Association Between the Affordable Care Act and Emergency Department Visits for Psychiatric Disease.

INTRODUCTION: Emergency department (ED) utilization for psychiatric disease is increasing, and a lack of health insurance has been identified as a potential cause of preventable or avoidable ED use. Through the Affordable Care Act (ACA), more uninsured individuals gained health insurance; however, the effects of increased health insurance coverage on ED utilization for psychiatric disease have not been examined. METHODS: We performed a longitudinal, cross-sectional analysis of data from the Nationwide Emergency Department Sample, the largest all-payer ED database in the US, which contains data on over 25 million ED visits each year. We examined ED utilization for psychiatric disease as the primary reason for visit among adults aged 18-64. We compared the proportion of ED visits with a psychiatric diagnosis during post-ACA years (2011-2016) to pre-ACA (2009) using logistic regression adjusted for age, gender, payer, and hospital region. RESULTS: The proportion of ED visits with psychiatric diagnosis increased from pre-ACA (4.9%) to post-ACA years (ranging from 5.0-5.5%). There was a significant difference in the proportion of ED visits with a psychiatric diagnosis when comparing each post-ACA year with pre-ACA, with adjusted odds ratios ranging from 1.01-1.09. Among ED visits with a psychiatric diagnosis, the most common age group was 26-49 years, and patients were more likely to be male than female and to have visited urban rather than rural hospitals. During post-ACA years (2014-2016), private and uninsured payers decreased, Medicaid payers increased, and Medicare payers increased in 2014 and decreased in 2015-2016 compared to pre-ACA. CONCLUSION: With the ACA more people gained health insurance, yet ED visits for psychiatric disease continued to increase. These results suggest that increasing access to health insurance alone is not sufficient to reduce ED utilization for patients with a psychiatric disease.

Mental Health and Substance Misuse-Related Emergency Department Discharges in Urban Counties of North Carolina.

BACKGROUND: National evidence suggests that there is considerable variation between regions in emergency department utilization for routine health care needs. Many emergency departments are poorly equipped to manage the needs of patients with mental health or substance misuse diagnoses, who could often be more effectively managed in other settings. We sought to quantify differences in the frequency of mental health and substance misuse-related emergency department encounters across urban counties in North Carolina. METHODS: Data from the 2010 North Carolina State Emergency Department and Inpatient Databases were analyzed with descriptive, bivariate, and multivariate statistics. Primary discharge diagnoses were classified using the International Classification of Disease, Ninth Revision, Clinical Modification codes included with the databases. RESULTS: The overall rate of mental health and substance misuse encounters in urban counties was 19.1 encounters per 1,000 people (4.5% of all emergency department encounters). This rate ranged from 6.4 encounters per 1,000 people (2.4% of encounters) in Wake County to 30.1 encounters per 1,000 people (6.4%) in Orange County. LIMITATIONS: There is a possibility of nondifferential classification error in the state databases, as coding practices and coding errors may vary between facilities. We were unable to confirm diagnoses through additional clinical information or Diagnostic and Statistical Manual criteria. CONCLUSION: Mental health and substance misuse-related encounters constitute a small percentage of emergency department encounters in North Carolina's urban counties, with significant variation between counties. Diverting some of these encounters to community-based mental health and substance misuse health care providers could reduce emergency department utilization while improving the quality of care delivered to this vulnerable patient population.

Reliability, validity and factor structure of the Appraisal of Self-Care Agency Scale-Revised (ASAS-R).

RATIONALE, AIMS AND OBJECTIVES: Self-care agency is a fundamental concept in nursing and health care research. Having self-care agency enhances an individual's health-promoting behaviours and/or specific capabilities for chronic disease self-management. The purpose of this study was to continue the development and psychometric testing of the Appraisal of Self-Care Agency - Revised (ASAS-R). METHODS: A cross-sectional methodological design was used to examine the reliability, validity and factor structure of the ASAS-R among individuals from the general population. The sample consisted of 629 adults who were randomly selected to conduct an exploratory factor analysis (EFA; n=240) and a confirmatory factor analysis (CFA; n=389) of the scale. A demographic questionnaire, the ASAS-R and the Health-Promoting Lifestyle Profile (HPLP-II) were the measures used to collect the data. RESULTS: The final 15-item three-factor ASAS-R had an overall Cronbach's alpha (α) of 0.89. The three factors extracted, rotated and scored in this study were labelled: having power for self-care, developing power for self-care and lacking power for self-care. All inter-items and item-to-total correlations met recommended criteria of r=0.30 to r=0.70, except for one of the items that had an item-to-total correlation of 0.71, slightly exceeding the maximum recommended item-to-total correlation. The three factors had Cronbach's alphas of 0.86, 0.83 and 0.79, respectively. The three factors together explained 61.7% of the scale items variance. Each item of the scale had a strong factor loading ranging from 0.52 to 0.81. All measures of model fit exceeded the recommended criteria, indicating that the 15-item ASAS-R had a very good fit (χ(2) /d.f.=1.97, GFI=0.94, AGFI=0.92, CFI=0.96, TLI=0.95, RMSEA=0.05, RMR=0.05 and the PCLOSE=0.48). CONCLUSIONS: The 15-item three-factor ASAS-R is a short, reliable and valid instrument to measure self-care agency among individuals from the general population, but further psychometric evaluation is needed among individuals with chronic diseases, especially those with diabetes mellitus.

Factor analysis of the Appraisal of Self-care Agency Scale in American adults with diabetes mellitus.

PURPOSE: The purpose of this methodological secondary data analysis study is to examine the reliability, construct validity, and dimensionality of the Appraisal of Self-care Agency Scale (ASAS) in an American sample of adults with diabetes mellitus. METHODS: The sample consisted of 141 insulin-requiring adults with diabetes mellitus recruited from a Diabetes Care Center in the southern United States. The ASAS, along with Hurley's Insulin Management Diabetes Self-efficacy and Insulin Management Diabetes Self-care Scales, was used in the study to determine convergent validity, thus contributing to the construct validity of the ASAS. Other data analysis consisted of internal consistency estimates of reliability, Pearson correlations, and factor analysis. RESULTS: The findings suggest that the ASAS consists of a single substantive dimension and has adequate construct validity and reliability. CONCLUSION: Revision of certain items and conducting further analysis of the scale, prior to its adoption in clinical practice, should be considered.

Essential educational content for advanced practice in psychiatric consultation liaison nursing.

Psychiatric Consultation Liaison Nursing (PCLN), an advanced practice subspecialty of psychiatric mental health nursing, has evolved over the last 4 decades in response to increased recognition of the importance of psychophysiological interrelationships and their impact on wellness, physical illness, and recovery. PCLN specialists practice in many countries although there are few PCLN programs in schools of nursing. This article defines PCLN, reviews its history, and recommends essential educational content for inclusion in a master's curriculum to prepare graduates for competent and effective PCLN practice. The educational content is based on the work of the PCLN Core Curriculum Task Force of the International Society of Psychiatric Consultation Liaison Nurses and is integrated with the 1990 Standards of Psychiatric Consultation Liaison Nursing Practice and the 2000 Standards of Psychiatric-Mental Health Nursing Practice. The relationship of the PCLN educational content to other national curriculum guidelines is discussed in the proposed PCLN curriculum content.