Psychiatric Emergency Department Readmissions Among Asian and Pacific Islander Subgroups

BACKGROUND. Acute care psychiatric readmissions are an important indicator of community mental health system quality of care. While racial disparities have been found in acute psychiatric readmissions, most research has focused on differences between African American and Latino population groups compared to Whites. Despite being the fastest growing non-white demographic group in the United States, Asians and Pacific Islanders are understudied. Using data from Hawaii with detailed race and ethnicity coding including Native Hawaiian, Filipino, Japanese, and Chinese subgroups, this study considered: (1) The rate of psychiatric Emergency Department (ED) readmissions for individuals with a prior psychiatric ED admission; (2) time to psychiatric ED readmission and (3) differences in readmission rates and times by race/ethnicity.

Methods: Data from the Hawaii Health Information Corporation all payer hospital database was used to construct a longitudinal dataset of individuals (N = 21,802) with primary diagnosis ICD-9 codes for serious mental illness (Anxiety, Mood, or Psychotic Disorder) and at least one psychiatric ED visit during the study period (2007 to 2012). Two models were estimated, 1)Negative binominal multilevel models were used to estimate the count of ED readmissions; and 2)a multilevel survival analysis model was used to estimate an individual’s time to subsequent ED admissions. Both models included race/ethnicity, gender, age at index admission, primary and comorbid diagnoses, payer sources, and year as independent variables.

RESULTS: 21,561 individuals had at least 1 psychiatric ED visit between 2007 and 2012. On average individuals had 2 acute admissions per 100 months with a range of 1 to 11 readmissions per month. In the negative binomial model, being Chinese (IRR = 1.65, p< 0.001), Filipino (IRR = 1.19, p< 0.001), Native Hawaiian (IRR = 1.09, p=0.04) or Japanese (IRR = 1.17, p< 0.01) was associated with higher rates of readmission compared to whites.  Schizophrenia was associated with the highest rate of readmission, depression had lowest rate of readmission. Comorbidity and substance use were associated with higher rates of readmission. Factors associated with a shorter time to readmission were being black (HR = 1.18, p= 0.04), Chinese (HR = 1.69, p < 0.001), Filipino (HR = 1.18, p = 0.001), or Japanese (HR = 1.23, p < 0.001) (vs. white) race/ethnicity, older age, a diagnosis of schizophrenia (vs. anxiety, bipolar and depression), Medicaid insurance (compared to private), number of comorbid diagnoses and suicidality.

CONCLUSIONS.This analysis identified distinct patterns of readmission rates by Asian and Pacific Islander subgroup. Once admitted to the hospital, individuals of Chinese, Filipino, Native Hawaiian or Japanese ancestry were more likely to be readmitted relative to white individuals. Furthermore, Chinese, Filipino, or Japanese (vs. white) race/ethnicity appear to be readmitted for emergency care sooner, indicating possible issues in cultural appropriateness of community mental health care, access to care, or quality of care. Community mental health systems should focus on developing culturally appropriate interventions to reducing acute care episodes.