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 ResearchFebruary 2003

Rapid Analysis of Mental Services (RAMS)A phase - Approch

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

we’ve got new questions forMental Health 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 stayb. readmissionsc. 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.EARLREHOSPRehospitalisation within 28 days

5.ADMLOS (TLOS>28)Single Admission Episode longer than 28 days

6.READMReadmission

7. NLS (LOS>28)“New Long Stay”Consecutive in-hospital presence > 28 days

Rapid Analysis of Mental Services (RAMS) ADM Phase - Analytical Data Management

time

admission event

contacts

separation

RAMS Outcomes Datasets (SHCN Mental Services, 1/10/1999-30/9/2002)

Outcomes N Dataset Name Statistical Unit

Time of Reference Observations per patient

Model

”Excessive Cumulative LOS”HIGHLOS (TTLOS>45)Cum. 3yrs LOS per subject higher than 45 days (75%)

3,243 HIGHLOS Individual SubjectOutcome condition met or last record

Single Cox PH

”High number of Contacts”HIGHCONT (N_CONT>100)More than 100 Contacts during the last 3 yrs (75%)

3,243 HIGHCONT Individual SubjectOutcome condition met or last record

Single Cox PH

“Revolving Door Patients”REVOLVE (N_ADM>3)Four or more Admissions during the last 3 years

3,243 REVOLVE Individual SubjectOutcome condition met or last record

Single Cox PH

“Early Rehospitalisation”EARLREHOSPRehospitalisation within 28 days

“New Readmission”READMReadmission at any time

6,283 READMReadmission /

Last Record

Previous Discharge to outcome condition

or last recordMultiple

Cox PH / Andersen-Gill method

(left truncation)

“Excessive LOS”ADMLOS (TLOS>28)Admission longer than 28 days

6,494 ADMIS Admission EventLast available

admission event per admission

Multiple GEE / Logistic

“New Long Stay”NLS (LOS>28)Consecutive in-hospital presence for more than 28 days

22,932 NLS Admission Event Admission Event Multiple GEE / Logistic

3,243 _FIRSRC_ Individual Subject First record Single

3,243 _LASTRC_ Individual Subject Last record Single

302,664 RAMSCOHO Any Record All records Multiple

RAMS catchment area (Melbourne Metro): individual subjects

Mental Health Subjects(x 1.000 , N = 3118)

-0.1 - 2.42.5 - 5.66.0 - 7.99.4 - 12.8

12.9

Demographic and clinical characteristics

Variable (Categories) _LASTRC_ HIGHLOS P()* HIGHCONT P()* REVOLVE P()*

N (%) 3243 (100.0) 891 (27.5) 819 (25.3) 347 (10.7)

Age** 36 (5-103) 33 (12-92) 37 (9-91) 34 (15-87)

GenderMales 1696 (52.2) 443 (26.1) 420 (24.8) 187 (11.1)Females 1547 (47.8) 448 (29.0) 399 (25.7) 159 (10.2)

Country of BirthAustralia 2446 (75.4) 643 (26.3) 596 (24.4) 265 (10.8)Europe-America 485 (15.0) 156 (32.2) .0120 134 (28.0) 52 (10.9)Middle East-Africa 104 (3.2) 30 (28.8) 31 (29.5) 11 (10.8)Asia 208 (6.4) 62 (29.8) 58 (27.4) 18 (8.6)

ICD10 MDCF0: Organic 361 (11.1) 111 (38.0) <.0001 65 (19.8) .0155 32 (9.1)F1: Substance Abuse 880 (27.1) 137 (18.2) <.0001 170 (21.4) .0038 120 (14.3) <.0001F2: Schizophrenia 1539 (47.5) 379 (27.6) 497 (34.0) <.0001 229 (15.1) <.0001F3: Mood Disorder 1515 (46.7) 301 (22.1) <.0001 303 (21.0) <.0001 182 (12.2) .0089F4: Neurotic 749 (23.1) 105 (15.9) <.0001 133 (19.4) <.0001 93 (12.8) .0339F5: Behavioural 79 (2.4) 12 (19.7) 11 (15.1) .0430 9 (11.8)F6: Personality Disorder 654 (20.1) 102 (18.3) <.0001 124 (21.1) .0109 106 (17.2) <.0001F7: Mental retardation 56 (1.7) 13 (30.2) <.0001 10 (20.0) 13 (25.4) .0005F8: Psych. Development 31 (1.0) 5 (21.7) 2 (9.5) 5 (16.7)F9: Emotional 104 (3.2) 18 (23.1) 28 (31.8) 7 (6.8)Z72: Lifestyle/Addiction 346 (10.7) 71 (20.5) .0020 87 (23.9) 62 (15.1) .0021

Postcodes N>100Dandenong [3175] 307 (9.5) 105 (34.1) .0060 91 (29.6) 44 (14.0) .0434Noble Park [3174] 220 (6.8) 90 (41.1) <.0001 71 (32.1) .0149 39 (17.7) .0004Clayton [3168] 122 (3.8) 34 (27.4) 41 (32.8) .0477 13 (10.6)Cranbourne [3977] 121 (3.7) 34 (25.9) 29 (22.1) 15 (11.8)Cheltenham [3192] 119 (3.7) 43 (36.1) .0310 28 (23.7) 4 (3.4) .0097Springvale [3171] 107 (3.3) 25 (24.3) 27 (25.0) 10 (9.5)Bentleigh East [3165] 102 (3.1) 38 (38.4) .0130 32 (31.4) 21 (21.2) .0006

*UNIVARIATE TEST - category vs. complementary, ** median (range)

Socioeconomic and service related characteristicsVariable (Categories) _LASTRC_ HIGHLOS P()* HIGHCONT P()* REVOLVE P()*

N (%) 3243 (100.0) 891 (27.5) 819 (25.3) 347 (10.7)

EmployedYes 344 (10.6) 49 (14.2) <.0001 54 (15.6) <.0001 20 (5.8) .0020No 2899 (89.4) 842 (29.0) 765 (26.4) 326 (11.2)

Subordinate/Non ManagerialYes 2686 (82.8) 791 (29.4) <.0001 745 (27.8) <.0001 319 (11.9) <.0001No 557 (17.2) 100 (17.9) 74 (13.1) 27 (4.8)

Education: 7-10 years +Yes 2266 (69.9) 629 (27.8) 635 (28.1) <.0001 279 (12.3) <.0001No 977 (30.1) 262 (26.8) 184 (18.8) 67 (6.8)

Assisted by a carerYes 368 (11.3) 161 (43.7) <.0001 130 (34.1) <.0001 59 (15.9) .0006No 2875 (88.6) 730 (25.4) 689 (24.1) 287 (10.0)

Admission CentreClayton 1130 (34.5) 228 (25.6) .0320 399 (35.3) <.0001 110 (9.7) <.0001Dandenong 1380 (42.6) 359 (26.0) <.0001 247 (18.3) <.0001 174 (12.6) .0026Acute Child 267 (8.2) 95 (35.6) .0020 58 (22.7) 20 (7.4)Aged Care 466 (14.4) 209 (44.9) <.0001 115 (26.4) 42 (8.9)

Average LOS0-1 days 1071 (33.0) NA 274 (25.6) 23 (2.1) <.0001 1-3 days 1488 (45.9) NA 336 (22.6) .0013 182 (11.6)>3 days 684 (21.1) NA 209 (30.6) .0003 141 (18.0)

Average Post Discharge Delay0-3 days 1991 (61.4) 593 (29.8) .0002 494 (24.8) 119 (6.0) <.00014-6 days 334 (10.3) 91 (27.2) 139 (37.8) <.0001 71 (17.4) <.00011 wk or more 918 (28.3) 207 (22.5) <.0001 186 (17.2) <.0001 156 (14.1) <.0001

No.Contacts per Month0-1 1946 (60.1) 399 (20.5) <.0001 NA 65 (3.3) <.00011-3 555 (17.1) 159 (28.7) NA 72 (11.8)>3 742 (22.9) 333 (44.9) <.0001 NA 209 (26.0) <.0001

*UNIVARIATE TEST - category vs. complementary, ** median (range)

Risk Model [HIGHLOS]Outcome:Cumulative .LOS>45

Cox Regression ResultsVariable

1.23 ; 1.05-1.44

1.60 ; 1.03-2.461.94 ; 1.28-2.951.53 ; 1.11-2.111.60 ; 1.09-2.351.67 ; 1.19-2.331.54 ; 1.22-1.951.26 ; 1.01-1.570.64 ; 0.49-0.841.53 ; 1.09-2.140.54 ; 0.36-0.81

1.62 ; 1.31-2.01

0.59 ; 0.44-0.790.69 ; 0.58-0.810.68 ; 0.54-0.862.63 ; 2.23-3.111.48 ; 1.22-1.801.79 ; 1.32-2.442.32 ; 1.71-3.151.39 ; 1.14-1.710.58 ; 0.35-0.970.55 ; 0.44-0.680.78 ; 0.67-0.910.63 ; 0.54-0.740.74 ; 0.61-0.890.93 ; 0.81-1.070.99 ; 0.99-1.00

HAZARD RATIO

0.25 0.5 1.0 2.0 5.0

Decreased Risk Increased Risk

Average post-discharge delay: 1 wk or more

Hampton Park [3976]Doveton [3177]

Cheltenham [3192]Clayton South [3169]Bentleigh East [3165]

Noble Park [3174]Dandenong [3175]

OtherZ72: Lifestyle/Addiction

Z51-Z65 Social Problems

Occupation: Subordinate/Non ManagerialEducation: 7-10 years +

Employed

Average post-discharge delay: 4-6 days>3 Contacts per month

1-3 Contacts per monthAged Care

Acute ChildDandenong

F9: EmotionalF4: Neurotic

F3: Mood DisorderF2: Schizophrenia

F1: Substance AbuseMaleAge

HR ; 95% CI

Risk Model: [REVOLVE]Outcome:T.No.Adm.>=4

Cox Regression Results

1.92 ; 1.04-3.54

0.35 ; 0.13-0.94

1.96 ; 1.23-3.12

0.60 ; 0.37-0.97

1.49 ; 1.11-2.00

1.70 ; 1.14-2.53

1.60 ; 1.28-2.00

6.27 ; 4.67-8.42

2.33 ; 1.66-3.28

0.50 ; 0.28-0.88

1.40 ; 1.09-1.81

4.48 ; 2.82-7.12

2.92 ; 1.87-4.55

0.39 ; 0.17-0.90

2.33 ; 1.31-4.14

1.97 ; 1.53-2.53

1.40 ; 1.07-1.83

1.33 ; 1.06-1.66

1.02 ; 0.81-1.28

0.98 ; 0.97-0.99

HAZARD RATIO

0.01 0.25 0.5 1.0 2.0 5.0 10.0

Doveton [3177]

Cheltenham [3192]

Bentleigh East [3165]

Continent of Birth: Asia

Assisted by a carer

Occupation: Subordinate/Non Managerial

Average post-discharge delay: 1 wk or more

>3 Contacts per month

1-3 Contacts per month

Acute Child

Dandenong

Average LOS>3 days

Average LOS: 1-3 days

F9: Emotional

F7: Mental retardation

F6: Personality Disorder

F4: Neurotic

F3: Mood Disorder

Male

Age

Variable HR ; 95% CI

Decreased Risk Increased Risk

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)

Links

Centre for Health Systems Research http://www.med.monash.edu.au/healthservices/chsr

The RAMS projecthttp://www.med.monash.edu.au/healthservices/chsr/projects/rams