Assessing quality indicators related to mental health emergency room utilization

Quality improvement in mental health (MH) systems is a priority in most countries [1‐3]. One in four individuals will experience a mental illness (MI) in their lifetimes [4]. The prevalence of MI is increasing particularly as populations age, with healthcare costs expected to reach $80 billion in Canada by 2021 [5]. In 2013, 60% of the Canadian MH budget was allocated to hospital inpatient services [6]. MH systems in developed countries (United Kingdom, Australia, Belgium, etc.) have undergone major transformation in recent decades aimed at improving overall performance [7‐11], primary care [12, 13], service integration [14, 15], care continuity [16], and in adopting multidisciplinary teams, and recovery best-practices (e.g. care pathways, intensive case management, assertive community treatment) [17‐19]. In Canada, the 2005 Quebec MH reform [20] followed international trends [7‐11], integrating MH and primary care services, and introducing recovery best-practices for improved healthcare quality [21]. International studies supported these reforms in demonstrating that 43–67% of individuals [22‐24], did not consult with healthcare professionals for MI or SUD. The ERs became the preferred destination for individuals facing deteriorating MH conditions [25]. Canadian and American studies estimate that 4–12% of ER visits are for MH reasons [26‐28], increasing ER use by 15% or more in the past few years [27, 29]. ER use serves as a barometer for estimating quality in MHS.

Indicators used to assess MHS quality and impact on MH reforms include access, continuity and appropriateness of care [2, 30, 31], with ER attendance as a key indicator of health system access [32, 33]. Canadian and international studies have reported elevated rates of high (more than 4) and very high (more than 12) ER visits/year among PMI, particularly those with co-occurring MI and chronic physical illnesses or SUD [34‐36], as compared with other patients [36‐41]. PMI also tended toward recurrent ER use over many years [38, 42], depending upon symptom severity, or medication adjustment issues [43]. Fear of stigma may have discouraged disclosure among primary care patients, leading to under-diagnosis, and suboptimal patient management, another factor in ER overuse for MH reasons [43, 44]. Studies found that 8–32% of patients are hospitalized for MH reasons [45‐48], identifying a relationship between high ER use and psychiatric hospitalization [49]. Among PMI, high ER users also use outpatient services frequently [37, 49]. Their multiple, serious needs persist despite concerted professional efforts to address them [35]. As PMI receive little attention to their problems in daily living [22‐24], the ERs become the first point of service for conditions that do not require emergency services. One US study suggested that treatment in community-level services was adequate for many MH cases, as 20–40% those treated in ERs were not urgent [50]. This situation reflects lack of access to care elsewhere in the MH network [51] and the inability of patients to obtain appointments in a timely manner.

The avoidance of repeated ER visits/hospitalizations through better continuity of care following an ER visit or hospitalization is critical for MHS improvement, especially among patients with more severe and co-occurring conditions [52]. Outpatient appointments held within 7 to 30 days of discharge may address potential side effects associated with medication changes, and promote treatment compliance [30], avoiding return ER visits/hospitalizations, which occur within 30 days after discharge in 10–15% of cases [53]. One study found that only 17% of re-hospitalized patients had received a follow-up appointment prior to discharge [54]. Moreover, PMI remained in hospital longer than others [55‐58], increasing the likelihood of readmission as compared with those discharged after brief admissions [55]. Best practices recommend short hospitalizations [55], and close post-discharge follow-up [59] for enhancing social integration and recovery.

Previous studies have assessed the impact of MH reforms [60, 61] in terms of service utilization, access to care, ER (re)admission rates, and hospitalization [62‐64]. Others evaluated best practices in patient management [65]. Yet, to the best of our knowledge, no study has focused on quality indicators related to ER use for any reason among PMI in the context of system reforms, including access, continuity or appropriateness of care. Moreover, very few studies have assessed ER use or service quality using large samples of PMI, or included robust longitudinal frameworks [46, 66, 67]. Based on data from the Quebec Integrated Chronic Disease Surveillance System (QICDSS), this descriptive study compared data from 2014 to 15 and 2005–06 on MHS quality indicators in relation to ER use, in order to evaluate the impact of the 2005 Quebec MH reform on access, continuity and appropriateness of care provided to PMI. We hypothesized that overall ER use would be reduced over the course of the reform, and the integration of ER and MH medical services in Quebec health networks reinforced.

This study evaluated changes in MHS quality related to ER use in terms of access, continuity and appropriateness of care for a cohort of PMI, comparing data from 2014–15 vs. 2005–06 when the Quebec MH reform was introduced. We hypothesized that overall ER use would decrease, and that service integration would improve between Quebec ERs and other MH medical services. As hypothesized, ERs and hospitalization for any reasons decreased for PMI from 2005–06 to 2014–15; but their decrease in ER use was two times less than that of patients without MI. Outpatient consultations for MH reasons in the year preceding ER visits also improved considerably: in 2014–15, less than half of PMI had no outpatient consultations for the year prior to their ER visit. Contrary to expectation, indicators of continuity of care or appropriateness revealed either deterioration or only slight improvement from 2005–06 to 2014–15. Positive changes were generally less pronounced for PMI compared with patients without MI. However, some improvement occurred on outpatient consultations for MH reasons following hospitalizations; they increased considerably but were very low overall. Regarding ER visits over 5 consecutive years, rates decreased slightly over time.

The overall findings confirmed a 12% annual prevalence of PMI, similar to rates reported in other North American epidemiological studies, ranging from 12 to 18% [70, 71]. Concerning ER use among PMI, rates in this study, at close to 40%, were much higher than in other North American studies, at 4–12% [26‐28, 46]. Our results may be explained by the fact that we investigated ER use for any reason among a cohort of patients diagnosed with MI over a 12-month period. Other studies have tended to investigate ER use for MH reasons only. Yet our data were less likely to underestimate ER use by PMI, as opposed to studies that reported data on ER use for MH reasons exclusively. Such methodological distinctions limit the usefulness of comparisons.

Regarding socio-demographic composition of the cohort, we noted that PMI were slightly more materially and socially deprived than other ER patients, suggesting considerable vulnerability among PMI using ERs, as portrayed elsewhere [72, 73]. Older patients received lower quality care overall, including fewer outpatient consultations prior to ER visits, and fewer within 1 week or month after an ER visit or hospitalization for MH reasons; their rates of return to ERs within 30 days, hospitalizations exceeding 30 days, and recurrent ER use over 3 years for any reason were also lowest. Under-diagnosis of MI [74, 75] or lower prioritization of MH issues among older patients may explain these lower outpatient consultation rates. The fact that older PMI often presented with chronic, co-occurring physical illness may explain their other poor outcomes, and need for additional care, which drove their return ER visits [76], and extended hospitalization rates further exacerbated by placement issues [56]. By contrast, the 12–17 year group received significantly more MHS before and after ER visits or hospitalizations, aimed at countering MI in adulthood [77, 78]. The MH reform may have played a role in prioritizing youth MH; early-onset MI occurs frequently [79], and carries a poor prognosis [80]. However, younger patients used fewer MHS overall, as highlighted in previous research [81, 82]. In Montreal, higher rates of outpatient consultations, return ER visits within 30 days, re-hospitalizations, and hospitalizations exceeding 30 days may have been due to greater numbers of vulnerable patients with complex problems [83]. More availability of primary care, walk-in clinics without follow-up in Montreal may also have increased outpatient consultations in the week preceding ER visits. Furthermore, rates of outpatient consultations, outpatient consultations following ER visits (within a week, or month) and hospitalizations (within a week), as well as higher recurring ER use over 3 years in rural areas, reflected their relative lack of primary care coverage as compared with cities [72].

Concerning access to services, we observed that ER use, frequency of use, and number/ length of hospitalizations were almost double for PMI versus other patients. International studies confirm the frequency of ER use [34, 37, 49], with hospitalization rates similar to ours at 15–32% [48, 56], and extended hospitalization among PMI [84]. Limited or delayed access to primary care and other services, and inadequate follow-up for PMI may explain these results [10, 50]. Yet decreased ER use and fewer hospitalizations over time did suggest some improvement in access to care. Measures introduced over the course of the Quebec MH reform aimed at reducing ER use/hospitalization and supporting PMI included: increased access to primary care, prevention strategies by MH teams in CLSCs, and increased mobile crisis services, and GPs working with respondent-psychiatrists (shared care). Incentives were also provided to improve MH supports in medical clinics [10, 21]. Decreased ER use and hospitalization rates in this study were contrary to results obtained in other North American studies, but only those for MH reasons [48, 85].

Overall, PMI who used ERs also used outpatient services twice as often as those who did not use ERs, but patterns of service use remained stable. By contrast, outpatient service use by PMI who did not use ERs decreased by 11%, confirming their high, and inappropriate use of health services [34, 86]. Yet the results also revealed that some patients received intensive, quality outpatient follow-up in terms of monthly access to family physicians. Moreover, close to 40% of patients received outpatient consultations for any reason within a week prior to ER visits, suggesting the occurrence of ER visits on physician recommendation. Yet the fact that most did not consult a physician before ER visits suggested ongoing difficulties with rapid access to medical clinics or psychiatrists, an interpretation further reinforced by evidence that more than half of patients had not consulted a physician for MH reasons in the year previous to an ER visit. In Quebec, 45% of PMI have no family physician [87], as opposed to 25% of the general population [88]. Previous research also reported that only 45% of PMI in Canada consulted their regular physician for MH problems [89]. Moreover, according to international studies, two thirds of PMI avoided seeking help altogether [22, 90], perhaps viewing their problems as too complex or specialized for GPs. Similarly, studies underline difficulties among GPs around providing MH care [91‐93].

Regarding continuity of care, we found that most patients did not receive follow-up appointments within 7 to 30 days after an ER visit, or hospitalization for MH reasons. The situation had deteriorated in 2014–15 compared with 2005–05 for outpatient consultations after ER visits, but follow-up to hospitalization had improved considerably. Most studies identified barriers to care continuity among PMI [94], with average failure rates at 58% (range 18 to 67%) on outpatient follow-up after ER visits or hospitalizations [94‐97], which coincides with our results. Improvement in outpatient consultation rates after hospitalizations may be explained by the MH reform priority on reducing hospitalizations [21], an international trend [7, 9, 98]. One-third of patients made return ER visits within 30 days, suggesting the persistence of problems in continuity of care. ER readmission rates for MI (with or without hospitalization) within 30 days range from 10 to 40% in the literature, depending on patient population [99, 100]. Severe MI (e.g. schizophrenia), co-occurring MI/SUD or MI/chronic physical illness are difficult to treat during an ER visit, particularly a first visit, requiring several medical consultations [34, 37, 52]. Our results showed that physical illness was the main reason for return to ERs among PMI. Medication use may also involve physical side effects requiring outpatient appointments proximal to discharge [1, 30].

Regarding appropriateness of care, 17% of patients were high/very high ER users, and often hospitalized. A systematic review found that high/very high ER users ranged from 0.03 to 18% among PMI [100], who were also high users of other services [34]; they tended to consult hospital-based professionals during crises [66]. High ER use may be explained by significant vulnerability, socioeconomic precariousness, and social isolation among PMI [72, 73], as well as the high prevalence of psychosocial problems associated with co-occurring physical conditions requiring specialized care combined with close follow-up in primary care [49]. Poor coordination of outpatient services and low overall continuity of care [37] frequently contribute to high hospitalization rates. Again, difficulties in the implementation of continuous services in the Quebec reform context may explain these results [10].

While most PMI made a single visit to an ER throughout the 2005–06 to 2014–15 period, nearly one in ten did so over three to five consecutive years during the same period. Moreover, ER use increased over three consecutive years, which may be explained by the chronicity often associated with MI. International studies reported that chronic episodic depression may last up to 3 years, especially when accompanied by suicidal ideation [101, 102]. Having two or more MI, SUD or severe MI such as personality disorders may also increase recurrent yearly ER use [43, 103]. Thus, our results highlight some of the challenges inherent in managing patients with complex MH profiles who require close monitoring or frequent medication readjustment by a multidisciplinary team in order to avoid recurring yearly ER use [10, 43]. The fact that recurring yearly ER use decreased over 5 consecutive years after 2005–06 suggests some post-reform improvement in the management of patients with serious and chronic problems. In Quebec, intensive case management and assertive community treatment targeting high ER users with serious MIs have been consolidated since the 2005–06 MH reform [21].

Even though only 3% of PMI were hospitalized for over 30 days, decreasing over time, their hospitalization rates were ten times that of patients without MI, while hospitalizations for this group were five times lower. An American study found that PMI remained in hospital 38% longer than others [48], while another reported hospitalization rates exceeding 30 days for PMI with severe disorders [59], similar to our results. Illness severity remains the main predictor for length of hospitalization, particularly in schizophrenia and psychosis [76, 83].

This study has limitations that should be acknowledged. First, outcomes of the reform may have been affected by the particular indicators selected to measure access, continuity and appropriateness of care. As well, the QICDSS used administrative databanks not originally designed for epidemiological research; they did not include statistics for physicians working in CLSCs who also follow vulnerable PMI [104]. Results from the QICDSS were also slightly underestimated due to a few percentages of missing data on ER diagnoses for the MH population. However, data extracted from the QICDSS may provide a basis for, and complement to, future epidemiological research. Finally, as this study involved ER service use in the Quebec MH population, comparative studies are needed for other Canadian provinces or countries to more adequately evaluate the quality of MHS.

This study is the first to evaluate recent data on MHS quality indicators related to ER use for a cohort of PMI in Quebec, and to compare results with data for the period coinciding with implementation of the Quebec MH reform (2005–06). While we hypothesized that the reform would improve access, continuity, and appropriateness of care, and reduce ER attendance, results did not strongly support these hypotheses. Some improvement occurred over the 10-year period, yet gains among PMI were generally smaller than among patients without MI. In fact, while slightly fewer PMI visited ERs over time, the decrease among patients without MI was twice as great. With service improvement targets unmet, MH seems to remain the “Cinderella” of the Quebec health and social service system. The literature on MHS quality improvement supports various strategies which, if better implemented, could be integrated into the Quebec system to increase ER functioning and enhance coordination between ERs and MH community networks. These include the consolidation of MH and primary care services and follow-up practices such as assertive community treatment (ACT), intensive community management (ICM) or case management, targeting patients with more severe or co-occurring MH profiles, including high or very high ER users. Shared-care, involving closer collaboration between psychiatrists and other MH primary care providers, particularly GPs, may also favor MHS quality improvement. More systematic and routine outpatient follow-up to ER visits or hospitalizations, based on inter-organizational collaboration, may also reduce return ER visits within 30 days. Improving access and continuity of care for the most vulnerable individuals may also reduce the high prevalence of ER use in this population. Alternative services such as crisis resolution teams and home intervention teams could also be implemented with good effect. Overall, there is much room for quality improvement in MHS, including better support for ERs by integrating them within solid community-based MH networks.