Published online before print September 28, 2006, doi: 10.1161/01.STR.0000244783.53274.a4
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(Stroke. 2006;37:2796.)
© 2006 American Heart Association, Inc.
Original Contributions |
The Impact of Poststroke Depression on Healthcare Use by Veterans With Acute Stroke
From the VA Stroke QUERI Research Coordinating Center (H.J., H.Q., L.D.R., X.W., L.J.Y.), Gainesville, Florida; the VA Stroke QUERI Clinical Coordinating Center, Roudebush VAMC, the Department of Neurology, Indiana University School of Medicine, and Regenstrief Institute, Inc (T.M.D., L.S.W.), Indianapolis, Indiana; and the College of Pharmacy (L.D.R.), University of Florida, Gainesville, Florida.
Correspondence to Huanguang Jia, PhD, VA RORC (151B), VA Medical Center, 1601 SW Archer Road, Gainesville, FL 32608. E-mail Huanguang. Jia{at}med.va.gov
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Abstract |
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Background and Purpose— Poststroke depression (PSD) is common among stroke survivors, and it is associated with worse functional outcomes and increased poststroke mortality. Limited information is available about its impact on healthcare use. This study assessed the impact of PSD on healthcare use by veterans with acute stroke.
Methods— In this retrospective, observational national study, 5825 veterans with acute stroke were identified from Veterans Affairs’ (VA) inpatient databases. To determine the patients’ comprehensive PSD and use status, VA and Medicare fee-for-service inpatient and outpatient as well as VA pharmacy data were used. PSD was established if a patient had an inpatient or outpatient depression diagnosis or if a patient received one of the antidepressants within the VA 12 months postindex stroke. Healthcare use referred to the number of hospital stays, outpatient visits, and cumulative length of inpatient stays under both VA and Medicare fee-for-service programs. Poisson regression was fitted to estimate the impact of PSD on use controlling for sociodemographic, clinical, and disease severity factors.
Results— Forty-one percent of the sample had PSD. After adjusting for patient demographic and clinical factors, we found that the patients with stroke with PSD had significantly (P<0.0001) more hospitalizations, outpatient visits, and longer length of stays 12 months poststroke compared with these patients with stroke without PSD.
Conclusions— Patients with PSD had greater 12-month poststroke healthcare use even when controlling for other demographic and clinical variables. Early detection and appropriate management of PSD for veterans with acute stroke may help reduce their poststroke healthcare use.
Key Words: poststroke depression • use
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Introduction |
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In the past few decades, a large number of studies have been published examining the prevalence of poststroke depression (PSD) and the impact of PSD on health outcomes. Despite methodological differences in study cohorts, depression detection, and sites of study focus, cumulative evidence shows that 25% to 40% of stroke patients have PSD1–6 and that PSD can negatively impact stroke patients’ postevent functional recovery, morbidity, mortality, and quality of life.7–9 The data suggest that patients with stroke with PSD may be at higher risk for healthcare use poststroke than those without PSD.
Several studies have examined the association between depressive symptoms and healthcare use with common findings that depression results in increased health service use,10–18 and depression significantly increased the risk of rehospitalization 6 months postindex hospitalization (adjusted hazard ratio=1.50, P=0.03) by elderly medical inpatients.13
Although providing important linkage between depression and health service use, none of these studies focused on PSD among patients with stroke. Our understanding about the impact of PSD on inpatient and outpatient use of medical services by patients with stroke is limited. In a recent study evaluating the relationship between PSD and healthcare use 3 years after stroke, Ghose et al identified a national cohort of 51 119 veterans with ischemic stroke in the Veterans Health Administration’s (VHA) inpatient database between October 1, 1990, and September 30, 1997.19 PSD, identified solely by inpatient diagnosis codes, was present in 5% of the stroke patient cohort within 3 years of their index stroke admission, and those with PSD had a significantly greater number of inpatient days and outpatient clinical stops poststroke compared with those patients with no PSD. However, the use of only inpatient depression diagnoses for identifying PSD cases in this cohort likely underestimated the magnitude and impact of PSD on healthcare use.
The Department of Veterans Affairs (VA), through the VHA, operates the largest integrated healthcare delivery system in the United States. In fiscal year 2005, the number of VHA enrollees totaled 7.7 million and 5.3 million veterans received treatment within the system.20 However, the VHA is not the only source of care for its enrollees who receive care from both VHA and non-VHA providers. This is particularly true for the enrollees who are eligible for multiple healthcare plans such as Medicare fee-for-service (FFS).21–24 In a recent study on the VHA and non-VHA healthcare use by veterans with acute stroke, we found that 67% of the inpatients in the state of Florida were VHA–Medicare FFS dual users within 12 months of their acute stroke hospitalization.25 These data suggest that incorporating healthcare use under the Medicare program by VHA enrollees with stroke might also provides a more comprehensive picture about the effect of PSD on healthcare use among the VHA patients with stroke. The objective of this study was to assess the impact of PSD on VHA and Medicare healthcare use during the first 12 months postindex stroke among veterans diagnosed with acute stroke.
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Materials and Methods |
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Data Sources
We extracted data needed for this study from 3 major sources. First, VHA data files abstracted from the VA Austin Automation Center (AAC) included the Patient Treatment File (PTF) main file and the Functional Status Outcomes Database (FSOD) for inpatient care information; the Event (SE) and Visit (SF) files for outpatient care data;26 and the Beneficiary Identification and Records Locator Subsystem (BIRLS) death file for patients’ mortality information in combination with the VHA and Medicare inpatients databases. Second, from the VHA Pharmacy Benefits Management Strategic Health Group, the Pharmacy Benefit Management (PBM) file was obtained for patient antidepressants dispensing information within the VHA system. Third, from the VA Information Resource Center (VIReC), veteran–Medicare merged data used for this study included: the Medicare Denominator file for Medicare beneficiary’s eligibility and sociodemographic information; the MedPAR file for Medicare inpatient care; the Medicare Part B’s Carrier file for noninstitutional care; and the Outpatient file for institutional outpatient care.
The VHA data are stored by federal fiscal year (FY), whereas the Medicare data are stored by calendar year (CY). To make these different timeframes compatible, we consistently used the FY system in this study. Because our study covered a period of 2 FYs (2001 for cohort identification and 2002 for 12-month postindex stroke follow up), 3 CYs (CY 1999 to 2002) of patient data from the Medicare databases were extracted for compatibility with the 2 FY data from VHA. Furthermore, to ensure that a patient identified in the VHA databases was the same person in the Medicare databases, we conducted a dual-system matching algorithm using a modified matching criteria developed by Fleming and Fisher.27 Full details about the matching criteria are reported elsewhere25 and our initial matching yielded 99%.
Sample Selection
For this study, we identified a national cohort of 5825 VHA patients with stroke. These patients (1) had received an inpatient care for acute stroke within the VHA between October 1, 2000, and September 30, 2001 (FY 2001); (2) survived at least 60 days postindex admission; (3) had an index stay less than 365 days; and (4) were confirmed VHA healthcare enrollees.
There is a lack of universal consensus about the classification of patients with stroke mostly because of the heterogeneity of the disease. Counting patients with stroke is highly dependent on the International Classification of Diseases, 9th Revision (ICD-9) codes used. Different ICD-9 codes may yield differing results. We modified Reker’s high-specificity ICD-9 stroke codes28 by including ICD-9 code 436.xx (acute, but ill-defined, cerebrovascular diseases). In other words, patients were included if they had at least one inpatient stay with primary admission or discharge diagnoses that matched the modified high specificity ICD-9 codes for stroke during 2001. This strategy has a high predictive value for identifying acute stroke events.19,28,29 For patients with more than one admission for stroke, the first admission was considered the index event. Institutional Review Board at the University of Florida and Research and Development Subcommittee for Clinical Investigations at the VA Medical Center in Gainesville, Florida, both reviewed and approved this study.
We confirmed the patient’s VHA enrollment status by using the Means Test Indicator (Means Test) in the VHA PTF Main file. The Means Test indicates a patient’s eligibility to receive care within the VHA system. Patients were excluded if their Means Test was coded as either "N" or "NO" indicating they were "nonveterans" (n=59).
Sociodemographic Variables
The sociodemographic variables included: patient age, race/ethnicity, gender, marital status, priority for VHA medical care, and VHA–Medicare dually eligible status.
Patient self-reported racial/ethnic information was extracted from Medicare’s Denominator file if available; otherwise, the data were obtained from VHA inpatient or outpatient data files. Patient gender was obtained from the VHA inpatient or outpatient databases. Patient priority for VHA medical care was created based on the Means Test Indicator in the VHA PTF Main database. Patients’ priority for VHA health care was coded as high if their Means Test category indicated they were all compensable service-connected (0% to 100%) veterans and special category of veterans (AS) or nonservice-connected low-income veterans (AN). Patients’ priority was coded as low if their Means Test indicated they were subject to a copayment for care rendered based on income and/or net worth (C).26
Clinical and Disease Severity Variables
The variables used for risk and disease severity adjustment in our final analyses included stroke types, medical comorbid conditions, intensive care unit use, mechanical ventilation or intubation use, atrial fibrillation, dysphasia, malnutrition, and admission type during index hospitalization as well as recurrent stroke event within the first 12 months postindex hospitalization discharge date. These clinical measurements have been used previously as severity proxies in stroke-related outcome studies.30–33 A modified Charlson comorbidity index was used to assess the patients’ medical comorbid conditions at the index with the higher the weighted summary score, the more severe the burden of comorbidity.34
Dependent Variables
The 3 dependent measures were: (1) number of hospitalization stays, (2) number of outpatient visits, and (3) number of cumulative inpatients days or length of stays incurred within the first 12 months postindex stroke admission under both the VHA and Medicare FFS programs.
Independent Variables or Poststroke Depression Algorithm
Patients’ PSD status was established if (1) their primary or secondary, VHA or Medicare FFS, inpatient or outpatient diagnosis matched one of the ICD-9 codes for depression; or (2) if they were dispensed one of the antidepressants on the VHA formulary system with the guideline-recommended minimum daily dosage within 12 months postindex stroke. Patient-level diagnosis and medication dispensing were obtained from 2001 to 2002 VHA and Medicare inpatient and outpatient as well as VHA pharmacy databases.
We used ICD-9 codes previously reported in related studies of depression among VHA enrollees, including 296.2x (single episode or unspecified major depressive disorders), 296.3x (recurrent major depressive disorders), 311.xx (depressive disorder, not elsewhere classified), 300.4 (reactive depression), 309.0 (depressive reaction acute), and 309.1 (depressive reaction prolonged).19,35,36 We also included the codes 331.9 (cerebral depression) and 437.8 (cerebrovascular depression) because we hypothesized that these may be specifically used to indicate depression related to brain injury, although these codes are not typically used in administrative studies of nonstroke-related depression. Table 1 shows the antidepressants and guideline-recommended minimum daily dosage that we used to determine patient PSD status.
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In a separate study to validate this algorithm for PSD, we identified 185 veterans with acute stroke from our national sample. We found that the most sensitive case-finding algorithm for PSD included having an ICD-9 depression code or receiving a prescription for an approved dosage of antidepressant medication. This algorithm displayed 62% sensitivity, 89% specificity, and a positive predictive value of 85%.
Statistical Analysis
All data were analyzed using SAS version 8.1 (SAS Institute). First, descriptive statistics were obtained on the sociodemographic, clinical and disease severity, and use variables. Statistical inference (
2 test on discrete variables and t test on continuous variables) was performed to compare these variables between the patients with PSD and those patients without PSD. Second, collinearity diagnostics (conditional indices and variance proportion) were calculated to measure degrading or harmful multicollinearity among all independent and controlling variables. Consequently, we chose to remove the gender variable from our final models for multicollinearity consideration. Third, Poisson regression models were used to estimate the impact of PSD on the use variables controlling for the sociodemographic, clinical, and disease severity factors discussed previously. Given the sample size of >5000, we used a Bonferroni correction (dividing the 0.05 significance level by the number of covariates), resulting in a significance level of 0.0029 for inpatient stays and outpatient visits and 0.0031 for length of stay.
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Results |
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Forty-one percent of the study sample (N=5825) had PSD by our PSD algorithm. Of the 2399 patients with PSD, 63% had an ICD-9 depression diagnosis and 37% did not have a depression diagnosis but received one of the antidepressants with the guideline-recommended minimum daily dosage within the VHA system. Table 2 shows the characteristics of the study sample and the results of comparing demographic, clinical, and use characteristics between the patients with PSD and patients without PSD. Demographically, the patients with PSD were significantly more likely to be younger, white, high priority for VHA health care, and dually eligible for VHA and Medicare FFS programs. Clinically, the patients with PSD were significantly (P<0.05) more likely to have more comorbid conditions, to receive acute care, to be diagnosed with dysphasia during index hospitalization, and to have recurrent stroke within 12 months postindex. Compared with the patients without PSD, the patients with PSD consistently had more average number of inpatient stays (2.4 versus 1.8, P<0.0001), outpatient visits (30.7 versus 20.0, P<0.0001), and longer length of inpatient stays (25.0 versus 17.9, P<0.0001) within both VHA and Medicare FFS programs within the first 12 months postindex stroke.
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Table 3 shows the results from our Poisson regression analyses: the coefficients were unstandardized and the significance level after Bonferroni correction was reported for each model. After adjusting for the patients’ demographic and clinical factors, patients with PSD consumed significantly more inpatient and outpatient care and had longer lengths of stay 12 months postindex stroke compared with the patients with no PSD. More specifically, we estimated that patients with PSD had inpatient stays 1.2 times, outpatient visits 1.3 times, and length of stays 1.4 times that of the patients without PSD, respectively, within the first 12 months of the index stroke. To test the sensitivity of our analyses, we ran and reran each model separately with and without those who died within 60 days of stroke. For each response variable (inpatient stays, outpatient visits, and length of stay), the overall conclusions were the same. The sizes of the independent variables’ coefficients were about the same in all instances.
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Discussion |
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This study contributes to current literature in providing a comprehensive understanding of PSD and its relationship to increased health service use among VHA patients with stroke. For the first time, we merged the VHA medical data with Medicare FFS claim data and VHA pharmacy data and used a validated algorithm to identify PSD cases. These approaches allowed us to capture and incorporate the PSDs that were detected outside the VHA system, whereas previous studies consistently used VHA medical data only. We found that (1) 6% of the study sample had a PSD diagnosis under the Medicare program, (2) 15% received an antidepressant dispensing from the VHA system or had their PSD diagnoses beyond VHA and Medicare programs, and (3) 20% had their PSD detected within the VHA system. In other words, if we were to use the VHA medical data alone as previous studies consistently used, the rate of the PSD diagnosis would be only 20%. Similarly, using only Medicare data would likewise result in a significant undercounting of PSD cases. As a result, we found that rate of PSD was higher among this study sample than the previous study reports (41% versus 25% to 40%). Our findings suggest that using VHA medical data for PSD alone may underestimate the PSD among the VHA patients with stroke.
Second, our results consistently showed that patients with PSD had significantly more inpatient stays, outpatient visits, and longer length of stays within the 12 months of their acute stroke hospitalization even after controlling for the patients’ sociodemographic and clinical factors. These results showing the impact of PSD on healthcare use are consistent with previous research findings that showed VHA patients with stroke with PSD had a significantly greater number of inpatient days and outpatient visits poststroke compared with those patients with no PSD.19 Different from prior studies, however, we used merged data of both VHA and Medicare and a PSD algorithm that provided a more complete understanding of the patients’ PSD status and poststroke use. This impact on healthcare use was apparent although we controlled for other important demographic variables, chronic health conditions, and disease severity indicators.
The limitations of this study are mostly associated with medical administrative data being used. Generally, medical administrative data are created primarily for overseeing a healthcare system rather than for research purposes, and these data often do not provide variables on patient severity, functional status, and patient condition at admission.37,38 As a result, researchers rely on diagnostic coding (eg, ICD-9 CM or CPT) to identify patient cohorts and for risk adjustments. Coding is often problematic in administrative data. For example, for patients with multiple medical conditions, the code that is entered as the primary reason for admission may be incorrectly attributed. Generalizability of our findings is limited by our study’s focus only on the VHA enrollees with acute stroke. As a result of the unique characteristics of the VHA patients (eg, more male, older, and patients with more comorbidity conditions), our findings may not be applicable to the general population. Furthermore, we were unable to adjust our analyses for patients’ depression before stroke because the prestroke data were not available for this study.
Summary
Despite this limitation, our findings indicate that VHA patients with stroke with PSD had more inpatient stays, outpatient visits, and longer length of stay compared with the patients with no PSD. These results suggest that early detection and successful intervention of PSD for the veterans with acute stroke may help reduce patients’ poststroke healthcare use, reduce overall cost of care, prevent premature deaths, and improve functional recover and quality of life.39,40
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Acknowledgments |
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Sources of Funding
This material is based on a project funded by the VA HSR&D (STR 03-168), and the research was supported by VA Rehabilitation Outcomes Research Center of Excellence in Gainesville, Florida, and the VA Center of Excellence on Implementing Evidence-based Practice in Indianapolis, Indiana.
Disclosures
The views and opinions expressed in this article reflect those of the authors and do not necessarily reflect those of the Department of Veterans Affairs.
Received July 27, 2006; accepted August 2, 2006.
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