Trends in Healthcare Utilization Among Older Adults with and without Mental Health Problems in the United States: 1997-2012

Background/Purpose: People with mental health problems are at an elevated risk for physical comorbidities and premature mortality. There is growing concern that inadequate utilization of healthcare, including overuse, underuse, and misuse of certain services, contributes to poor health outcomes among people with mental health problems. Despite these concerns, there is limited research examining the trends in healthcare utilization among people with mental health problems and whether these trends differ from people without mental health problems. The nearly universal insurance coverage among older adults in the US allows us to study the impact of mental health problems on healthcare utilization that is independent of access to care.

The purpose of our study was to better understand the trends of healthcare utilization among older adults with mental health problems and how they differed from older adults without mental health problems.

Methods: Individuals 65 years or older (n=108,534) were selected from the National Health Interview Survey (NHIS) series of 1997-2012, approximately 94% were covered by Medicare. Mental health problems were measured by a score of ≥13 on the Kessler Psychological Distress Scale (K6), a standardized screener for past-year mental health problems, such as anxiety or mood disorders. Three variables of past year healthcare utilization were examined: 1) Any contact with a primary care physician (PCP); 2) overnight hospital stay; and 3) repeat visits to the emergency department (ED). Multivariate logistic regression was conducted using Stata to account for the complex survey design of the NHIS.

Results: Older adults with mental health problems had a two-fold risk for repeat ED visits (OR=2.19, p<.001) and overnight hospital stays (OR=1.78, p<.001) after adjusting for socio-demographics and physical comorbidities. The odds of contact with a PCP did not differ between the two groups.

Between 1997 and 2012 the linear trends in the prevalence of repeat ED visits differed significantly between older adults with mental health problems (OR=1.02, p<.05), who experienced a 2.4% increase each year, and older adults without mental health problems (OR=1.00, p=.65), who experienced no per year increase. There were no significant trend differences between the two groups in contacts with a general doctor (OR=1.01, p<.001), which increased by 1.4% per year, and overnight hospital stays (OR=0.99, p<.001), which decreased 1.3% per year. 

Conclusions/Implications: Older adults with mental health problems utilize inpatient care and emergent care at higher rates than older adults without mental health problems. In particular, the rates of repeat ED visits increased significantly over the past 16 years among older adults with mental health problems, indicating a widening gap in the adequacy of services for this population even with near universal access to care. The findings suggest that improvement in health insurance coverage alone is insufficient. Integrative care models and interventions targeting mental health patients’ ability to navigate the health system are needed to reduce the overuse of costly care and improve health outcomes among this vulnerable population.