Explaining Trends in Use of VA Inpatient Psychiatric Services James Alan Neff and Stephanie L. McFall We examined the expansion of Veterans Administration (now Department of Veterans Affairs - VA) inpatient psychiatric services from 1963 to 1984. Aggregate national trends in VA inpatient episodes between 1963 and 1984 document not only increased use of inpatient services but also "decentralization," or a shift to providing psychiatric services in general VA medical centers. The national trends show a dramatic increase in admissions to psychiatric bed sections over the period 1963-1978, with admissions staying at this high levelfrom 1976-1981 and dropping only slightly in the 1980s. Admission trends were disaggregated intofirst admissions and readmissions to psychiatric and general hospitals in a single VA medical district for the period 1972-1981. First admissions declined over the study periodfor both hospital types; readmissions increased initially, but declined somewhat at the end of the period. The admission trends and patterns in source of first admissions suggest that the growth of VA services reflects psychiatric "decentralization, "as well as deinstitutionalization within VA.
Perhaps the major issue in the literature on mental health service delivery over the past few decades has been the phenomenon of deinstitutionalization (Bachrach 1983) and the apparent shift in "locus of psychiatric care" from inpatient to outpatient settings. In the course of the debate over deinstitutionalization, arguments have shifted from This manuscript was prepared while the authors were associated with the HSR&D Field Program, VA Medical Center, Durham, North Carolina. Opinions expressed are the authors' own and do not necessarily reflect those of the Department of Veterans Affairs. Address correspondence and reprint requests to James Alan Neff, Ph.D., Associate Professor, Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX 78284. Stephanie L. McFall, Ph.D. is Research Assistant Professor, Survey Research Laboratory, University of Illinois at Chicago Circle.
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rhetoric to careful, critical analyses of trends in psychiatric service use (Goldman 1983; Goldman, Adams, and Taube 1983; Thompson, Bass, and Witkin 1982). Critical analysis of trends in utilization of Department of Veterans Affairs (VA) inpatient psychiatric services is important in the face of concern over the appropriate levels of resource allocation to health services for veterans. The expansion of psychiatric services in VA [known as the Veterans Administration (the VA) at the time of this research] is clear in National Institute of Mental Health (NIMH) inventory data on patient care episodes: inpatient episodes in the VA increased by 143 percent between 1955 and 1975 in contrast to a 37 percent decrease in inpatient episodes in state and county mental hospitals (Witkin 1980). The latter decrease largely reflects the discharge of patients from inpatient care to outpatient care throughout the United States. The coincident increase in VA inpatient service use during this same period is striking. The explanation of such growth in use of VA services is of general importance as the Department of Veterans Affairs (VA) represents the largest health care delivery system in the United States (National Academy of Sciences 1977; Lasker 1981). More specifically, examination of processes ongoing in VA is important given suggestions that increases in VA inpatient service use may, in part, reflect the absorption of veterans discharged from state and county facilities during deinstitutionalization of those systems (Goldman 1983; Goldman, Adams, and Taube 1983).
METHODS Our methodological approach is to examine national VA system data first, to provide a context for further, more geographically limited analyses of trends in VA psychiatric first admissions and readmissions. We examine two data sources: (1) aggregate statistics for the system, reported annually, including the numbers of hospitals providing care, both general and psychiatric and the number of discharges with a mental disorder as primary diagnosis; and (2) additional information on first admissions and readmissions for patients discharged from general and psychiatric hospitals in VA Medical District 8, which is approximately coterminous with North Carolina. This information was available on computer beginning in 1971.
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AGGREGATE NATIONAL TRENDS: DECENTRALIZATION AND DEINSTITUTIONALIZATION
At least two organizational processes may bear upon the growth of VA inpatient services. First, VA annual reports document a long history of deinstitutionalization efforts within the VA system through the provision of community-based and outpatient services for the care and treatment of the mentally ill. Community residential placements date to 1954; day care and "trial visit" programs were initially reported in 1959, and halfway houses were first described in 1961. Outpatient mental health clinics have grown dramatically, as well (Manderscheidt and Witkin 1983), reflecting both deinstitutionalization efforts and the expansion of VA ambulatory care services in 1973 under Public Law 93-82. Change in this direction was summarized that year in the VA's Annual Report (1973): The VA has increased its emphasis on rapid intensive treatment and short hospital stay, with continuing treatment, or as necessary, on an outpatient basis. In an effort to cut down on the distressing incidence of "patienthood" and dependency on the hospital, the VA has vastly increased its commitment to various kinds of outpatient facilities. (p. 20)
Whether or not such statements document the existence of an official policy of deinstitutionalization, the language used is consistent with the type of rhetoric used to launch deinstitutionalization of mental health services in other settings. A second process, not as widely recognized, is the decentralization of VA psychiatric services from specialized neuropsychiatric hospitals to psychiatric bed sections in VA general hospitals. The period 1963-1978 saw a decrease in average daily census of VA psychiatric hospitals from 54,006 to 15,097. Half of 42 neuropsychiatric facilities in the VA system were redesignated as general medical centers in the same time frame, most intensively in the early 1970s. In a parallel trend, the number of psychiatric bed sections in general VA hospitals increased from 72 to 105, only partly due to the redesignation of facilities. Shifts toward psychiatric treatment in general medical centers were thought to enhance access to psychiatric services, while encouraging improvements in the quality of medical services provided in former psychiatric facilities. Some evidence supporting the importance of deinstitutionalization and decentralization of VA psychiatric services is found in aggregate statistics on VA inpatient service utilization, which were published annually in the Report of the Administrator. Figure 1 presents statistics on admissions to psychiatric bed sections in both psychiatric and general hospitals for the period 1963 to 1978, and for all VA medical centers to
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Figure 1: Psychiatric Admissions and Discharges, VA General and Psychiatric Hospitals, 1963-1984
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1984. While classification of patients on the basis of diagnostic category would yield a more accurate analysis, service use by bed section has been reported for a longer period. Also, the patterns of discharges of patients with psychiatric diagnoses mirrors that of admissions to psychiatric bed sections, although at a higher level. Dramatic increases in admissions to psychiatric bed sections are apparent overall (a 210 percent increase for the period 1963-1978 and a 194 percent increase over the entire period)-far more striking for general (449 percent) than for psychiatric (30 percent) hospitals. Ind'eed, admissions to psychiatric bed sections in psychiatric hospitals actually began to decline after 1970, perhaps reflecting realignment in the number of beds allocated to psychiatry services in designated psychiatric facilities. Overall, the number of beds dedicated to psychiatry services declined from 53,144 in 1963 to 23,684 in 1984. In relative terms, this represents a decline from 44 percent to 30 percent of VA system beds. These figures document decentralization starting in about 1970;
VA Inpatient Psychiatric Services
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the increase in admissions to psychiatric bed sections took place almost exclusively in general hospitals. Deinstitutionalization in the VA is documented by the combination of increased admissions/discharges and a declining patient census (Goldman 1983), and discharges exceeding admissions over many years. DISAGGREGATING ADMISSIONS/READMISSIONS FOR ONE MEDICAL DISTRICT
Trend data can be disaggregated into first and subsequent admissions to further clarify the nature of overall increases in psychiatric admissions. Individual patient discharge information was obtained and admission/readmission patterns for the period 1972-1981 were examined in a single VA medical district. The VA Patient Treatment File (PTF) contains information on patient characteristics, date of admission, bed section, diagnoses, surgical episodes, length of stay, and disposition for each episode of hospitalization. This information system is based on all discharge records from all VA medical centers since fiscal year 1970. The major change in this system over the 1972-1981 period that might affect interpretation of PTF trends was the update from the ICDA-8 to the ICD-9-CM diagnostic scheme in 1981. However, since the analyses did not feature fine diagnostic comparisons, and this change only affected one year of the analyses, this revision posed few problems. Due to the magnitude of the computations required for analysis of individual patient discharges, our analysis of the PTF data focused on a single VA medical district, encompassing most of North Carolina and small areas of Virginia, South Carolina, and Tennessee. Of a total of 314,770 records over a ten-year period (1972-1981), 103,153 were potentially classified as psychiatric admissions either on the basis of assignment to a psychiatric bed section or of a principal or associated psychiatric diagnosis (290-314 in the ICDA-8 classification; 290-319 in the ICD-9-CM classification). Psychiatric admissions for each year were sorted by social security number and merged to order all psychiatric episodes for each patient by year of admission. Classification of first and subsequent admissions was not without problems. Without information on hospitalizations prior to the study period, some misclassifications were inevitable, with the probability of classification error greatest in the first two years. We minimized this problem by also examining admissions for one year prior to the time period presented. First admissions were then necessarily defined as the patient's first verifiable admission for the period. Overall, 45 percent of
HSR: Health Services Research 25:1 (April 1990, Part II)
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the psychiatric episodes were classified as first admissions under this definition. We also differentiated the four general medical centers in Medical District 8 from the Salisbury VA Medical Center, traditionally a psychiatric hospital. Trends for admissions with primary diagnoses of mental disorder during the period 1972-1981 for psychiatric and general hospitals in Medical District 8 are presented in Figure 2. The verifiable first admissions show a fairly steady decline throughout the study period. The trend is similar in both the psychiatric hospital and the general hospitals, although the volume of admissions was consistently higher for the general hospitals. Readmissions for the period 1972-1981 showed curvilinear trends, with readmissions increasing throughout the 1970s but beginning to decline after 1980. Again, trends were similar for psychiatric and general hospitals, with a greater volume of readmissions in the
Figure 2: Trends in First Admissions and Readmissions to Psychiatric and General Hospitals, VA Medical District 8, 1972-1981 2500-
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four general hospitals. Medical District 8 reflects the general pattern shown in the aggregate figures of Figure 1: total psychiatric admissions increased over most of the period, with some leveling off or modest declines starting in the late 1970s. Trends in length of stay also document deinstitutionalization in the VA. In the psychiatric hospital, the median length of stay for first admissions, from 1972 to 1981, decreased from 39 to 18 days. The general hospitals showed little change in length of stay: the median length of stay fluctuated between 13 and 17 days over the period, with no evidence of a clear-cut trend. To provide a context for evaluating VA trends, it is instructive to consider the nature of changes in the state mental health delivery system during the period. While modest declines in the North Carolina state hospital population were reported from 1960 to 1967 (-9.8 percent), the rate of decline was much sharper between 1969 and 1976 (-49.7 percent) (North Carolina Division of Mental Health 1974; North Carolina Division of Mental Health, Mental Retardation, Substance Abuse Services 1981-1982). It is notable that the most intense period of state deinstitutionalization in Medical District 8 occurred during a period of increasing VA psychiatric service use, largely involving increases in readmissions. These statistics provide substantial evidence of deinstitutionalization in VA facilities in this district. While total admissions increased, this was largely a function of expanding readmissions, not of an influx of new patients into the system. Interestingly, there was a drop in both first admissions and readmissions in the late 1970s. This downturn was consistent with trends noted for VA and other facilities in early 1980s publications of the National Institute of Mental Health (Witkin 1980), although the reasons underlying such trends were unclear. TRENDS IN SOURCE OF FIRST ADMISSIONS
To further clarify the factors underlying first-admission trends, we examined trends by source of admissions. Sources included direct admissions; transfers from VA community nursing homes, domiciliary care facilities, other VA hospitals, and state and county mental hospitals; and admissions from outpatient care. For psychiatric hospitals, first psychiatric episodes were primarily direct admissions. The proportion of direct admissions fluctuated -from 89 percent in 1972 to a low of 82 percent in the mid-1970s and again up to 91 percent in 1981. There were few transfers from state and county mental hospitals. With the exception of 1976, when state and county mental hospitals contrib-
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uted 5.9 percent of first admissions to the VA psychiatric hospital, the proportion of patients from this source generally decreased over the period, and after 1978 accounted for less than 1 percent of first admissions. Also notable is the rise of admissions from outpatient care in the late 1970s. Before 1972, entrants from outpatient treatment accounted for less than 1 percent of first admissions. After the mid-1970s, the proportion of first-admission patients from VA outpatient clinics fluctuated between 4 and 6 percent. Trends for VA general hospitals differed somewhat. First, the percentage of all first admissions representing direct admissions declined across the time period from 82 percent to 74 percent. Second, transfers from state and county mental hospitals were negligible (less than 1 percent) throughout the study period. Finally, marked increases were found in admissions from outpatient treatment, beginning in 1975 (5 percent of admissions). This source of patients continued to grow in importance throughout the period, and in 1982 entrants from outpatient clinics made up 18 percent of first admissions.
DISCUSSION This article has sought to explain the increase in VA inpatient psychiatric service use. Our examination has emphasized the complexity of the VA psychiatric service delivery system and has documented VA implementation of both deinstitutionlalization and decentralization. Disaggregating admissions trends into first admissions and readmissions showed a general decline in first admissions and increased readmissions, consistent with the process of deinstitutionalization occurring within the VA psychiatric service delivery system. The increase in admissions from outpatient care shown in our PTF analyses is consistent with apparent VA deinstitutionalization and the growth of VA outpatient services. While these trends are suggestive, our analyses have only addressed inpatient service use. The lack of a uniform data base for outpatient services has precluded analyses tracking the flow of veterans between inpatient and outpatient treatment modalities in VA. Detailed analysis of systemwide trends within VA is problematic in the absence of an integrated data base for inpatient and outpatient services and given the inconsistent reporting of outpatient use in VA annual reports. A thorough analysis of the process of deinstitutionalization within VA should also examine trends in nursing home use. Nursing homes are increasingly a locus of care for the elderly and the mentally ill
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(Linn, Gurel, Williford, et al. 1985; National Academy of Sciences 1977; Redrick 1974). We expect increasing use of nursing homes with the aging of the veteran population. We made a partial assessment of such issues with 1972-1981 data from VA Medical District 8. Overall, we found increasing numbers of transfers of psychiatric patients to VA and community nursing homes beginning in 1976. The absolute number of such transfers was not large, however-fewer than 200 per year from five hospitals. This represents between 3 and 4 percent of discharges of patients with a principal psychiatric diagnosis. While there was no dramatic increase in transfers to nursing homes in this VA medical district, both the number of patients treated and the average daily census of VA nursing homes has increased nationally (Lasker 1981). We thus cannot rule out the possibility that increased use of VA nursing homes may result partly from deinstitutionalization of the elderly in VA psychiatric services. Although Goldman, Adams, and Taube (1983) have suggested the possibility that growth in the VA system may reflect an absorption of veterans deinstitutionalized from state and county facilities, our analyses provide no support for such a contention. Specifically, in our examination of VA admissions and readmissions trends in Medical District 8, a significant absorption effect would likely be manifest in a jump in first admissions in the early to mid-1970s, as deinstitutionalization got fully underway in North Carolina. No such increase occurred. The most notable increase in admissions was from VA outpatient sources. While it is acknowledged that the officially recorded source of admission may not be highly sensitive, few veterans appear to have been transferred from state to VA hospitals. Acknowledged limitations of our data prevent us from definitively ruling out the absorption hypothesis, although it seems unlikely in Medical District 8. However, processes ongoing in other segments of the mental health delivery system may affect VA trends as well, although we cannot evaluate these possibilities directly. Specifically, changes, such as a large increase in the provision of psychiatric care in general, short-term hospitals and a shift toward private ownership of psychiatric facilities, have occurred in the private sector (Schlesinger and Dorwart 1984). As Kiesler and Sibulkin (1982) report, admissions to private mental hospitals (both nonprofit and for-profit) from the mid-1960s to 1979 have roughly doubled, with growth concentrated in the for-profit hospitals. Although these trends in the private psychiatric market are interesting, it seems unlikely that there are any simple links between the deinstitutionalization of state and county facilities, the growth of VA inpatient services, and the growth of the private for-
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profit psychiatric hospital sector. As the Thompson, Bass, and Witkin (1982) analysis of the growth of outpatient psychiatric services over the past few decades suggests, it is likely that the growth of the private forprofit sector reflects increased demand for mental health services from new sources, rather than from changes in the public sector. Several research possibilities are raised by this study. First, our PTF analysis dealt with only a single, largely rural, VA medical district. As the nature and rate of deinstitutionalization of state facilities have been found to vary from state to state as a function of a variety of factors (Aviram, Syme, and Cohen 1976), our analyses might be extended to explore possible influences on deinstitutionalization in different medical districts. Such influences might include: urbanicity, the service mix of facilities, demographic characteristics of the local veteran population, facility size, medical school affiliations, or the availability of non-VA services. Second, data from state and local mental health agencies regarding veterans in various state inpatient, outpatient, and community programs may provide descriptive comparisons of the demographics, medical histories, and diagnostic characteristics of veterans receiving treatment from different providers. Such preliminary analyses may provide clues regarding the determinants of VA and non-VA psychiatric service use. Understanding the flow of individuals between service delivery systems has important practical implications. Given the magnitude of the veteran population, and the inevitable aging of this population (Horgan, Taylor, and Wilensky 1983; Ewalt and Lipkin 1982), it is important to examine the determinants of the use of VA versus non-VA delivery systems. While, historically, only a small segment of veterans have used the VA, potential changes in VA and non-VA systems may alter this picture in the future. Research on factors influencing the demand for VA services may point to the need for more formalized linkages between differing mental health delivery systems to enhance continuity of care for the veteran population. This article has documented the importance of the organizational processes of psyfhiatric decentralization and deinstitutionalization for explaining trends in use of VA inpatient psychiatric services. While our understanding of deinstitutionalization is handicapped by lack of a uniform and integrated data base on psychiatric services, a variety of data sources can be applied to such problems (Sibulkin and Kiesler 1982). Innovative use of data from state and local agencies, VA sources, and National Institute of Mental Health sources may help to address old issues and prompt new questions regarding psychiatric service utilization.
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ACKNOWLEDGMENTS Computer and secretarial resources provided by the Durham Field Program are gratefully acknowledged. We wish to acknowledge the comments of David Langmeyer, James W. Luckey, and Jean Brender. An earlier version of this article was presented at the Annual Meeting of the Southern Sociological Society, April 1984.
REFERENCES Annual Report of the Administrator. Washington, DC: Office of the Veterans Administration Administrator, 1973. Annual Report of the Administrator. Washington, DC: Office of the Veterans Administration Administrator, 1984. Aviram, U., S. L. Syme, and J. B. Cohen. "The Effects of Policies and Programs on Reduction of Mental Hospitalization." Social Science and Medicine 10 (November/December 1976):571-770. Bachrach, L. L. "An Overview of Deinstitutionalization." In New Directions for Mental Health Services: Deinstitutionalization, No. 17. Edited by L. L. Bachrach. San Francisco: Jossey-Bass, 1983. Ewalt, J. R., and J. 0. Lipkin. "The Future of Veterans Administration Hospital Programs for Psychiatric Patients." Hospital and Community Psychiatry 33 (September 1982):732-34. Goldman, H. H. "The Demography of Deinstitutionalization." In New Directions for Mental Health Services: Deinstitutionalization, No. 17. Edited by L. L. Bachrach. San Francisco: Jossey-Bass, 1983. Goldman, H. H., N. H. Adams, and C. A. Taube. "Deinstitutionalization: The Data Demythologized." Hospital and Community Psychiatry 34, no. 2 (February 1983):129-34. Horgan, C. A., A. Taylor, and G. Wilensky. "Aging Veterans: Will They Overwhelm the VA Medical Care System?" Health Affairs 2, no. 3 (Fall 1983): 77-86. Kiesler, C. A., and A. E. Sibulkin. "People, Clinical Episodes, and Mental Hospitalization." In Advances in Applied Social Psychology. Edited by R. F. Kidd and M. J. Saks. Hillsdale, NJ: Erlbaum Associates, 1982. Lasker, J. "Veterans' Medical Care: The Politics of an American Government Health Service." In Challenges and Innovations in U.S. Health Care. Edited by A. W. Imershein. Boulder, CO: Westview Press, 1981. Linn, M. W., L. Gurel, W. 0. Williford, J. Overall, B. Gurland, P. Laughlin, and A. Barchiesi. "Nursing Home Care as an Alternative to Psychiatric Hospitalization: A Veterans Administration Cooperative Study." Archives of General Psychiatry 42 (June 1985):544-51. Manderscheidt, R. W., and M. J. Witkin. "The Specialty Mental Health Services Delivery System - United States." In Mental Health, United States, 1983. Edited by C. A. Taube and S. A. Barrett. National Institute of Mental Health, DHHS Publication (ADM) 83-1275, Rockville, MD, 1983.
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National Academy of Sciences. Study of Health Carefor American Veterans. Washington, DC. 1977. North Carolina Division of Mental Health. 1974 Annual Report of Patient Movement, State Hospitals for the Mentally Ill. Report ARR-15. Raleigh: North Carolina Department of Human Resources, 1974. North Carolina Division of Mental Health, Mental Retardation, Substance Abuse Services. Annual Statistical Report, North Carolina State Psychiatric Hospitals, Fiscal Year 1981-1982. Raleigh: North Carolina Department of Human Resources, 1982. Redrick, R. W. Patterns in the Use of Nursing Homes by the Aged Mentally Ill. Statistical Note 107. Rockville, MD: National Institute of Mental Health, 1974. Schlesinger, M., and R. Dorwart. "Ownership and Mental Health Services." New EnglandJournal of Medicine 31 1, no. 15 (October 11, 1984):959-65. Sibulkin, A. E., and C. A. Kiesler. "Guide to National Data on Inpatient Care for Mental Disorders." (Abstract). JSAS Catalog of Selected Documents in Psychology, Vol. 12 (1982). Thompson, J. W., R. D. Bass, and M. J. Witkin. "Fifty Years of Psychiatric Services: 1940-1990." Hospital and Community Psychiatry 33, no. 9 (September 1982):711-16. Witkin, M. J. Changes in Numbers of Additions to Mental Health Facilities, by Modality, United States, 1971, 1975, and 1977. Mental Health Statistical Note 157, National Institute of Mental Health, Division of Biometry and Epidemiology, Survey and Reports Branch, Rockville, MD, September 1980.
Perhaps the major issue in the literature on mental health service delivery over the past few decades has been the phenomenon of deinstitutionalization (Bachrach 1983) and the apparent shift in "locus of psychiatric care" from inpatient to outpatient settings. In the course of the debate over deinstitutionalization, arguments have shifted from This manuscript was prepared while the authors were associated with the HSR&D Field Program, VA Medical Center, Durham, North Carolina. Opinions expressed are the authors' own and do not necessarily reflect those of the Department of Veterans Affairs. Address correspondence and reprint requests to James Alan Neff, Ph.D., Associate Professor, Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX 78284. Stephanie L. McFall, Ph.D. is Research Assistant Professor, Survey Research Laboratory, University of Illinois at Chicago Circle.
258
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rhetoric to careful, critical analyses of trends in psychiatric service use (Goldman 1983; Goldman, Adams, and Taube 1983; Thompson, Bass, and Witkin 1982). Critical analysis of trends in utilization of Department of Veterans Affairs (VA) inpatient psychiatric services is important in the face of concern over the appropriate levels of resource allocation to health services for veterans. The expansion of psychiatric services in VA [known as the Veterans Administration (the VA) at the time of this research] is clear in National Institute of Mental Health (NIMH) inventory data on patient care episodes: inpatient episodes in the VA increased by 143 percent between 1955 and 1975 in contrast to a 37 percent decrease in inpatient episodes in state and county mental hospitals (Witkin 1980). The latter decrease largely reflects the discharge of patients from inpatient care to outpatient care throughout the United States. The coincident increase in VA inpatient service use during this same period is striking. The explanation of such growth in use of VA services is of general importance as the Department of Veterans Affairs (VA) represents the largest health care delivery system in the United States (National Academy of Sciences 1977; Lasker 1981). More specifically, examination of processes ongoing in VA is important given suggestions that increases in VA inpatient service use may, in part, reflect the absorption of veterans discharged from state and county facilities during deinstitutionalization of those systems (Goldman 1983; Goldman, Adams, and Taube 1983).
METHODS Our methodological approach is to examine national VA system data first, to provide a context for further, more geographically limited analyses of trends in VA psychiatric first admissions and readmissions. We examine two data sources: (1) aggregate statistics for the system, reported annually, including the numbers of hospitals providing care, both general and psychiatric and the number of discharges with a mental disorder as primary diagnosis; and (2) additional information on first admissions and readmissions for patients discharged from general and psychiatric hospitals in VA Medical District 8, which is approximately coterminous with North Carolina. This information was available on computer beginning in 1971.
VA Inpatient Psychiatric Services
259
AGGREGATE NATIONAL TRENDS: DECENTRALIZATION AND DEINSTITUTIONALIZATION
At least two organizational processes may bear upon the growth of VA inpatient services. First, VA annual reports document a long history of deinstitutionalization efforts within the VA system through the provision of community-based and outpatient services for the care and treatment of the mentally ill. Community residential placements date to 1954; day care and "trial visit" programs were initially reported in 1959, and halfway houses were first described in 1961. Outpatient mental health clinics have grown dramatically, as well (Manderscheidt and Witkin 1983), reflecting both deinstitutionalization efforts and the expansion of VA ambulatory care services in 1973 under Public Law 93-82. Change in this direction was summarized that year in the VA's Annual Report (1973): The VA has increased its emphasis on rapid intensive treatment and short hospital stay, with continuing treatment, or as necessary, on an outpatient basis. In an effort to cut down on the distressing incidence of "patienthood" and dependency on the hospital, the VA has vastly increased its commitment to various kinds of outpatient facilities. (p. 20)
Whether or not such statements document the existence of an official policy of deinstitutionalization, the language used is consistent with the type of rhetoric used to launch deinstitutionalization of mental health services in other settings. A second process, not as widely recognized, is the decentralization of VA psychiatric services from specialized neuropsychiatric hospitals to psychiatric bed sections in VA general hospitals. The period 1963-1978 saw a decrease in average daily census of VA psychiatric hospitals from 54,006 to 15,097. Half of 42 neuropsychiatric facilities in the VA system were redesignated as general medical centers in the same time frame, most intensively in the early 1970s. In a parallel trend, the number of psychiatric bed sections in general VA hospitals increased from 72 to 105, only partly due to the redesignation of facilities. Shifts toward psychiatric treatment in general medical centers were thought to enhance access to psychiatric services, while encouraging improvements in the quality of medical services provided in former psychiatric facilities. Some evidence supporting the importance of deinstitutionalization and decentralization of VA psychiatric services is found in aggregate statistics on VA inpatient service utilization, which were published annually in the Report of the Administrator. Figure 1 presents statistics on admissions to psychiatric bed sections in both psychiatric and general hospitals for the period 1963 to 1978, and for all VA medical centers to
260
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Figure 1: Psychiatric Admissions and Discharges, VA General and Psychiatric Hospitals, 1963-1984
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1984. While classification of patients on the basis of diagnostic category would yield a more accurate analysis, service use by bed section has been reported for a longer period. Also, the patterns of discharges of patients with psychiatric diagnoses mirrors that of admissions to psychiatric bed sections, although at a higher level. Dramatic increases in admissions to psychiatric bed sections are apparent overall (a 210 percent increase for the period 1963-1978 and a 194 percent increase over the entire period)-far more striking for general (449 percent) than for psychiatric (30 percent) hospitals. Ind'eed, admissions to psychiatric bed sections in psychiatric hospitals actually began to decline after 1970, perhaps reflecting realignment in the number of beds allocated to psychiatry services in designated psychiatric facilities. Overall, the number of beds dedicated to psychiatry services declined from 53,144 in 1963 to 23,684 in 1984. In relative terms, this represents a decline from 44 percent to 30 percent of VA system beds. These figures document decentralization starting in about 1970;
VA Inpatient Psychiatric Services
261
the increase in admissions to psychiatric bed sections took place almost exclusively in general hospitals. Deinstitutionalization in the VA is documented by the combination of increased admissions/discharges and a declining patient census (Goldman 1983), and discharges exceeding admissions over many years. DISAGGREGATING ADMISSIONS/READMISSIONS FOR ONE MEDICAL DISTRICT
Trend data can be disaggregated into first and subsequent admissions to further clarify the nature of overall increases in psychiatric admissions. Individual patient discharge information was obtained and admission/readmission patterns for the period 1972-1981 were examined in a single VA medical district. The VA Patient Treatment File (PTF) contains information on patient characteristics, date of admission, bed section, diagnoses, surgical episodes, length of stay, and disposition for each episode of hospitalization. This information system is based on all discharge records from all VA medical centers since fiscal year 1970. The major change in this system over the 1972-1981 period that might affect interpretation of PTF trends was the update from the ICDA-8 to the ICD-9-CM diagnostic scheme in 1981. However, since the analyses did not feature fine diagnostic comparisons, and this change only affected one year of the analyses, this revision posed few problems. Due to the magnitude of the computations required for analysis of individual patient discharges, our analysis of the PTF data focused on a single VA medical district, encompassing most of North Carolina and small areas of Virginia, South Carolina, and Tennessee. Of a total of 314,770 records over a ten-year period (1972-1981), 103,153 were potentially classified as psychiatric admissions either on the basis of assignment to a psychiatric bed section or of a principal or associated psychiatric diagnosis (290-314 in the ICDA-8 classification; 290-319 in the ICD-9-CM classification). Psychiatric admissions for each year were sorted by social security number and merged to order all psychiatric episodes for each patient by year of admission. Classification of first and subsequent admissions was not without problems. Without information on hospitalizations prior to the study period, some misclassifications were inevitable, with the probability of classification error greatest in the first two years. We minimized this problem by also examining admissions for one year prior to the time period presented. First admissions were then necessarily defined as the patient's first verifiable admission for the period. Overall, 45 percent of
HSR: Health Services Research 25:1 (April 1990, Part II)
262
the psychiatric episodes were classified as first admissions under this definition. We also differentiated the four general medical centers in Medical District 8 from the Salisbury VA Medical Center, traditionally a psychiatric hospital. Trends for admissions with primary diagnoses of mental disorder during the period 1972-1981 for psychiatric and general hospitals in Medical District 8 are presented in Figure 2. The verifiable first admissions show a fairly steady decline throughout the study period. The trend is similar in both the psychiatric hospital and the general hospitals, although the volume of admissions was consistently higher for the general hospitals. Readmissions for the period 1972-1981 showed curvilinear trends, with readmissions increasing throughout the 1970s but beginning to decline after 1980. Again, trends were similar for psychiatric and general hospitals, with a greater volume of readmissions in the
Figure 2: Trends in First Admissions and Readmissions to Psychiatric and General Hospitals, VA Medical District 8, 1972-1981 2500-
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four general hospitals. Medical District 8 reflects the general pattern shown in the aggregate figures of Figure 1: total psychiatric admissions increased over most of the period, with some leveling off or modest declines starting in the late 1970s. Trends in length of stay also document deinstitutionalization in the VA. In the psychiatric hospital, the median length of stay for first admissions, from 1972 to 1981, decreased from 39 to 18 days. The general hospitals showed little change in length of stay: the median length of stay fluctuated between 13 and 17 days over the period, with no evidence of a clear-cut trend. To provide a context for evaluating VA trends, it is instructive to consider the nature of changes in the state mental health delivery system during the period. While modest declines in the North Carolina state hospital population were reported from 1960 to 1967 (-9.8 percent), the rate of decline was much sharper between 1969 and 1976 (-49.7 percent) (North Carolina Division of Mental Health 1974; North Carolina Division of Mental Health, Mental Retardation, Substance Abuse Services 1981-1982). It is notable that the most intense period of state deinstitutionalization in Medical District 8 occurred during a period of increasing VA psychiatric service use, largely involving increases in readmissions. These statistics provide substantial evidence of deinstitutionalization in VA facilities in this district. While total admissions increased, this was largely a function of expanding readmissions, not of an influx of new patients into the system. Interestingly, there was a drop in both first admissions and readmissions in the late 1970s. This downturn was consistent with trends noted for VA and other facilities in early 1980s publications of the National Institute of Mental Health (Witkin 1980), although the reasons underlying such trends were unclear. TRENDS IN SOURCE OF FIRST ADMISSIONS
To further clarify the factors underlying first-admission trends, we examined trends by source of admissions. Sources included direct admissions; transfers from VA community nursing homes, domiciliary care facilities, other VA hospitals, and state and county mental hospitals; and admissions from outpatient care. For psychiatric hospitals, first psychiatric episodes were primarily direct admissions. The proportion of direct admissions fluctuated -from 89 percent in 1972 to a low of 82 percent in the mid-1970s and again up to 91 percent in 1981. There were few transfers from state and county mental hospitals. With the exception of 1976, when state and county mental hospitals contrib-
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uted 5.9 percent of first admissions to the VA psychiatric hospital, the proportion of patients from this source generally decreased over the period, and after 1978 accounted for less than 1 percent of first admissions. Also notable is the rise of admissions from outpatient care in the late 1970s. Before 1972, entrants from outpatient treatment accounted for less than 1 percent of first admissions. After the mid-1970s, the proportion of first-admission patients from VA outpatient clinics fluctuated between 4 and 6 percent. Trends for VA general hospitals differed somewhat. First, the percentage of all first admissions representing direct admissions declined across the time period from 82 percent to 74 percent. Second, transfers from state and county mental hospitals were negligible (less than 1 percent) throughout the study period. Finally, marked increases were found in admissions from outpatient treatment, beginning in 1975 (5 percent of admissions). This source of patients continued to grow in importance throughout the period, and in 1982 entrants from outpatient clinics made up 18 percent of first admissions.
DISCUSSION This article has sought to explain the increase in VA inpatient psychiatric service use. Our examination has emphasized the complexity of the VA psychiatric service delivery system and has documented VA implementation of both deinstitutionlalization and decentralization. Disaggregating admissions trends into first admissions and readmissions showed a general decline in first admissions and increased readmissions, consistent with the process of deinstitutionalization occurring within the VA psychiatric service delivery system. The increase in admissions from outpatient care shown in our PTF analyses is consistent with apparent VA deinstitutionalization and the growth of VA outpatient services. While these trends are suggestive, our analyses have only addressed inpatient service use. The lack of a uniform data base for outpatient services has precluded analyses tracking the flow of veterans between inpatient and outpatient treatment modalities in VA. Detailed analysis of systemwide trends within VA is problematic in the absence of an integrated data base for inpatient and outpatient services and given the inconsistent reporting of outpatient use in VA annual reports. A thorough analysis of the process of deinstitutionalization within VA should also examine trends in nursing home use. Nursing homes are increasingly a locus of care for the elderly and the mentally ill
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(Linn, Gurel, Williford, et al. 1985; National Academy of Sciences 1977; Redrick 1974). We expect increasing use of nursing homes with the aging of the veteran population. We made a partial assessment of such issues with 1972-1981 data from VA Medical District 8. Overall, we found increasing numbers of transfers of psychiatric patients to VA and community nursing homes beginning in 1976. The absolute number of such transfers was not large, however-fewer than 200 per year from five hospitals. This represents between 3 and 4 percent of discharges of patients with a principal psychiatric diagnosis. While there was no dramatic increase in transfers to nursing homes in this VA medical district, both the number of patients treated and the average daily census of VA nursing homes has increased nationally (Lasker 1981). We thus cannot rule out the possibility that increased use of VA nursing homes may result partly from deinstitutionalization of the elderly in VA psychiatric services. Although Goldman, Adams, and Taube (1983) have suggested the possibility that growth in the VA system may reflect an absorption of veterans deinstitutionalized from state and county facilities, our analyses provide no support for such a contention. Specifically, in our examination of VA admissions and readmissions trends in Medical District 8, a significant absorption effect would likely be manifest in a jump in first admissions in the early to mid-1970s, as deinstitutionalization got fully underway in North Carolina. No such increase occurred. The most notable increase in admissions was from VA outpatient sources. While it is acknowledged that the officially recorded source of admission may not be highly sensitive, few veterans appear to have been transferred from state to VA hospitals. Acknowledged limitations of our data prevent us from definitively ruling out the absorption hypothesis, although it seems unlikely in Medical District 8. However, processes ongoing in other segments of the mental health delivery system may affect VA trends as well, although we cannot evaluate these possibilities directly. Specifically, changes, such as a large increase in the provision of psychiatric care in general, short-term hospitals and a shift toward private ownership of psychiatric facilities, have occurred in the private sector (Schlesinger and Dorwart 1984). As Kiesler and Sibulkin (1982) report, admissions to private mental hospitals (both nonprofit and for-profit) from the mid-1960s to 1979 have roughly doubled, with growth concentrated in the for-profit hospitals. Although these trends in the private psychiatric market are interesting, it seems unlikely that there are any simple links between the deinstitutionalization of state and county facilities, the growth of VA inpatient services, and the growth of the private for-
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profit psychiatric hospital sector. As the Thompson, Bass, and Witkin (1982) analysis of the growth of outpatient psychiatric services over the past few decades suggests, it is likely that the growth of the private forprofit sector reflects increased demand for mental health services from new sources, rather than from changes in the public sector. Several research possibilities are raised by this study. First, our PTF analysis dealt with only a single, largely rural, VA medical district. As the nature and rate of deinstitutionalization of state facilities have been found to vary from state to state as a function of a variety of factors (Aviram, Syme, and Cohen 1976), our analyses might be extended to explore possible influences on deinstitutionalization in different medical districts. Such influences might include: urbanicity, the service mix of facilities, demographic characteristics of the local veteran population, facility size, medical school affiliations, or the availability of non-VA services. Second, data from state and local mental health agencies regarding veterans in various state inpatient, outpatient, and community programs may provide descriptive comparisons of the demographics, medical histories, and diagnostic characteristics of veterans receiving treatment from different providers. Such preliminary analyses may provide clues regarding the determinants of VA and non-VA psychiatric service use. Understanding the flow of individuals between service delivery systems has important practical implications. Given the magnitude of the veteran population, and the inevitable aging of this population (Horgan, Taylor, and Wilensky 1983; Ewalt and Lipkin 1982), it is important to examine the determinants of the use of VA versus non-VA delivery systems. While, historically, only a small segment of veterans have used the VA, potential changes in VA and non-VA systems may alter this picture in the future. Research on factors influencing the demand for VA services may point to the need for more formalized linkages between differing mental health delivery systems to enhance continuity of care for the veteran population. This article has documented the importance of the organizational processes of psyfhiatric decentralization and deinstitutionalization for explaining trends in use of VA inpatient psychiatric services. While our understanding of deinstitutionalization is handicapped by lack of a uniform and integrated data base on psychiatric services, a variety of data sources can be applied to such problems (Sibulkin and Kiesler 1982). Innovative use of data from state and local agencies, VA sources, and National Institute of Mental Health sources may help to address old issues and prompt new questions regarding psychiatric service utilization.
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ACKNOWLEDGMENTS Computer and secretarial resources provided by the Durham Field Program are gratefully acknowledged. We wish to acknowledge the comments of David Langmeyer, James W. Luckey, and Jean Brender. An earlier version of this article was presented at the Annual Meeting of the Southern Sociological Society, April 1984.
REFERENCES Annual Report of the Administrator. Washington, DC: Office of the Veterans Administration Administrator, 1973. Annual Report of the Administrator. Washington, DC: Office of the Veterans Administration Administrator, 1984. Aviram, U., S. L. Syme, and J. B. Cohen. "The Effects of Policies and Programs on Reduction of Mental Hospitalization." Social Science and Medicine 10 (November/December 1976):571-770. Bachrach, L. L. "An Overview of Deinstitutionalization." In New Directions for Mental Health Services: Deinstitutionalization, No. 17. Edited by L. L. Bachrach. San Francisco: Jossey-Bass, 1983. Ewalt, J. R., and J. 0. Lipkin. "The Future of Veterans Administration Hospital Programs for Psychiatric Patients." Hospital and Community Psychiatry 33 (September 1982):732-34. Goldman, H. H. "The Demography of Deinstitutionalization." In New Directions for Mental Health Services: Deinstitutionalization, No. 17. Edited by L. L. Bachrach. San Francisco: Jossey-Bass, 1983. Goldman, H. H., N. H. Adams, and C. A. Taube. "Deinstitutionalization: The Data Demythologized." Hospital and Community Psychiatry 34, no. 2 (February 1983):129-34. Horgan, C. A., A. Taylor, and G. Wilensky. "Aging Veterans: Will They Overwhelm the VA Medical Care System?" Health Affairs 2, no. 3 (Fall 1983): 77-86. Kiesler, C. A., and A. E. Sibulkin. "People, Clinical Episodes, and Mental Hospitalization." In Advances in Applied Social Psychology. Edited by R. F. Kidd and M. J. Saks. Hillsdale, NJ: Erlbaum Associates, 1982. Lasker, J. "Veterans' Medical Care: The Politics of an American Government Health Service." In Challenges and Innovations in U.S. Health Care. Edited by A. W. Imershein. Boulder, CO: Westview Press, 1981. Linn, M. W., L. Gurel, W. 0. Williford, J. Overall, B. Gurland, P. Laughlin, and A. Barchiesi. "Nursing Home Care as an Alternative to Psychiatric Hospitalization: A Veterans Administration Cooperative Study." Archives of General Psychiatry 42 (June 1985):544-51. Manderscheidt, R. W., and M. J. Witkin. "The Specialty Mental Health Services Delivery System - United States." In Mental Health, United States, 1983. Edited by C. A. Taube and S. A. Barrett. National Institute of Mental Health, DHHS Publication (ADM) 83-1275, Rockville, MD, 1983.
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National Academy of Sciences. Study of Health Carefor American Veterans. Washington, DC. 1977. North Carolina Division of Mental Health. 1974 Annual Report of Patient Movement, State Hospitals for the Mentally Ill. Report ARR-15. Raleigh: North Carolina Department of Human Resources, 1974. North Carolina Division of Mental Health, Mental Retardation, Substance Abuse Services. Annual Statistical Report, North Carolina State Psychiatric Hospitals, Fiscal Year 1981-1982. Raleigh: North Carolina Department of Human Resources, 1982. Redrick, R. W. Patterns in the Use of Nursing Homes by the Aged Mentally Ill. Statistical Note 107. Rockville, MD: National Institute of Mental Health, 1974. Schlesinger, M., and R. Dorwart. "Ownership and Mental Health Services." New EnglandJournal of Medicine 31 1, no. 15 (October 11, 1984):959-65. Sibulkin, A. E., and C. A. Kiesler. "Guide to National Data on Inpatient Care for Mental Disorders." (Abstract). JSAS Catalog of Selected Documents in Psychology, Vol. 12 (1982). Thompson, J. W., R. D. Bass, and M. J. Witkin. "Fifty Years of Psychiatric Services: 1940-1990." Hospital and Community Psychiatry 33, no. 9 (September 1982):711-16. Witkin, M. J. Changes in Numbers of Additions to Mental Health Facilities, by Modality, United States, 1971, 1975, and 1977. Mental Health Statistical Note 157, National Institute of Mental Health, Division of Biometry and Epidemiology, Survey and Reports Branch, Rockville, MD, September 1980.
