Tomovic Milos, Balfour Margaret E, Cho Ted, Prathap Nishanth, Harootunian Gevork, Mehreen Raihana, Ostrovsky Andrey, Goldman Matthew L
School of Medicine, Georgetown University, Washington, D.C. (Tomovic); Connections Health Solutions and Department of Psychiatry, University of Arizona, Tucson (Balfour); Department of Pediatrics, University of California San Francisco, San Francisco (Cho); Center for Health Information and Research (CHIR), College of Health Solutions, Arizona State University, Tempe (Prathap, Harootunian); Social Innovation Ventures, Lewes, Delaware (Mehreen, Ostrovsky); Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle (Goldman).
Psychiatr Serv. 2024 Jul 1;75(7):614-621. doi: 10.1176/appi.ps.20230232. Epub 2024 Feb 27.
Crisis services are undergoing an unprecedented expansion in the United States, but research is lacking on crisis system design. This study describes how individuals flow through a well-established crisis system and examines factors associated with reutilization of such services.
This cross-sectional study used Medicaid claims to construct episodes describing the flow of individuals through mobile crisis, specialized crisis facility, emergency department, and inpatient services. Claims data were merged with electronic health record (EHR) data for the subset of individuals receiving care at a crisis response center. A generalized estimating equation was used to calculate adjusted odds ratios for demographic, clinical, and operational factors associated with reutilization of services within 30 days of an episode's end point.
Of 41,026 episodes, most (57.4%) began with mobile crisis services or a specialized crisis facility rather than the emergency department. Of the subset (N=9,202 episodes) with merged EHR data, most episodes (63.3%) were not followed by reutilization. Factors associated with increased odds of 30-day reutilization included Black race, homelessness, stimulant use, psychosis, and episodes beginning with mobile crisis services or ending with inpatient care. Decreased odds were associated with depression, trauma, and involuntary legal status. Most (59.3%) episodes beginning with an involuntary legal status ended with a voluntary status.
Crisis systems can serve a large proportion of individuals experiencing psychiatric emergencies and divert them from more restrictive and costly levels of care. Understanding demographic, clinical, and operational factors associated with 30-day reutilization may aid in the design and implementation of crisis systems.
危机服务在美国正经历前所未有的扩张，但缺乏关于危机系统设计的研究。本研究描述了个体如何在一个成熟的危机系统中流动，并考察与此类服务再次使用相关的因素。
这项横断面研究利用医疗补助索赔数据构建事件，描述个体在移动危机、专门危机设施、急诊科和住院服务中的流动情况。索赔数据与在危机应对中心接受治疗的个体子集中的电子健康记录（EHR）数据合并。使用广义估计方程计算与事件终点后30天内服务再次使用相关的人口统计学、临床和运营因素的调整比值比。
在41,026个事件中，大多数（57.4%）始于移动危机服务或专门危机设施，而非急诊科。在合并了EHR数据的子集中（N = 9,202个事件），大多数事件（63.3%）之后没有再次使用。与30天内再次使用几率增加相关的因素包括黑人种族、无家可归、使用兴奋剂、精神病，以及始于移动危机服务或结束于住院治疗的事件。几率降低与抑郁症、创伤和非自愿法律状态相关。大多数始于非自愿法律状态的事件（59.3%）以自愿状态结束。
危机系统可以为很大一部分经历精神科紧急情况的个体提供服务，并使他们避免接受限制更多、成本更高的护理级别。了解与30天内再次使用相关的人口统计学及临床和运营因素，可能有助于危机系统的设计和实施。
