during the last 3 years
“Early Rehospitalisation”
EARLREHOSP Rehospitalisation within 28 days
“New Readmission”
READM Readmission at any time
“Excessive LOS”
ADMLOS (TLOS>28) Admission longer than 28 days
“New Long Stay”
NLS (LOS>28) Consecutive in-hospital presence for more than 28 days
N
3,243 3,243 3,243 6,283 6,494 22,932
Dataset Name HIGHLOS HIGHCONT REVOLVE READM ADMIS NLS Statistical Unit
Individual Subject Individual Subject Individual Subject Readmission / Last Record Admission Event Admission Event
Time of Reference Observations per patient Model
Outcome condition met or last record Single Outcome condition met or last record Single Outcome condition met or last record Single Previous Discharge to outcome condition or last record Multiple Last available admission event per admission Multiple Admission Event Multiple Cox PH Cox PH Cox PH Cox PH / Andersen-Gill method (left truncation) GEE / Logistic GEE / Logistic 3,243
_FIRSRC_
Individual Subject First record Single 3,243
_LASTRC_
302,664
RAMSCOHO
Individual Subject Any Record Last record All records Single Multiple
RAMS catchment area (Melbourne Metro): individual subjects
Mental Health Subjects (x 1.000 , N = 3118) 0.1 - 2.4
2.5 - 5.6
6.0 - 7.9
9.4 - 12.8
12.9
Variable (Categories)
N (%) Age** Gender Males Females Country of Birth Australia Europe-America Middle East-Africa Asia ICD10 MDC F0: Organic F1: Substance Abuse F2: Schizophrenia F3: Mood Disorder F4: Neurotic F5: Behavioural F6: Personality Disorder F7: Mental retardation F8: Psych. Development F9: Emotional Z72: Lifestyle/Addiction Postcodes N>100 Dandenong [3175] Noble Park [3174] Clayton [3168] Cranbourne [3977] Cheltenham [3192] Springvale [3171] Bentleigh East [3165]
Demographic and clinical characteristics
P(
c 2
)* _LASTRC_
3243 (100.0) 36 (5-103) 1696 (52.2) 1547 (47.8) 2446 (75.4) 485 (15.0) 104 (3.2) 208 (6.4) 361 (11.1) 880 (27.1) 1539 (47.5) 1515 (46.7) 749 (23.1) 79 (2.4) 654 (20.1) 56 (1.7) 31 (1.0) 104 (3.2) 346 (10.7) 307 (9.5) 220 (6.8) 122 (3.8) 121 (3.7) 119 (3.7) 107 (3.3) 102 (3.1)
HIGHLOS
891 (27.5) 33 (12-92) 443 (26.1) 448 (29.0) 643 (26.3) 156 (32.2) 30 (28.8) 62 (29.8) 111 (38.0) 137 (18.2) 379 (27.6) 301 (22.1) 105 (15.9) 12 (19.7) 102 (18.3) 13 (30.2) 5 (21.7) 18 (23.1) 71 (20.5) 105 (34.1) 90 (41.1) 34 (27.4) 34 (25.9) 43 (36.1) 25 (24.3) 38 (38.4)
*UNIVARIATE TEST - category vs. complementary, ** median (range)
.0120
<.0001
<.0001
<.0001
<.0001
<.0001
<.0001
.0020
.0060
<.0001
.0310
.0130
HIGHCONT
819 (25.3)
P(
c 2
)*
37 (9-91)
REVOLVE
347 (10.7) 34 (15-87) 420 (24.8) 399 (25.7) 596 (24.4) 134 (28.0) 31 (29.5) 58 (27.4) 65 (19.8) 170 (21.4) 497 (34.0) <.0001
303 (21.0) <.0001
133 (19.4) <.0001
11 (15.1) 124 (21.1) 10 (20.0) 2 (9.5) 28 (31.8) 87 (23.9) .0155
.0038
.0430
.0109
32 (9.1) 120 (14.3) 229 (15.1) 182 (12.2) 93 (12.8) 9 (11.8) 106 (17.2) 13 (25.4) 5 (16.7) 7 (6.8) 62 (15.1) <.0001
<.0001
.0089
.0339
<.0001
.0005
.0021
91 (29.6) 71 (32.1) 41 (32.8) 29 (22.1) 28 (23.7) 27 (25.0) 32 (31.4) .0149
.0477
187 (11.1) 159 (10.2) 265 (10.8) 52 (10.9) 11 (10.8) 18 (8.6) 44 (14.0) 39 (17.7) 13 (10.6) 15 (11.8) 4 (3.4) 10 (9.5) 21 (21.2)
P(
c 2
)*
.0434
.0004
.0097
.0006
Variable (Categories)
Socioeconomic and service related characteristics
_LASTRC_ HIGHLOS P(
c 2
)* HIGHCONT P(
c 2
)* REVOLVE
N (%) 3243 (100.0) 891 (27.5) 819 (25.3) 347 (10.7) Employed Yes No Subordinate/Non Managerial Yes No Education: 7-10 years + Yes No 344 (10.6) 2899 (89.4) 2686 (82.8) 557 (17.2) 2266 (69.9) 977 (30.1) 49 (14.2) 842 (29.0) 791 (29.4) 100 (17.9) 629 (27.8) 262 (26.8) <.0001
<.0001
Assisted by a carer Yes No Admission Centre Clayton Dandenong Acute Child Aged Care 368 (11.3) 2875 (88.6) 1130 (34.5) 1380 (42.6) 267 (8.2) 466 (14.4) 161 (43.7) 730 (25.4) <.0001
228 (25.6) 359 (26.0) 95 (35.6) 209 (44.9) .0320
<.0001
.0020
<.0001
Average LOS 0-1 days 1-3 days >3 days Average Post Discharge Delay 0-3 days 4-6 days 1 wk or more 1071 (33.0) 1488 (45.9) 684 (21.1) 1991 (61.4) 334 (10.3) 918 (28.3) NA NA NA 593 (29.8) 91 (27.2) 207 (22.5) .0002
<.0001
No.Contacts per Month 0-1 1-3 >3 1946 (60.1) 555 (17.1) 742 (22.9) 399 (20.5) 159 (28.7) 333 (44.9)
*UNIVARIATE TEST - category vs. complementary, ** median (range)
<.0001
<.0001
54 (15.6) 765 (26.4) <.0001
745 (27.8) 74 (13.1) <.0001
635 (28.1) 184 (18.8) <.0001
130 (34.1) 689 (24.1) <.0001
399 (35.3) 247 (18.3) 58 (22.7) 115 (26.4) <.0001
<.0001
274 (25.6) 336 (22.6) 209 (30.6) .0013
.0003
494 (24.8) 139 (37.8) 186 (17.2) <.0001
<.0001
NA NA NA 20 (5.8) 326 (11.2) 319 (11.9) 27 (4.8) 279 (12.3) 67 (6.8) 59 (15.9) 287 (10.0) 110 (9.7) 174 (12.6) 20 (7.4) 42 (8.9) 23 (2.1) 182 (11.6) 141 (18.0) 119 (6.0) 71 (17.4) 156 (14.1) 65 (3.3) 72 (11.8) 209 (26.0)
P(
c 2
)*
.0020
<.0001
<.0001
.0006
<.0001
.0026
<.0001 <.0001
<.0001
<.0001
<.0001
<.0001
Risk Model [HIGHLOS]
Outcome:Cumulative .LOS>45
Variable Cox Regression Results
Age Male F1: Substance Abuse F2: Schizophrenia F3: Mood Disorder F4: Neurotic F9: Emotional Dandenong Acute Child Aged Care 1-3 Contacts per month >3 Contacts per month Average post-discharge delay: 4-6 days Average post-discharge delay: 1 wk or more Employed Education: 7-10 years + Occupation: Subordinate/Non Managerial Z51-Z65 Social Problems Z72: Lifestyle/Addiction Other Dandenong [3175] Noble Park [3174] Bentleigh East [3165] Clayton South [3169] Cheltenham [3192] Doveton [3177] Hampton Park [3976]
0.25
0.5
1.0
2.0
Decreased Risk Increased Risk
HAZARD RATIO 5.0
HR ; 95% CI
0.99 ; 0.99-1.00
0.93 ; 0.81-1.07
0.74 ; 0.61-0.89
0.63 ; 0.54-0.74
0.78 ; 0.67-0.91
0.55 ; 0.44-0.68
0.58 ; 0.35-0.97
1.39 ; 1.14-1.71
2.32 ; 1.71-3.15
1.79 ; 1.32-2.44
1.48 ; 1.22-1.80
2.63 ; 2.23-3.11
0.68 ; 0.54-0.86
0.69 ; 0.58-0.81
0.59 ; 0.44-0.79
1.23 ; 1.05-1.44
1.62 ; 1.31-2.01
0.54 ; 0.36-0.81
1.53 ; 1.09-2.14
0.64 ; 0.49-0.84
1.26 ; 1.01-1.57
1.54 ; 1.22-1.95
1.67 ; 1.19-2.33
1.60 ; 1.09-2.35
1.53 ; 1.11-2.11
1.94 ; 1.28-2.95
1.60 ; 1.03-2.46
Variable
Age Male F3: Mood Disorder F4: Neurotic F6: Personality Disorder F7: Mental retardation F9: Emotional Average LOS: 1-3 days Average LOS>3 days Dandenong Acute Child 1-3 Contacts per month >3 Contacts per month Average post-discharge delay: 1 wk or more Occupation: Subordinate/Non Managerial Assisted by a carer Continent of Birth: Asia Bentleigh East [3165] Cheltenham [3192] Doveton [3177]
0.01
Risk Model: [REVOLVE]
Outcome:T.No.Adm.>=4
Cox Regression Results 0.25
0.5
1.0
2.0
5.0
Decreased Risk
HAZARD RATIO
Increased Risk
HR ; 95% CI 10.0
0.98 ; 0.97-0.99
1.02 ; 0.81-1.28
1.33 ; 1.06-1.66
1.40 ; 1.07-1.83
1.97 ; 1.53-2.53
2.33 ; 1.31-4.14
0.39 ; 0.17-0.90
2.92 ; 1.87-4.55
4.48 ; 2.82-7.12
1.40 ; 1.09-1.81
0.50 ; 0.28-0.88
2.33 ; 1.66-3.28
6.27 ; 4.67-8.42
1.60 ; 1.28-2.00
1.70 ; 1.14-2.53
1.49 ; 1.11-2.00
0.60 ; 0.37-0.97
1.96 ; 1.23-3.12
0.35 ; 0.13-0.94
1.92 ; 1.04-3.54
Conclusions / Action lines
• RAMS has produced a model to scale down CMI and perform rapid analysis for population health • Results of predictive modelling are relevant to the organisation of health services • The longitudinal structure of the model may be applied at the patient level • Validated concepts and statistical results may be incorporated into CMI to support integrated care • RAMS carries forward the SPHIS model, now capable of including contacts in the community
Areas of improvement:
• CMI lacks important information on known predictors of patient outcomes (medicines, compliance) that should be incorporated in the database to be relevant for fully integrated care • Overall health services utilisation is underestimated. Admissions for mental health patients not related to mental health services are not currently included. • A direct consequence is that comorbidity is underreported. CMI does include few non-MH diagnoses.
• All the above factors may induce uncontrollable bias in all statistical analyses. For instance, the impact of chronic diseases, excessive use of medicines or non compliance is practically unknown. •
Action plan:
• Finalisation of the project report • Refinement and publication of the results in collaboration with the clinical experts • Publication and update of all SPHIS/RAMS material on dedicated website • Presentation of the model to users/DHS • Preparation of drafts for further development (data linkage with VAED/PBS, state-level analysis, national and international comparative studies)
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