Cummings Janet R, Allen Lindsay, Clennon Julie, Ji Xu, Druss Benjamin G
Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia.
Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia.
JAMA Psychiatry. 2017 May 1;74(5):476-484. doi: 10.1001/jamapsychiatry.2017.0303.
With the future of the Affordable Care Act and Medicaid program unclear, it is critical to examine the geographic availability of specialty mental health treatment resources that serve low-income populations across local communities.
To examine the geographic availability of community-based specialty mental health treatment resources and how these resources are distributed by community socioeconomic status.
DESIGN, SETTING, AND PARTICIPANTS: Measures of the availability of specialty mental health treatment resources were derived using national data for 31 836 zip code tabulation areas from 2013 to 2015. Analyses examined the association between community socioeconomic status (assessed by median household income quartiles) and resource availability using logistic regressions. Models controlled for zip code tabulation area-level demographic characteristics and state indicators.
Dichotomous indicators for whether a zip code tabulation area had any (1) outpatient mental health treatment facility (more than nine-tenths of which offer payment arrangements for low-income populations), (2) office-based practice of mental health specialist physician(s), (3) office-based practice of nonphysician mental health professionals (eg, therapists), and (4) mental health facility or office-based practice (ie, any community-based resource).
Of the 31 836 zip code tabulation areas in the study, more than four-tenths (3382 of 7959 [42.5%]) of communities in the highest income quartile (mean income, $81 207) had any community-based mental health treatment resource vs 23.1% of communities (1841 of 7959) in the lowest income quartile (mean income, $30 534) (adjusted odds ratio, 1.74; 95% CI, 1.50-2.03). When examining the distribution of mental health professionals, 25.3% of the communities (2014 of 7959) in the highest income quartile had a mental health specialist physician practice vs 8.0% (637 of 7959) of those in the lowest income quartile (adjusted odds ratio, 3.04; 95% CI, 2.53-3.66). Similarly, 35.1% of the communities (2792 of 7959) in the highest income quartile had a nonphysician mental health professional practice vs 12.9% (1029 of 7959) of those in the lowest income quartile (adjusted odds ratio, 2.77; 95%, 2.35-3.26). In contrast, outpatient mental health treatment facilities were less likely to be located in the communities in the highest vs lowest income quartiles (12.9% [1025 of 7959] vs 16.5% [1317 of 7959]; adjusted odds ratio, 0.43; 95% CI, 0.37-0.51). More than seven-tenths of the lowest income communities with any resource (71.5% [1317 of 1841]) had an outpatient mental health treatment facility.
Mental health treatment facilities are more likely to be located in poorer communities, whereas office-based practices of mental health professionals are more likely to be located in higher-income communities. These findings indicate that mental health treatment facilities constitute the backbone of the specialty mental health treatment infrastructure in low-income communities. Policies are needed to support and expand available resources for this critical infrastructure.
鉴于《平价医疗法案》和医疗补助计划的未来尚不明朗，审视为当地社区低收入人群提供服务的专科心理健康治疗资源的地理可及性至关重要。
研究基于社区的专科心理健康治疗资源的地理可及性，以及这些资源如何按社区社会经济地位分布。
设计、地点和参与者：利用2013年至2015年31836个邮政编码分区的全国数据得出专科心理健康治疗资源可及性的衡量指标。分析使用逻辑回归研究社区社会经济地位（按家庭收入中位数四分位数评估）与资源可及性之间的关联。模型控制了邮政编码分区层面的人口特征和州指标。
关于邮政编码分区是否拥有以下资源的二分指标：（1）门诊心理健康治疗机构（其中超过十分之九为低收入人群提供付费安排）；（2）心理健康专科医生的门诊执业；（3）非医生心理健康专业人员（如治疗师）的门诊执业；（4）心理健康机构或门诊执业（即任何基于社区的资源）。
在研究的31836个邮政编码分区中，收入最高四分位数社区（平均收入81207美元）中超过十分之四（7959个社区中的3382个[42.5%]）拥有任何基于社区的心理健康治疗资源，而收入最低四分位数社区（平均收入30534美元）中这一比例为23.1%（7959个社区中的1841个）（调整后的优势比为1.74；95%置信区间为1.50 - 2.03）。在审视心理健康专业人员的分布时，收入最高四分位数社区中有25.3%（7959个社区中的2014个）有心理健康专科医生执业，而收入最低四分位数社区中这一比例为8.0%（7959个社区中的637个）（调整后的优势比为3.04；95%置信区间为2.53 - 3.66）。同样，收入最高四分位数社区中有35.1%（7959个社区中的2792个）有非医生心理健康专业人员执业，而收入最低四分位数社区中这一比例为12.9%（7959个社区中的1029个）（调整后的优势比为2.77；95%置信区间为2.35 - 3.26）。相比之下，门诊心理健康治疗机构在收入最高四分位数社区中的分布可能性低于最低四分位数社区（12.9%[7959个社区中的1025个]对16.5%[7959个社区中的1317个]；调整后的优势比为0.43；95%置信区间为0.37 - 0.51）。在拥有任何资源的最低收入社区中，超过十分之七（71.5%[1841个社区中的1317个]）有门诊心理健康治疗机构。
心理健康治疗机构更有可能位于较贫困社区，而心理健康专业人员的门诊执业更有可能位于高收入社区。这些发现表明，心理健康治疗机构构成了低收入社区专科心理健康治疗基础设施的支柱。需要制定政策来支持和扩大这一关键基础设施的可用资源。
