By Brenda L. Mooney
Tracking down former patients with serious mental illnesses (SMI) such as schizophrenia and bipolar disorder and bringing them back into the VA healthcare system can save lives, according to a recently published study.
In fact, the mortality rate for patients with SMI who had dropped out of the VA system but were brought back in was almost 6 times less than for those who did not return for medical care, according to the study, “Reduced Mortality Among Department of Veterans Affairs Patients With Schizophrenia or Bipolar Disorder Lost to Follow-up and Engaged in Active Outreach to Return for Care.” It was published in the March issue of the American Journal of Public Health.
Authors were from the VHA’s Office of the Medical Inspector in Washington and the Serious Mental Illness Resource and Evaluation Center (SMITREC), Center for Clinical Management Research in Ann Arbor, MI.
Researchers developed a list of patients with SMI who had last been treated in fiscal years 2005 to 2006 but had been lost to follow-up for at least one year. Those patients were contacted by personnel, usually local recovery coordinators or suicide prevention coordinators, at 138 VAMCs.
About 72%, 2,375 of 3,306, of the patients on the contact list returned for VA care. Controlling for demographic and clinical factors, the mortality rate of returning patients was dramatically lower for those patients than for veterans who did not return for care: 0.5% vs 3.9%; adjusted odds ratio = 5.8; P < .001.
These findings were especially important because VA is the largest single provider of SMI care in the United States, according to an online presentation by Amy M. Kilbourne, PhD, MPH, associate director of the VA Ann Arbor SMITREC.
Kilbourne noted that homelessness disproportionately affects veterans with SMI, making it more difficult to keep them in the healthcare system. In fact, she noted, 12.3% of veterans with SMI had an ICD-9 code or encounter for homelessness services in FY 2009. About 25% of the U.S. homeless population has SMI, according to the presentation.
An earlier study with Kilbourne as lead author found that, compared to non-SMI patients, VA patients diagnosed with bipolar disorder were more likely to report difficulty in receiving care they needed or seeing a specialist, while those diagnosed with schizophrenia were more likely to report dissatisfaction, including thoroughness by their provider and the provider’s explanation of problems.
In the more recent research, patients lost to follow-up typically were unmarried males whose illness was not service-connected, according to Kilbourne’s presentation. Comorbidities were common; about 14% were diagnosed with diabetes, 6% with dementia, 4% with cerebrovascular disease and 3% with some type of cancer.
Of those refusing to return for care, 33% said they did not perceive the need, 22% said they were dissatisfied with VA services and 20% said they lacked transportation or the time. About 7% said they wanted to solve their problems by themselves.
An earlier study also found that inconsistent use of healthcare services for schizophrenia and bipolar disorder is associated with poorer outcomes.
That 2008 study analyzed VHA National Psychosis Registry data for 164,150 veterans with those disorders to identify characteristics associated with 5-year patterns of survival and with retention in the VA system.
While most of those veterans, 63%, stayed in the system and received consistent care for at least 12 months, others did not. Inconsistent utilization was associated with younger age, no service-connected disability, and less physical comorbidity, regardless of diagnosis, according to the 2008 study published in Community Mental Health Journal .
Since that time, VA’s capacity for handing mental health patients has significantly improved. VA has increased its mental health staff from about 14,000 in fiscal year 2006 to more than 21,000 in fiscal year 2011, according to a recent Government Accountability Office report.
Since the 1970s, mortality rates have declined, extending average lifespan by almost a decade.
Lack of sleep has long been a feature of military service.