Jacob Sacks, MD, Matthew Lezama, BS, George Harrison, MD, Christina Mangurian, MD, James W. Dilley, MD, Martha Shumway, PhD

University of California, San Francisco and San Francisco General Hospital

Research Questions

•Who accesses services at a community mental health clinic targeting the underserved among the LGBTQ and HIV communities?

•Are there differences in demographics, psychiatric diagnoses, or major medical diagnoses between typical-utilizers and high-utilizers of clinic services?

BackgroundWhile many authors have published on the topic of “high utilizers” of mental health services (1), there is a dearth of literature describing the phenomena in the LBGTQ or HIV-positive populations. The term “high utilizer” has been used to describe a subset of mental health consumers who consume a disproportionate share of mental health services and resources. Studies have found that between 5-18% of people consume 27-63% of the services provided (2-6). Attempts have been made to describe the demographic and clinical variables associated with high utilization in the general population.  In the general population, features like homelessness, psychotic disorders, bipolar disorder, and substance abuse diagnoses have been shown to correlate with high service utilization in large public mental health systems (7).  The LGBTQ community is underserved by our healthcare systems and underrepresented in our research. LGBTQ individuals have higher rates of mental health diagnoses and service utilization than heterosexuals (8-12) in addition to high incidence of substance use disorders (13, 14). HIV-positive individuals also have high prevalence of psychiatric diagnoses (15). Previous findings indicate that nonwhites and Hispanics in the HIV population may underutilize outpatient services (16). Accurate characterization of the subset of  LGBTQ and HIV-positive consumers who are “high utilizers” could have important implications for program development. Since high utilization may indicate unmet needs in this specific population, describing the patterns of use and characteristics of this group may help us to allocate healthcare resources more efficiently and effectively.

MethodsSubjects: Clients who used a high number of outpatient services (n=50) and clients who used a typical number of services (n=50) between March 1, 2011 and February 28, 2012.

Study Type: Retrospective Chart Review

Study Procedure:

•High and typical service users were determined by analyzing all billing data during the study period. Clients were split into quintiles based on the number of service minutes they utilized. 50 clients were randomly selected from the 3rd quintile (typical users) and 50 from the 5th quintile (high users).

•Using pre-existing intake assessments and progress notes, clients were characterized by their demographics, diagnoses, and social histories.

Data Analysis:

Logistic regression was used to examine relationships between client characteristics and being a high user of outpatient services.

Results: Demographics

Summary:

•High service utilizers were:

• Significantly older (51.9) on average than typical users (44.6).

• More likely to be gay or lesbian (90%) than typical users (74%).

• Predominately Caucasian (76%), and less likely than typical users to be African American or Latino.

• More likely to have a history of childhood abuse (non-sexual) or neglect (38%) compared to typical users (20%).

•There were no significant differences between groups with respect to gender, education, entitlement income, or housing stability.

Results: Psychiatric Diagnoses

Summary:

•The percentage of clients with schizophrenia or any psychotic disorder was identical (16%) between both groups.

•There was no significant difference in the percentage of mood disorder diagnoses.

•A greater percentage of high service utilizers were diagnosed with PTSD, but this difference was not statistically significant. However, high utilizers were more likely to have a non-PTSD anxiety disorder (42%) than typical users (22%).

•High utilizers were less likely to have a current substance use problem (38%) compared to typical users (60%).

•Conversely, high utilizers were more likely to have a past, but not current, substance use problem (ie: an axis I substance abuse diagnosis in full-sustained remission) (44%) than typical users (16%).

•There was no significant difference between the percentage of personality disorders in general, but high utilizers were more likely to have a specific diagnosis of borderline personality disorder (16%) than typical users (4%).

Results: Medical Diagnoses

Summary:

•High users were less likely to have a medical diagnosis of HIV (72%) compared to typical users (86%).

•Combining both groups shows that 79% of all clients sampled had an HIV diagnosis.

•The percentage of clients with a diagnosis of diabetes was identically low in both groups (2%).

•There was a statistically significant difference between the percentage of clients in with a lipid abnormality (ie: hyperlipidema, dyslipidemia, hypercholesterolemia). 12% of high users were diagnosed with lipid abnormalities, compared to only 2% of typical users.

DiscussionThe overall sample of individuals accessing services at Alliance Health Project suggests a population of mostly white, gay-identified males with some college education on SSI with stable housing, having high prevalence of depressive disorders, anxiety disorders, and substance use disorders. 79% are HIV positive.

It is difficult to say whether high-utilization as defined in our study represents “over-utilization” vs. increased access to care in this typically underserved population. Much of the published literature defines high-utilization in inpatient and emergency settings. It is possible that high utilization of outpatient clinic services would result in desirable decreases in the utilization of emergency and inpatient services. More research in this area would be useful.

In our study, identifying as gay or lesbian was associated with higher likelihood of being a high utilizer of services. This may be a result of the targeted mission and welcoming environment of our particular setting to this specific group. Alternately, this may be reflective of the higher rates of mental health diagnoses in lesbian and gay populations.

Latino and African American individuals were less likely to be high utilizers of clinic services. This could indicate that individuals with higher service needs are more likely to access services at agencies specifically targeted to their specific racial/ethnic group. The possibility of language barriers is also considered. White individuals were no more likely to be high utilizers.

Diagnosis of anxiety disorder other than PTSD was associated with higher service utilization, while diagnoses of psychotic and bipolar disorders were not. Given that psychotic and bipolar disorders are often associated with high utilization in the literature, this may represent a finding specific to our patient population or clinical setting. 

The substance use variables indicate that having a substance-related disorder diagnosed on axis I did not predict high service utilization. However, having a substance use disorder in remission was associated with higher service utilization while current problem substance abuse was not associated with high service utilization. This may reflect the difficulty that active substance users have complying with outpatient treatment in a clinic setting. It is also possible that those with substance use disorders in remission are utilizing more clinic services in order to support their abstinence.

Borderline personality disorder was associated with high service utilization whereas “any personality disorder” was not. This may indicate an opportunity for programming targeted to this specific group which may increase the efficiency of service allocation.

HIV diagnosis was associated with a lower likelihood of being a high utilizer of services. This may indicate that a higher level of engagement with primary care providers (which is typical of the HIV positive population in out clinic) may help address some of the mental health needs in this population. 

Of note, diagnoses were assigned by a variety of clinicians and not using a standardized instrument, which may lead to individual and cultural variability in reporting of certain diagnoses (e.g., underdiagnosing of personality or substance-use disorders due to stigma or access to other services).

Further efforts will include increasing the sample size to better examine the statistical significance of relationships between client characteristics and service utilization as well as further characterizing the specific types of services used (psychotherapy vs. group therapy vs. medication management vs. case management vs. substance abuse treatment) in relation to overall service utilization.

 

Odds RatioFull Sample High Users Typical Users

n=100 n=50 n=50

Schizophrenia / Psychotic Disorder 16% 16% 16% 1.0Bipolar Disorder 17% 16% 18% 0.9Depression / Dysthymia 56% 64% 48% 1.9Other Mood Disorder 10% 8% 12% 0.6PTSD 14% 18% 10% 2.0Other Anxiety Disorder 32% 42% 22% 2.6 Problem Substance Use--Current 49% 38% 60% 0.4 Problem Substance Use--Past(but not current)

30% 44% 16% 4.1

Any Personality Disorder 17% 18% 16% 1.2Borderline Personality Disorder 10% 16% 4% 4.6

Cognitive Disorder 9% 14% 4% 3.9Global Assessment of Functioning Score (GAF) 56.0 55.1 56.7 1.0

=p<.10 =p<.05 =p<.01

%s / Means

Psychiatric DiagnosesOdds Ratio

Full Sample High Users Typical Usersn=100 n=50 n=50

HIV 79% 72% 86% 0.4

Diabetes 2% 2% 2% 1.0Lipid Abnormality 7% 12% 2% 6.7

=p<.10 =p<.05 =p<.01

%s / Means

Medical DiagnosesOdds Ratio

Full Sample High Users Typical Usersn=100 n=50 n=50

Age (mean years) 48.2 51.9 44.6 1.1

GenderMale 89% 88% 90% -Female 11% 12% 10% 1.2

Transgender 4% 6% 2% 3.1

Gay / Lesbian 82% 90% 74% 3.2

Race / EthnicityAfrican American 12% 8% 16% 0.3

Latino 16% 10% 22% 0.3 Other/Mixed 9% 6% 12% 0.3White 63% 76% 50% -

EducationLess Than College 23% 14% 32% 0.4Some College 44% 52% 36% 1.44-Year College or More 33% 34% 32% -

Entitlement IncomeGeneral Assistance 9% 4% 14% 0.3SSI 62% 70% 54% 2.0

Has Stable Housing 82% 88% 76% 2.3

History of:Suicide Attempts 42% 44% 40% 1.2Childhood Sexual Abuse 20% 26% 14% 2.2Other Childhood Abuse / Neglect 29% 38% 20% 2.5 Adult Sexual Assault 4% 0% 4%Adult Domestic Violence 15% 14% 16% 0.9Other Adult Interpersonal Violence 5% 4% 6% 0.7

=p<.10 =p<.05 =p<.01

Demographic Characteristics%s / Means

NR7-72