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CME / ABIM MOC / CE

Mental Health Hospitalization Trends and Outcomes Amid Telemedicine Use

  • Authors: News Author: Kelli Whitlock Burton; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 8/5/2022
  • Valid for credit through: 8/5/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

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    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

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Target Audience and Goal Statement

This activity is intended for primary care physicians, psychiatrists, nurses, pharmacists, physician assistants, and other members of the healthcare team who care for patients with serious mental illness.

The goal of this activity is for learners to be better able to assess the effects of telemental health on quality outcomes of mental health care.

Upon completion of this activity, participants will:

  • Evaluate the outcomes of telehealth compared with in-person outpatient visits
  • Assess the effects of telemental health on quality outcomes of mental health care
  • Outline implications for the healthcare team


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News Author

  • Kelli Whitlock Burton

    Freelance writer, Medscape

    Disclosures

    Kelli Whitlock Burton has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine

    Disclosures

    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/Nurse Planner

  • Leigh Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CMSRN, CNE, CHCP, has no relevant financial relationships.

Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Yaisanet Oyola, MD, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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CME / ABIM MOC / CE

Mental Health Hospitalization Trends and Outcomes Amid Telemedicine Use

Authors: News Author: Kelli Whitlock Burton; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 8/5/2022

Valid for credit through: 8/5/2023

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Clinical Context

The explosion in telehealth began as a means to protect patients and healthcare workers during the COVID-19 pandemic, but it has been propagated by the forces of economics and convenience. Still, many healthcare professionals wonder how effective and safe telehealth is. A systematic review by Albritton and colleagues, published in the February 2022 issue of the Annals of Internal Medicine, addressed this question.[1]

Telehealth may be particularly helpful in the care of mental illness, which has traditionally been undertreated in the US healthcare system.

High use of telemental health services by patients with serious mental illness (SMI) who live in nonmetropolitan US counties is associated with improvements in key outcomes, including greater posthospitalization follow-up, new research suggests.

Study Synopsis and Perspective

In a nationwide study, researchers drew on Medicare data from nearly 3000 counties covering the period from 2000 to 2018. Results show that counties in which there was greater use of telemental health services reported higher increases of clinical visits and better follow-up after hospitalization among patients with bipolar 1 disorder and schizophrenia or other psychotic disorders.

In the study, "clinical visits" referred to both in-person and telemental health visits.

"These findings really support the idea that telemental health can be safe and effective and beneficial for in-person care for people with severe mental illness," coinvestigator Haiden Huskamp, PhD, professor of healthcare policy at Harvard Medical School, Boston, Massachusetts, told Medscape Medical News.

The findings were published online June 27 in JAMA Network Open.[2]

Continuing Trend?

Past studies have pointed to a sharp increase in the use of telepsychiatry services for patients with SMI. As reported by Medscape Medical News, this is a trend some clinicians say is likely to continue after the pandemic.[3]

Use of telemedicine during the pandemic received a boost by the temporary suspension of certain Medicare rules that restrict telehealth use. Debate continues at the federal and state levels on whether to make that suspension permanent. Dr Huskamp said that more information is needed about the efficacy and accessibility of telemental health.

To investigate, researchers used Medicare fee-for-service data from 118,170 patients in 2916 counties. More than two thirds of the patients were aged 65 years or younger.

During the study period, telemental health service increased from 0.03 visits per patient with SMI in 2010 to 0.19 visits per patient in 2018. This increase was broad, with the number of counties reporting high use of telemental health increasing from 2% in 2010 to 17% in 2018.

Compared with counties in which there was no telemental health services, those counties with high use were less densely populated and had fewer healthcare professionals and hospital beds.

The number of overall visits with a mental health professional increased slightly in high-use counties compared with in no-use counties, going from 4.65 visits in 2010 to 4.79 visits in 2018. The number of in-person visits during that period declined from 4.55 visits in 2010 to 3.73 visits in 2018, which suggests that the overall increase was a result of higher use of telemental health.

In the high-use group, the number of patients who had at least 4 mental health care visits increased 8.0%, and the number of patients who had a follow-up visit within 30 days of a hospitalization increased 20.4%.

A "Helpful Option"

"Telemedicine doesn't address the national shortage of providers, but it definitely helps in underserved areas [and] rural areas," Dr Huskamp said.

"We need more mental health providers and need to develop new models of care that can leverage the providers we have in the best way possible. This is at least a helpful option, especially when you're thinking about the maldistribution of providers across the country," she added.

The study results showed that there was no difference in medication adherence between low- and high-use counties.

There was greater contact with mental health care providers in counties with high use of telemental health, and patients in the high-use group were 7.6% more likely to be hospitalized within a year compared with their peers in counties that had no telemental health use.

For example, it could mean that counties with greater telemental health use did a better job of identifying and responding to patients' need for acute care, she noted. It could also be a reflection of the loss of psychiatric inpatient care in low-use communities.

Another Tool

Commenting on the findings for Medscape Medical News, Robert Caudill, MD, director of telemedicine and information technology programs at the University of Louisville School of Medicine in Kentucky, called the increase in hospitalization in high-use counties "surprising." However, he noted, it might be a reflection of the need to fine-tune telemental health for patients with SMI.

Dr Caudill noted that an interprofessional approach that includes psychiatric care and case management is generally considered to be the gold standard in treating patients with the types of mental illness included in this study.

Although some of that care can be delivered effectively via telemedicine, it is possible other aspects, such as case management, are better handled in person, he said.

"I don't think it is the role of telehealth to make in-person care obsolete. It is simply a tool to be used when appropriate," said Dr Caudill, who is a past chair of the American Telemedicine Association's Telemental Health Special Interest Group.

The study was funded by the National Institutes of Mental Health. Dr Huskamp and Dr Caudill have disclosed no relevant financial relationships.

Study Highlights

  • The study was conducted among Medicare beneficiaries who received healthcare in nonmetropolitan areas in the US. Study data were assessed at the county level between 2010 and 2018.
  • Researchers focused on patients with a diagnosis code for schizophrenia and bipolar I disorder, and only visits to mental health professionals were considered in the data analysis.
  • The median number of telemental health visits per 100 patients in a year was at least 10.6. Counties were classified according to the use of telehealth for mental illness: no telemental health, low (more than to the median of all counties), moderate (above median to the 90th percentile [29.7 telemental visits per 100 patients in a year]), and high (more than the 90th percentile for telemental health).
  • Outcomes were as follows:
    • Receipt of a minimum number of mental health visits in a year
    • Medication adherence
    • Emergency department visits and hospitalizations
    • Outpatient follow-up after mental health hospitalizations
  • There were 2916 counties with a total of 188,170 patients in the sample; 65.2% of patients were men and the mean age was 58.3 years.
  • In 2018, high use of telemental health services was associated with more less dense populations and fewer health care professionals.
  • The use of telemental health in all counties increased from 0.03 visits per patient in 2010 to 0.19 visits per patient in 2018.
  • The average numbers of mental health visits (in person or telemental) per patient in counties with no telemental health were 4.22 in 2010 and 4.29 in 2018. The respective numbers in high telemental health service counties were 4.65 and 4.79. The number of in-person visits declined over time in the high telemental health service counties.
  • Compared with counties with no telemental health services, counties in the high telemental health services group had an 8.0% relative higher rate of having at least 4 mental health visits per year, as well as a 6.5% relative increase in having an outpatient follow-up within 7 days of hospitalization. High telemental health counties had 7.6% higher rate of mental health hospitalizations compared with no telemental service counties.
  • Medication adherence was not affected by telemental health service.
  • The main study results were similar in a secondary analysis of patients younger than 65 years and those aged 65 years and older. Most outcomes were not affected by patients' dual eligibility for Medicaid and Medicare, but those who were not dual eligible had a higher rate of medication adherence in high telemental health counties.

Clinical Implications

  • In a previous meta-analysis, telehealth was associated with the same or better outcomes compared with in-person care for diverse conditions such as diabetes, chronic respiratory illness, and chronic pain. However, no studies used telehealth to diagnose illness or provide preventive care, and there were no data on the effects of telehealth on health equity and disparities. With limited data, there did not appear to be a higher risk for harms associated with telehealth vs in-person care.
  • The current study finds that telemental services were associated with a modest increase in mental health services and follow-up after mental health hospitalizations. Telemental health services did not affect medication adherence and were associated with a higher rate of mental health hospitalizations.
  • Implications for the healthcare team: The healthcare team can institute telemental health services with the expectation that they can modestly expand connections with patients. An interprofessional approach that includes psychiatric care and case management is generally considered to be the gold standard in treating patients with the types of mental illness included in this study.

 

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