Pediatric Pulmonology 49:1177–1181 (2014)
Depression, Illness Severity, and Healthcare Utilization in Cystic Fibrosis Carolyn Snell, PhD,* Serena Fernandes,
MD,
I. Simona Bujoreanu,
PhD,
and Georgina Garcia,
MD
Summary. Cystic fibrosis (CF) is an illness associated with high healthcare utilization and healthcare costs, even when compared to other chronic illnesses. In a variety of medical populations, depression has been found to be associated with lower adherence and poorer medical outcomes. The current study is a retrospective chart review of a matched set of 40 patients with CF, half with and half without a depressive disorder diagnosis. Participants were matched on the basis of their age, gender and lung function, and compared in terms of their illness severity (lung function and weight), medical adherence, and healthcare utilization during the year prior to and following diagnosis of depression and a comparable time period for the non-depressed group. Results show an association between depression and BMI, with only the depressed group showing significant decreases in the year following their depressive disorder diagnosis (from a mean BMI z-score of 0.48 to 1.04). Depression was also strongly associated with greater healthcare utilization and healthcare costs relative to those of comparably medically ill controls, in that depressed youth were hospitalized at over three times the rate of non-depressed youth, and their healthcare costs were more than four times higher (mean number of admissions per year for the depressed group of 4.00 vs. 1.20 for the non-depressed group; mean annual costs of $280,000 for the depressed vs. $60,116 for the non-depressed). These findings highlight the importance of addressing the mental health needs of chronically ill patients as a path to better health outcomes and decreasing need for medical services. Pediatr Pulmonol. 2014; 49:1177–1181. ß 2014 Wiley Periodicals, Inc. Key words: healthcare cost; depression; children; cystic fibrosis; adherence. Funding source: none reported.
INTRODUCTION
Cystic fibrosis (CF) is an illness associated with high healthcare utilization and healthcare costs, even when compared to other chronic illnesses such as diabetes1 with annual medical cost in 2009 over $48,000 per patient.1 This is likely due to a variety of factors, including chronicity of symptoms, extended life expectancy (with mean expectancy having risen to 37 years over the past decade), and availability of advanced new therapies (CF Registry; 2008–2012).2 Consequently, costs associated with CF care have also been rising dramatically over the years (59% increase between the years of 2001 and 2007).3 In this context, it appears important to identify factors associated with higher costs and more health service use, in order to determine whether there may be more clinically effective and/or cost-effective ways to provide quality care to individuals who have chronic higher service usage and healthcare costs. A link between depressive symptoms and poorer medical adherence and medical outcomes has been documented in a variety of chronically medically ill populations.4,5 Treatment adherence is a major challenge in CF even for youth without depression, with up to 50% of adolescents with CF reporting doing less than half of their prescribed therapies ß 2014 Wiley Periodicals, Inc.
and 30% doing none.6 The presence of depressive symptoms in children and adolescents has been shown to be associated with lower adherence to airway clearance regimens.7 This is in line with the adult population with CF, where the presence of depression negatively affects lung respiratory function, quality of life, and therapeutic regimen adherence7–10 and in turn leads to increased need for inpatient and outpatient medical care.10
Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, Massachusetts 02115. Conflict of interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Correspondence to: Carolyn Snell, PhD, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115. E-mail: [email protected] Received 26 June 2013; Accepted 5 January 2014. DOI 10.1002/ppul.22990 Published online 12 March 2014 in Wiley Online Library (wileyonlinelibrary.com).
1178
Snell et al.
To date there have been no studies of the relationships between depression, overall treatment adherence, medical outcomes, and healthcare utilization in youth with CF. The current study examined the potential relationships between these factors, with the goals of identifying the impact of mental health issues on health outcomes and healthcare costs in CF. We hypothesized that youth with CF who had depression would have poorer medical outcomes, lower adherence, and greater healthcare utilization than comparably medically ill youth with CF but with no depression.
MATERIALS AND METHODS Participants
This study is a retrospective chart review of 40 adolescents with CF ages 12–21 who received medical treatment at a large tertiary children’s hospital with an embedded CF center between 2009 and 2011. The patients included a cohort of 20 depressed patients with CF and a matched cohort of 20 non-depressed patients. Depressed patients were identified by the Psychiatry Consultation Service and were matched on age, gender, and healthcare variables with patients from the same center identified using the Cystic Fibrosis Foundation Patient Registry.2 The CF Registry is a nationwide database of health outcomes and healthcare utilization for patients with CF that includes clinical data such as lab values, respiratory cultures, genetic testing, medication use, comorbid medical diagnoses, and pulmonary function test results from each CF-related clinic visit and hospital stay for patients, organized by center. Study inclusion criteria for both groups included an identified relationship with the CF center/hospital as defined by at least two pulmonary clinic visits within the 12-month period prior to the index clinic visit or hospitalization. A hospitalization was considered “index” if it was the first contact with the Psychiatry Consultation Service during which participants received one or more of the following diagnoses for a current depressive episode: Major Depressive Disorder, Depressive Disorder NOS, Adjustment Disorder with Depressed Mood, or Dysthymic Disorder. Other than the evaluation and treatment provided by the Psychiatry Consultation Service, no systematic data was available on the mental health treatment of individuals in the depressed group. Exclusion criteria for participants in the non-depressed group identified via the CF Registry were the presence of depression diagnoses or concerns as determined via center coordinator medical record review. The “index” clinic visit for the non-depressed group was identified as a visit when the participants’ demographic characteristics and average FEV1 over the past 12 months matched the depressed participants’ at their index hospitalization. This Pediatric Pulmonology
12-month time frame was chosen given that the CF Registry reports health and healthcare utilization data annually for 12-month periods and because the dates of depression onset for individuals in the depressed group were unknown. Procedure
Hospital IRB approval was obtained to review retrospectively charts of patients seen by the PCS, and to pull concurrent data from the CF Registry, for which a separate IRB was already in existence. Matching of study participants occurred according to the following criteria: (1) age in years at the time of the psychiatric consultation, (2) sex, and (3) range of severity of lung disease measured as the average FEV1 obtained at pulmonary clinic visits during the 12 months prior to index hospitalization or pulmonary clinic visit. The method of classifying lung function for patients with CF into three severity ranges was used previously in research11 and is a well established and accepted method for determining levels of lung disease severity: 70–100% predicted represents mild disease; 40–69% is seen as moderate lung disease, and
Depression, Illness Severity, and Healthcare Utilization in Cystic Fibrosis Carolyn Snell, PhD,* Serena Fernandes,
MD,
I. Simona Bujoreanu,
PhD,
and Georgina Garcia,
MD
Summary. Cystic fibrosis (CF) is an illness associated with high healthcare utilization and healthcare costs, even when compared to other chronic illnesses. In a variety of medical populations, depression has been found to be associated with lower adherence and poorer medical outcomes. The current study is a retrospective chart review of a matched set of 40 patients with CF, half with and half without a depressive disorder diagnosis. Participants were matched on the basis of their age, gender and lung function, and compared in terms of their illness severity (lung function and weight), medical adherence, and healthcare utilization during the year prior to and following diagnosis of depression and a comparable time period for the non-depressed group. Results show an association between depression and BMI, with only the depressed group showing significant decreases in the year following their depressive disorder diagnosis (from a mean BMI z-score of 0.48 to 1.04). Depression was also strongly associated with greater healthcare utilization and healthcare costs relative to those of comparably medically ill controls, in that depressed youth were hospitalized at over three times the rate of non-depressed youth, and their healthcare costs were more than four times higher (mean number of admissions per year for the depressed group of 4.00 vs. 1.20 for the non-depressed group; mean annual costs of $280,000 for the depressed vs. $60,116 for the non-depressed). These findings highlight the importance of addressing the mental health needs of chronically ill patients as a path to better health outcomes and decreasing need for medical services. Pediatr Pulmonol. 2014; 49:1177–1181. ß 2014 Wiley Periodicals, Inc. Key words: healthcare cost; depression; children; cystic fibrosis; adherence. Funding source: none reported.
INTRODUCTION
Cystic fibrosis (CF) is an illness associated with high healthcare utilization and healthcare costs, even when compared to other chronic illnesses such as diabetes1 with annual medical cost in 2009 over $48,000 per patient.1 This is likely due to a variety of factors, including chronicity of symptoms, extended life expectancy (with mean expectancy having risen to 37 years over the past decade), and availability of advanced new therapies (CF Registry; 2008–2012).2 Consequently, costs associated with CF care have also been rising dramatically over the years (59% increase between the years of 2001 and 2007).3 In this context, it appears important to identify factors associated with higher costs and more health service use, in order to determine whether there may be more clinically effective and/or cost-effective ways to provide quality care to individuals who have chronic higher service usage and healthcare costs. A link between depressive symptoms and poorer medical adherence and medical outcomes has been documented in a variety of chronically medically ill populations.4,5 Treatment adherence is a major challenge in CF even for youth without depression, with up to 50% of adolescents with CF reporting doing less than half of their prescribed therapies ß 2014 Wiley Periodicals, Inc.
and 30% doing none.6 The presence of depressive symptoms in children and adolescents has been shown to be associated with lower adherence to airway clearance regimens.7 This is in line with the adult population with CF, where the presence of depression negatively affects lung respiratory function, quality of life, and therapeutic regimen adherence7–10 and in turn leads to increased need for inpatient and outpatient medical care.10
Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, Massachusetts 02115. Conflict of interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Correspondence to: Carolyn Snell, PhD, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115. E-mail: [email protected] Received 26 June 2013; Accepted 5 January 2014. DOI 10.1002/ppul.22990 Published online 12 March 2014 in Wiley Online Library (wileyonlinelibrary.com).
1178
Snell et al.
To date there have been no studies of the relationships between depression, overall treatment adherence, medical outcomes, and healthcare utilization in youth with CF. The current study examined the potential relationships between these factors, with the goals of identifying the impact of mental health issues on health outcomes and healthcare costs in CF. We hypothesized that youth with CF who had depression would have poorer medical outcomes, lower adherence, and greater healthcare utilization than comparably medically ill youth with CF but with no depression.
MATERIALS AND METHODS Participants
This study is a retrospective chart review of 40 adolescents with CF ages 12–21 who received medical treatment at a large tertiary children’s hospital with an embedded CF center between 2009 and 2011. The patients included a cohort of 20 depressed patients with CF and a matched cohort of 20 non-depressed patients. Depressed patients were identified by the Psychiatry Consultation Service and were matched on age, gender, and healthcare variables with patients from the same center identified using the Cystic Fibrosis Foundation Patient Registry.2 The CF Registry is a nationwide database of health outcomes and healthcare utilization for patients with CF that includes clinical data such as lab values, respiratory cultures, genetic testing, medication use, comorbid medical diagnoses, and pulmonary function test results from each CF-related clinic visit and hospital stay for patients, organized by center. Study inclusion criteria for both groups included an identified relationship with the CF center/hospital as defined by at least two pulmonary clinic visits within the 12-month period prior to the index clinic visit or hospitalization. A hospitalization was considered “index” if it was the first contact with the Psychiatry Consultation Service during which participants received one or more of the following diagnoses for a current depressive episode: Major Depressive Disorder, Depressive Disorder NOS, Adjustment Disorder with Depressed Mood, or Dysthymic Disorder. Other than the evaluation and treatment provided by the Psychiatry Consultation Service, no systematic data was available on the mental health treatment of individuals in the depressed group. Exclusion criteria for participants in the non-depressed group identified via the CF Registry were the presence of depression diagnoses or concerns as determined via center coordinator medical record review. The “index” clinic visit for the non-depressed group was identified as a visit when the participants’ demographic characteristics and average FEV1 over the past 12 months matched the depressed participants’ at their index hospitalization. This Pediatric Pulmonology
12-month time frame was chosen given that the CF Registry reports health and healthcare utilization data annually for 12-month periods and because the dates of depression onset for individuals in the depressed group were unknown. Procedure
Hospital IRB approval was obtained to review retrospectively charts of patients seen by the PCS, and to pull concurrent data from the CF Registry, for which a separate IRB was already in existence. Matching of study participants occurred according to the following criteria: (1) age in years at the time of the psychiatric consultation, (2) sex, and (3) range of severity of lung disease measured as the average FEV1 obtained at pulmonary clinic visits during the 12 months prior to index hospitalization or pulmonary clinic visit. The method of classifying lung function for patients with CF into three severity ranges was used previously in research11 and is a well established and accepted method for determining levels of lung disease severity: 70–100% predicted represents mild disease; 40–69% is seen as moderate lung disease, and
