Letter

To the Editor: Overuse of emergency department services for nonurgent medical problems can lead to negative outcomes, including increased costs, adverse health outcomes, overcrowding, long wait times, and reduced patient satisfaction ( 1, 2 ). Recent research points to such overuse among many vulnerable populations, including adults with serious mental illness. Possible explanations include the documented high rates of somatic comorbidity among people with serious mental illness and related issues of service accessibility and quality of somatic care ( 3 ). Given growing concern about the quality and coordination of somatic and psychiatric care, there is surprisingly limited research on the issue of somatic emergency department use among those with serious mental illness. Of note, we were unable to find any studies conducted in the Department of Veterans Affairs(VA).

The VA offers comprehensive and colocated mental health and somatic care, which provides a unique opportunity to examine emergency department use for medical care among veterans with mental illness. We report findings regarding self-reported rates of emergency department use among 142 veterans with schizophrenia spectrum disorders who were enrolled in the VA Maryland Health Care System. The sample was drawn from a larger randomized study designed to assess quality of care among individuals with schizophrenia spectrum disorders. The study, which received institutional review board approval, was conducted between October 2000 and December 2003. All participants provided full informed consent.

Most of the veterans in the sample were men (131 veterans, or 92%). Eighty-two (58%) were African American, 50 were Caucasian (35%), and ten (7%) reported another racial identity. Participants ranged in age from 27 to 64 years (mean±SD age=49.8±7.1). Forty participants (28%) reported past-month alcohol use, and six (4%) endorsed past-month illicit drug use. Eighty-nine (63%) reported at least one comorbid medical condition (mean=1.2±1.2).

Almost half the sample (60 participants, or 42%) reported emergency department use in the past year for somatic care. Surprisingly, this rate was even higher than the rates of emergency department use found in a recent study conducted in the same geographic area as our study that compared a sample of nonveterans with serious mental illness who were receiving care in the public sector (37%) with a non-mentally ill matched group from the general population (20%) ( 4 ). Several variables were associated with past-year use of somatic emergency department services in our study. As in previous research ( 4 ), our results showed that individuals with respiratory problems, those with any comorbid condition, and those with more comorbid conditions reported significantly more emergency department use.

Our data do not include information about reasons for emergency department use, and we did not address rates of use among veterans without psychiatric diagnoses who were receiving care in the same service system. However, the higher reported rates suggest that in this sample the emergency department may be used to address both urgent and more routine primary care issues. Given the cost and quality-of-care issues associated with potential overuse and the availability of electronic administrative data within the national VA system, we hope that our initial findings stimulate interest in examining this issue more thoroughly. Such efforts would certainly contribute to the VA's ongoing quality improvement programs.

Data were associated with a Research Career Development Award sponsored by the National Institute of Mental Health (RCA-K08-MH-01960) and by a study funded by the Department of Veterans Affairs Health Services Research and Development, "Improving Health Services for Veterans With Schizophrenia" (VCR-990122).

The authors report no competing interests.

The authors are affiliated with the Mental Illness Research, Education, and Clinical Center, VA Capitol Health Care Network (VISN 5), Baltimore, and with the Department of Psychiatry, University of Maryland, School of Medicine, Baltimore.