Survival Models of Community Tenure and Length of Hospital Stay for the Seriously Mentally Ill: A 10-year Perspective

Objective: To examine the effects of personal and community characteristics, specifically race and rurality, on lengths of state psychiatric hospital and community stays using maximum likelihood survival analysis with a special emphasis on change over a ten year period of time. Data Sources: We used the administrative data of the Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS) from 1982- 1991 and the Area Resources File (ARF). Given these two sources, we constructed a history file for each individual who entered the state psychiatric system over the ten year period. Histories included demographic, treatment, and community characteristics. Study Design: We used a longitudinal, population-based design with maximum likelihood estimation of survival models. We presented a random effects model with unobserved heterogeneity that was independent of observed covariates. The key dependent variables were lengths of inpatient stay and subsequent length of community stay. Explanatory variables measured personal, diagnostic, and community characteristics, as well as controls for calendar time. Data Collection: This study used secondary, administrative and health planning data. Principal Findings: African-American clients leave the community more quickly than whites. After controlling for other characteristics, however, race does not affect hospital length of stay. Rurality does not affect length of community stays once other personal and community characteristics are controlled for. However, people from rural areas have longer hospital stays even after controlling for personal and community characteristics. The effects of time are significantly smaller than expected. Diagnostic composition effects and a decrease in the rate of first inpatient admissions explain part of this reduced impact of time. We also find strong evidence for the existence of unobserved heterogeneity in both types of stays and adjust for this in our final models. Conclusions: Our results show that information on client characteristics available from inpatient stay records is useful in predicting not only the length of inpatient stay but also the length of the subsequent community stay. This information can be used to target increased discharge planning for those at risk of more rapid readmission to inpatient care. Correlation across observed and unobserved factors affecting length of stay has significant effects on the measurement of relationships between individual factors and lengths of stay. Thus, it is important to control for both observed and unobserved factors in estimation.community tenure, length of psychiatric inpatient stay, survival analysis, state psychiatric hospital, maximum likelihood estimation

Diagnosis Measurement Error and Corrected Instrumental Variables

Health diagnosis indicators used as explanatory variables in econometric models often suffer from substantial measurement error. This measurement error can lead to seriously biased inferences about the effects of health conditions on the outcome measure of interest, and the bias generally spills over into inferences about the effects of policy/treatment variables. We generalize an existing instrumental variables (IV) method to make it compatible with the types of instruments typically available in large datasets containing health diagnoses. In particular, we relax the classical IV assumption that the instruments must have uncorrelated measurement errors. We identify and estimate the covariance matrix of the measurement errors and then use this information to derive a correction term to mitigate or eliminate the bias associated with classical IV. Our Monte Carlo simulations suggest that this corrected IV method can produce estimates far superior to those produced by OLS or classical IV.

The Lengths of Psychiatric Hospital Stays and Community Stays

We use advanced survival analysis methods to estimate the parameters affecting the joint distribution of exit dates from psychiatric hospitals and return dates to those hospitals. Data comes from Virginia state psychiatric hospital administrative records. We find that sex, marital status, employment status, diagnosis, and age help explain durations. We also find that there is significant duration dependence and unobserved heterogeneity which suggest that earlier analyses in this field that used simpler estimation methods were flawed.

Shortages of Rural Mental Health Professionals

This study presents a conceptual model of the supply and demand for mental health professionals. It uses national data to profile differences in the supply of mental health professionals in different types of rural and urban areas. It contrasts the availability of general health and mental health professionals. It examines shortage areas identified in 2000 and their related community characteristics. Because of the absence of data on a national level to describe many types of mental health professionals state licensure data for one state were used to show the volume and distribution of these practitioners. To improve rural mental health service delivery it will be necessary to implement system changes to promote the increased availability, competency, and support of rural health professionals.mental health, rural

The E¤ect of Rurality on Mental and Physical Health

Any time researchers choose to conduct a study on any aspect of rural health care, they are faced with a di¢ cult methodological choice regarding the oper- ational de?nition of rural to use in their study. While this seems to many who are not familiar with rural research to be a straightforward question (and often naive rural researchers expect to ?nd a single answer that is commonly agreed upon by experts in rural research), to date there is no single answer that is based on a consensus and supported by scienti?c evidence. Coburn, et al. (2007) states that ?there is no single, universally preferred de?nition of rural that serves all policy purposes.? One goal of this paper is to provide a method useful in informing the choice of rural de?nitions for a speci?c research study. This methods paper presents a systematic evaluation of the impact of the choice of rural de?nition on results. It was stimulated by the need to select a rural de?nition to use in related papers on the impact of community resources on mental and general health outcomes in other research by the authors. A na- tional dataset, the Community Tracking Survey, 2000-2001, includes individual level observations from household interviews. We merge it with county level data re?ecting community resources, and we use econometric methods to ana- lyze this multi-level data, accounting for individuals from the same family being included in the dataset. The e¤ect of using four di¤erent de?nitions of rural available for use in county level analysis is presented. A statistical analysis of the impact of the choice of a rural de?nition on outcomes and on the esti- mates and signi?cance of explanatory variables in the model is presented and is used to inform the selection of the de?nition to use in other research. Dif- ferences in results for mental health, physical health, and utilization of health care variables are evaluated. The choice of a rural definition is presented and justi?ed using the methodological analyses presented in this paper. Strengths and weaknesses of using county-level community characteristics as compared to data from larger geographic areas, such as Health Services Areas, or from smaller geographic areas, such as census tracts or zip codes, are discussed. Fi- nally, the need for a methods study to guide the use of multi-level geographic data to re?ect community characteristics within health care studies is proposed.rural, mental health, physical health, testing

Supply, Demand, and Equilibrium in the Market for CRNAs

This study determined the current trends in supply, demand and equilibrium (ie, the level of employment where supply equals demand) in the market for Certified Registered Nurse Anesthetists (CRNAs). It also forecasts future needs for CRNAs given different possible scenarios. The impact of the currect availablity of CRNAs, projected retirements, and changes in the demand for surgeries are considered in relation to CRNAs needed for the future. The study used data from many sources to estimate models associated with the supply and demand for CRNAs and the relationship to relevant community and policy characteristics such as per capita income of the community and managed care. These models were used to forecast changes in surgeries and in the supply of CRNAs in the future. The supploy of CRNAs has increased in recent years, stimulated by shortages of CRNAs and subsequent increases in the number of CRNAs trained. However, the increases have not offset the number of retiring CRNAs to maintain a constant age in the CRNA population. The average age will continue to increase for CRNAs in the near future despite increases in CRNAs trained. The supply of CRNAs in relation to surgeries will increase in the near future.Anesthesia manpower, CRNA, demand, nursing workforce, supply

Submerged Evidence of Early Human Occupation in the New York Bight

Large expanses of the continental shelf in eastern North America were dry during the last glacial maximum, about 20,000 years ago. Subsequently, Late Pleistocene and Early Holocene climatic warming melted glaciers and caused global sea level rise, flooding portions of the shelf and countless archaeological sites. Importantly, archaeological reconstructions of human subsistence and settlement patterns prior to the establishment of the modern coastline are incomplete without a consideration of the whole landscape once available to prehistoric peoples and now partially under water.This dissertation addresses Early to Mid-Holocene (Archaic period) hunter-gatherer occupation of the coastal plain, both subaerial and now submerged, in and adjacent to the New York Bight coastal province, stretching between southern New Jersey to the eastern end of Long Island, New York. The Hudson River slices through the apex of the New York Bight. Its banks have been the focus of human activity beginning approximately 12,000 years ago, and the archaeological potential of the estuary and surrounding lands is great. However, a portion of the prehistoric human record in the lower Hudson River is virtually invisible using traditional archaeological methods, as sea level rise has inundated portions of river valley on the continental shelf that likely witnessed prehistoric occupation. This dissertation proposes that the coastal plain and its river valleys in the Mid-Atlantic, specifically the New York Bight and the Hudson, were utilized by prehistoric peoples throughout the entire Holocene, but significant evidence of this occupation is now under water due to post-glacial sea level rise. Cultural continuity is also proposed for the lengthy Holocene, and the traditional regional chronology (Paleoindian, Archaic, and Woodland periods) and its implications for marked economic, demographic, and social change is challenged.Data from known Archaic period archaeological sites located on the subaerial coastal plain in the New York Bight are used to reconstruct settlement patterns and to determine high probability areas for underwater prehistoric sites. Analysis of a recently discovered submerged archaeological assemblage known as the Corcione collection and results of new underwater field work in the Hudson River Valley (offshore Sandy Hook and in Croton Bay) are discussed in the context of the terrestrial record

Clinical Faculty: Major Contributors to the Education of New CRNAs

This study examines the important contributions of clinical faculty toward the education of the future workforce of Ceertified Registered Nurse Anesthetists (CRNAs). Differences in workload, work activities and income amoung clinical faculty, academic faculty and nonfaculty are examined.crnas, labor makret

New Estimates for CRNA Vacancies

A national survey to estimate vacancy rates of Certified Registered Nurse Anestheists (CRNAs) in hospital and ambulatory surgical centers was conducted in 2007. Poisson regression methods were used to improve the precision of the estimates. A significat increase in the estiamted vacancy rate was reported for hospitals relative to an earlier study from 2002, although it is important to note that there were some methodologial differences between the 2 surveys explaining the part of the increase. Results from this study found the vacancy rate was higher in rural hospitals than in nonrural hospitals, and it was lower in ambulatory surgical centers. A number of simulations were run to predict the effects of relevant changes in the market for surgeries and nuber of CRNAs, which were compared to the predicitons from the previous survey. The remarkable factor since the last survey was the unusually large rate of new CRNAs entering the market, yet the vacancy rates remain relatively high.Certified Registered Nurse Anesthetist, demand, labor market, vacancies, workforce