Elsevier

General Hospital Psychiatry

Volume 56, January–February 2019, Pages 19-27
General Hospital Psychiatry

Research paper
Depressive symptoms and health care within 30 days after discharge from a cardiac hospital unit

https://doi.org/10.1016/j.genhosppsych.2018.10.001Get rights and content

Abstract

Objective

To determine the association between depressive symptoms in CHD patients and in- and outpatient health care utilization during the 30 days following treatment in a cardiac hospital unit.

Method

The study sample consisted of 949 CHD patients who completed a measure of depressive symptom severity (the Patient Health Questionnaire [PHQ-9]). Cardiac disease severity and medical comorbidities were assessed by chart review. Follow-up questionnaires were mailed to patients assessing in- and outpatient health care.

Results

Among patients with elevated depressive symptoms (PHQ-9 score of ≥7), 19.9% had at least one outpatient hospital visit (hospital-based medical centers, outpatient clinics, and emergency departments) within the first 30 days after the initial hospitalization, compared to 11.8% of patients without depressive symptoms (p = 0.002). This association remained significant after adjustment for sociodemographic and medical covariates. Elevated depressive symptoms also predicted a higher number of outpatient physician visits (adjusted OR = 2.36; 95% CI 1.75 – 3.18; p < 0.001). Results were similar for the PHQ-9 continuous score. There was no association between depressive symptoms and re-hospitalizations.

Conclusions

After hospitalization for cardiac care, patients with elevated depressive symptoms may be at higher risk for utilizing outpatient physician and outpatient hospital care. This is not explained by more severe cardiac disease or more comorbidities.

Introduction

Depression is common among patients with coronary heart disease (CHD) and leads to more recurrent cardiovascular events and a higher risk for mortality [[1], [2], [3]]. This has been linked to biological mechanisms such as low heart rate variability and higher levels of inflammation [[4], [5], [6], [7]], but also to behavioral mechanisms such as physical inactivity and smoking [1,7,8]. At the same time, CHD is assumed to increase the risk for comorbid depression [9,10].

It is well known that depression plays an important role in health care utilization and costs, in cardiac as well as non-cardiac populations. It has been shown that depression leads to poor medication adherence and thus increases health care costs [[11], [12], [13]]. In addition, depression has a direct impact on health care costs. Depressed people living in the community have an increased general health care utilization compared to non-depressed people, even though this association cannot be linked to specific types of health care services [14]. In samples of older adults, depression has been associated with more hospitalizations, longer mean length of stay and higher utilization of outpatient services [[15], [16], [17], [18], [19]]. In the German general adult population, depression has been associated with an almost twofold increased risk for hospitalization [20]. Most of these studies showed that the association is mainly due to more somatic comorbidities and increased functional impairment in depressed patients. However, depressive symptoms remained an independent risk factor for higher health care utilization [[15], [16], [17], [18]].

Cardiac patients with depression tend to have more outpatient contacts and hospitalizations than those without depression [[21], [22], [23]]. However, studies showing these associations have focused on a 12-month follow-up period or longer, and have included only patients after myocardial infarction (MI) [[21], [22], [23]]. The impact of depressive symptoms on short-term usage of outpatient services, particularly general practitioner (GP) visits and specialist care following a hospitalization, as well as the association with short-term re-hospitalizations in patients hospitalized for any CHD-related condition has not been investigated.

The current study aims to determine the association between depressive symptoms in coronary heart disease patients and the use of inpatient and outpatient health care during the 30 days following treatment in a cardiac hospital unit. Specifically, associations between depressive symptoms and number of subsequent hospitalizations as well as outpatient hospital visits and physician visits were analyzed.

Section snippets

Study design

The current study was part of the CDCare (“Depression Care for Hospitalized Coronary Heart Disease Patients”) study. Patients were considered eligible if they had a diagnosis of CHD and were hospitalized in one of the two university hospitals in Germany (Universitätsklinikum Münster; Charité – Universitätsmedizin Berlin). Patients were excluded if they had a chart-documented dementia disorder, cognitive impairment, insufficient language proficiency, the presence of a terminal disease or if they

Sample characteristics

Participant characteristics in the overall sample are shown in Table 1. Out of the 1265 patients from the CDCare study, we included 949 with sufficient data on utilization of health care, 190 of those were female (20.0%). Mean age in the overall sample was 63.8 years (SD = 10.1; range 36-88 years). In the sample for hospital re-admissions, 38.9% scored 7 or higher on the PHQ-9, mean score of the PHQ-9 was 6.2 (SD = 4.8).

In the sample for hospital re-admissions, 97 patients (10.2%) were

Discussion

The present study analysed the effect of depressive symptoms on the utilization of health care services during the 30 days following a cardiac-related hospitalization. The results provide evidence that depressive symptoms lead to higher utilization of outpatient health care services.

Specifically, CHD patients with elevated depressive symptoms had more outpatient hospital visits and physician visits than non-depressed patients. These findings are consistent with previous studies which also

Declaration of Interest

Jakob Hornung: No conflict of interest.

Stella Linnea Kuhlmann: No conflict of interest.

Maria Radzimanowski: No conflict of interest.

Silke Jörgens: No conflict of interest.

Wilhelm Haverkamp has been a member of the advisory boards of or has given presentations on behalf of the following companies: Astra-Zeneca, Bayer, Boehringer Ingelheim, Daiichi Sankyo, Eli Lilly, Grünenthal, GlaxoSmithKline, Lundbeck, Medicines Company, MSD, Novartis, Pfizer, Trommsdorff and Servier.

Peter Martus: No conflict

Acknowledgements

The present study was part of the CDCare (“Depression Care for Hospitalized Coronary Heart Disease Patients”) study. CDCare was supported by the German Federal Ministry of Education and Research (grant number: 01GY1154). The sponsor was not involved in study design, data collection, analyses and interpretation, in writing the article, and in the decision to submit the article for publication.

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