Use of home health and other healthcare delivery pathways among privately insured patients with and without treatment-resistant depression

Figures & data

Table 1. Baseline patient characteristics, HRU, and healthcare costs stratified by cohort and by HHS^a use.

	TRD cohort (N = 6411)		Non-TRD MDD Cohort (N = 33,068)		Non-MDD cohort (N = 149,884)
	With HHS	Without HHS	With HHS	Without HHS	With HHS	Without HHS
	N = 1152 (18.0%)	N = 5259 (82.0%)	N = 4084 (12.4%)	N = 28,984 (87.6%)	N = 9743 (6.5%)	N = 140,141 (93.5%)
Patients characteristics
Age at index date (years), mean ± SD [median]^b	45.0 ± 12.2 [47.6]	39.5 ± 13.3 [40.8]	45.8 ± 12.2 [48.2]	39.6 ± 13.1 [40.4]	47.2 ± 12.3 [50.0]	42.0 ± 13.4 [43.5]
Age categories, n (%)
18–24	121 (10.5)	1128 (21.4)	368 (9.0)	6062 (20.9)	700 (7.2)	22,332 (15.9)
25–34	132 (11.5)	885 (16.8)	460 (11.3)	4910 (16.9)	1178 (12.1)	23,791 (17.0)
35–44	234 (20.3)	1161 (22.1)	817 (20.0)	6679 (23.0)	1718 (17.6)	28,676 (20.5)
45–54	391 (33.9)	1325 (25.2)	1311 (32.1)	7175 (24.8)	2843 (29.2)	35,414 (25.3)
55–64	274 (23.8)	760 (14.5)	1128 (27.6)	4158 (14.3)	3304 (33.9)	29,928 (21.4)
Female, n (%)	716 (62.2)	3401 (64.7)	2533 (62.0)	18,507 (63.9)	5053 (51.9)	69,430 (49.5)
Geographical region, n (%)^c
Northeast	292 (25.3)	1290 (24.5)	1046 (25.6)	7382 (25.5)	2289 (23.5)	33,581 (24.0)
Midwest	317 (27.5)	1303 (24.8)	1113 (27.3)	7784 (26.9)	2790 (28.6)	34,772 (24.8)
South	362 (31.4)	1726 (32.8)	1155 (28.3)	8302 (28.6)	2852 (29.3)	44,920 (32.1)
West	159 (13.8)	859 (16.3)	683 (16.7)	5015 (17.3)	1662 (17.1)	24,258 (17.3)
Unknown	22 (1.9)	81 (1.5)	87 (2.1)	501 (1.7)	150 (1.5)	2610 (1.9)
Type of healthcare plan, n (%)
Preferred provider organization	906 (78.6)	4010 (76.3)	3106 (76.1)	22,199 (76.6)	7420 (76.2)	106,621 (76.1)
Point of service plan	115 (10.0)	764 (14.5)	454 (11.1)	4120 (14.2)	1108 (11.4)	19,782 (14.1)
Indemnity plan (fee-for-service)	112 (9.7)	396 (7.5)	414 (10.1)	2100 (7.2)	982 (10.1)	10,755 (7.7)
Other healthcare plan^d	19 (1.6)	89 (1.7)	110 (2.7)	565 (1.9)	233 (2.4)	2983 (2.1)
Exclusive provider organization	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Unknown	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Relationship to healthcare plan holder, n (%)
Employee (i.e. healthcare plan holder)	484 (42.0)	2316 (44.0)	2046 (50.1)	13,578 (46.8)	5072 (52.1)	71,273 (50.9)
Available work loss data	336 (29.2)	1572 (29.9)	1259 (30.8)	9106 (31.4)	3093 (31.7)	46,177 (33.0)
Spouse	443 (38.5)	1514 (28.8)	1269 (31.1)	7881 (27.2)	2944 (30.2)	37,448 (26.7)
Child	117 (10.2)	1103 (21.0)	372 (9.1)	5849 (20.2)	649 (6.7)	21,020 (15.0)
Other/unknown	108 (9.4)	326 (6.2)	397 (9.7)	1676 (5.8)	1078 (11.1)	10,400 (7.4)
Had ≥1 HHS visit^e, n (%)	294 (25.5)	154 (2.9)	1073 (26.3)	733 (2.5)	2436 (25.0)	2059 (1.5)
Quan-CCI, mean ± SD [median]^f	0.6 ± 1.3 [0]	0.2 ± 0.7 [0]	0.6 ± 1.2 [0]	0.2 ± 0.7 [0]	0.5 ± 1.1 [0]	0.1 ± 0.5 [0]
HRU and costs
HRU^e PPPY; all-cause number of visits, mean ± SD [median]
Inpatient visits	0.63 ± 1.7 [0.0]	0.24 ± 0.9 [0.0]	0.54 ± 2.0 [0.0]	0.23 ± 1.2 [0.0]	0.21 ± 1.0 [0.0]	0.06 ± 0.6 [0.0]
ED visits	1.29 ± 2.8 [0.0]	0.74 ± 1.9 [0.0]	1.03 ± 2.6 [0.0]	0.66 ± 1.8 [0.0]	0.57 ± 1.9 [0.0]	0.29 ± 1.1 [0.0]
Outpatient visits	21.35 ± 22.7 [15.0]	14.02 ± 15.7 [10.0]	20.01 ± 20.9 [14.0]	13.16 ± 15.2 [8.0]	13.94 ± 17.2 [8.0]	6.05 ± 10.1 [2.0]
Other visits	3.99 ± 9.7 [0.0]	1.58 ± 4.8 [0.0]	3.75 ± 8.2 [0.0]	1.40 ± 3.6 [0.0]	3.31 ± 9.3 [0.0]	0.79 ± 2.6 [0.0]
HHS visits^g	2.01 ± 7.7 [0.0]	0.17 ± 2.8 [0.0]	2.00 ± 6.5 [0.0]	0.10 ± 1.1 [0.0]	2.04 ± 8.1 [0.0]	0.07 ± 1.2 [0.0]
Healthcare costs^e (US $2015) PPPY; mean ± SD [median]
All-cause pharmacy and medical costs	32,372 ± 99,797 [5,777]	8976 ± 27,624 [2335]	27,581 ± 105,085 [4936]	7396 ± 30,476 [1779]	14,838 ± 49,725 [3030]	3469 ± 13,942 [512]
All-cause pharmacy costs	2468 ± 6923 [522]	1310 ± 5114 [209]	2202 ± 9301 [361]	995 ± 9517 [93]	2611 ± 8442 [363]	839 ± 5200 [6]
All-cause medical costs	29,904 ± 98,734 [4,011]	7666 ± 26,418 [1381]	25,379 ± 103,858 [3422]	6401 ± 25,259 [1197]	12,227 ± 47,608 [1563]	2630 ± 12,540 [252]
Inpatient costs	17,379 ± 88,914 [0]	2535 ± 17,366 [0]	14,597 ± 94,231 [0]	2110 ± 18,398 [0]	4324 ± 33,931 [0]	661 ± 8369 [0]
ED costs	1384 ± 4253 [0]	685 ± 2863 [0]	960 ± 3139 [0]	565 ± 2495 [0]	471 ± 2473 [0]	188 ± 1351 [0]
Outpatient costs	9,383 ± 24,539 [2,231]	4029 ± 14,093 [976]	8337 ± 27,801 [2094]	3393 ± 13,778 [859]	6481 ± 24,644 [1081]	1686 ± 7533 [195]
Other costs	1759 ± 10,376 [0]	418 ± 2878 [0]	1485 ± 8342 [0]	333 ± 2508 [0]	951 ± 7512 [0]	94 ± 1290 [0]
HHS costs^g	595 ± 3,442 [0]	34 ± 497 [0]	711 ± 5001 [0]	35 ± 1025 [0]	769 ± 7288 [0]	19 ± 601 [0]

Abbreviations. ED, Emergency department; HHS, Home health services; HRU, Health resource utilization; MDD, Major depressive disorder, PPPY, Per-patient-per-year; Quan-CCI, Quan-Charlson Comorbidity Index; SD, Standard deviation; TRD, Treatment-resistant depression.

^a Use of HHS was identified during the 24 months following the index date, based on place of service, provider type, and relevant procedure codes.

^b The index date was defined as the date of the first prescription fill for an antidepressant.

^c Based on United States census regions (http://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf).

^d Other healthcare plans include locked-in and independent practice association health insurance plans.

^e Identified during the 6-month baseline period, prior to the index date

^f Quan et al.²³

^g HHS visits and costs and other medical categories visits and costs are not mutually exclusive.

Figure 1. The five most common healthcare delivery pathways in the TRD, non-TRD MDD, and non-MDD cohorts. Abbreviations. HHS, Home health services; MDD, Major depressive disorder; TRD, Treatment-resistant depression.

Figure 2. Healthcare costs (the observation period was restricted to a maximum of 2 years following index date (all patients were required to have an observation period of at least 6 months)) in the TRD cohort, the unmatched non-TRD MDD, and non-MDD cohorts, stratified by HHS use (use of HHS was identified during the 24 months following index date, based on place of service, provider type and relevant procedure codes). Abbreviations. ED, Emergency department; HHS, Home health services; MDD, Major depressive disorder; PPPY, Per-patient-per-year; TRD, Treatment-resistant depression; US, United States.

Table 2. Follow-up direct HRU and days of work loss in the TRD cohort, the non-TRD MDD, and non-MDD cohorts, stratified by HHS use^a.

HRU per-patient-per-year (PPPY); mean ± SD [median]	TRD cohort (N = 6411)		Non-TRD MDD cohort (N = 33,068)		Non-MDD cohort (N = 149,884)
	With HHS	Without HHS	With HHS	Without HHS	With HHS	Without HHS
	N = 1152 (18.0%)	N = 5259 (82.0%)	N = 4084 (12.4%)	N = 28,984 (87.6%)	N = 9743 (6.5%)	N = 140,141 (93.5%)
Direct HRU
All-cause
Inpatient visits	0.85 ± 1.9 [0.5]	0.32 ± 1.0 [0.0]	0.53 ± 1.3 [0.0]	0.16 ± 1.0 [0.0]	0.38 ± 1.1 [0.0]	0.05 ± 0.7 [0.0]
Number of days	4.67 ± 13.9 [0.5]	1.31 ± 4.2 [0.0]	3.04 ± 10.1 [0.0]	0.57 ± 3.3 [0.0]	1.92 ± 7.3 [0.0]	0.17 ± 1.7 [0.0]
ED visits	1.68 ± 3.0 [0.8]	0.89 ± 1.8 [0.5]	1.18 ± 2.7 [0.5]	0.61 ± 1.4 [0.0]	0.74 ± 1.7 [0.0]	0.30 ± 0.9 [0.0]
Outpatient visits	35.20 ± 22.8 [30.0]	23.63 ± 17.4 [19.0]	26.70 ± 19.6 [21.8]	16.51 ± 14.5 [12.1]	16.80 ± 15.2 [12.5]	6.05 ± 8.4 [3.5]
Other visits	7.78 ± 13.4 [4.0]	2.17 ± 4.6 [0.5]	5.90 ± 10.4 [3.0]	1.42 ± 3.4 [0.0]	4.79 ± 9.6 [2.1]	0.71 ± 1.8 [0.0]
HHS^b	4.55 ± 11.0 [1.5]	0.00 ± 0.0 [0.0]	3.89 ± 8.7 [1.2]	0.00 ± 0.0 [0.0]	3.41 ± 8.1 [1.1]	0.00 ± 0.0 [0.0]
Mental health-related^c
Inpatient visits	0.32 ± 1.1 [0.0]	0.22 ± 0.9 [0.0]	0.14 ± 0.5 [0.0]	0.08 ± 0.5 [0.0]	0.02 ± 0.2 [0.0]	0.00 ± 0.1 [0.0]
Number of days	2.20 ± 10.2 [0.0]	1.04 ± 3.8 [0.0]	1.06 ± 5.8 [0.0]	0.36 ± 2.7 [0.0]	0.17 ± 2.8 [0.0]	0.02 ± 0.6 [0.0]
ED visits	0.27 ± 1.2 [0.0]	0.21 ± 0.8 [0.0]	0.11 ± 0.5 [0.0]	0.10 ± 0.5 [0.0]	0.02 ± 0.2 [0.0]	0.01 ± 0.1 [0.0]
Outpatient visits	12.97 ± 14.3 [8.0]	13.71 ± 14.7 [9.0]	8.21 ± 10.6 [4.0]	8.44 ± 11.2 [4.5]	0.77 ± 3.3 [0.0]	0.45 ± 2.6 [0.0]
Other visits	0.80 ± 3.2 [0.0]	0.68 ± 3.4 [0.0]	0.43 ± 2.6 [0.0]	0.30 ± 2.3 [0.0]	0.08 ± 1.5 [0.0]	0.02 ± 0.4 [0.0]
HHS^b	0.19 ± 1.1 [0.0]	0.00 ± 0.0 [0.0]	0.16 ± 1.4 [0.0]	0.00 ± 0.0 [0.0]	0.05 ± 1.4 [0.0]	0.00 ± 0.0 [0.0]
Days of work loss
Employee with available work loss data, n (%)	336 (29.2)	1572 (29.9)	1259 (30.8)	9106 (31.4)	3093 (31.7)	46,177 (33.0)
All-cause
Total work loss days	50.71 ± 62.7 [21.9]	34.64 ± 55.2 [14.0]	35.01 ± 52.5 [15.6]	19.49 ± 42.6 [6.5]	19.69 ± 36.9 [8.2]	5.07 ± 23.2 [0.0]
Medical-related absenteeism days^d	14.06 ± 13.5 [11.4]	9.13 ± 9.2 [7.5]	11.86 ± 13.0 [9.3]	6.01 ± 8.1 [3.5]	7.13 ± 9.5 [5.0]	1.59 ± 4.3 [0.0]
Disability days	36.65 ± 65.1 [0.0]	25.51 ± 56.7 [0.0]	23.15 ± 53.6 [0.0]	13.49 ± 42.8 [0.0]	12.56 ± 36.4 [0.0]	3.48 ± 22.8 [0.0]
Mental health-related^c
Total work loss days	18.50 ± 45.3 [3.3]	19.15 ± 40.1 [5.0]	7.74 ± 22.0 [1.3]	9.17 ± 27.7 [0.0]	0.46 ± 5.0 [0.0]	0.29 ± 4.5 [0.0]
Medical-related absenteeism days^d	4.55 ± 8.4 [2.4]	4.98 ± 6.9 [2.5]	3.13 ± 5.9 [0.5]	2.81 ± 5.5 [0.0]	0.26 ± 1.6 [0.0]	0.13 ± 1.3 [0.0]
Disability days	13.95 ± 44.7 [0.0]	14.17 ± 40.2 [0.0]	4.60 ± 21.4 [0.0]	6.36 ± 27.4 [0.0]	0.21 ± 4.7 [0.0]	0.16 ± 4.3 [0.0]

Abbreviations. ED, Emergency department; HHS, Home health services; HRU, Healthcare resource utilization; MDD, Major depressive disorder; TRD, Treatment-resistant depression.

^a The observation period was restricted to a maximum of 2 years following index date (all patients were required to have an observation period of at least 6 months). In the TRD cohort, the mean observation period was 21.8 and 20.8 months for the patients with and without HHS, respectively. In the non-TRD MDD cohort, the mean observation period was 21.2 and 19.8 months for the patients with and without HHS, respectively. In the non-MDD cohort, the mean observation period was 19.6 and 17.7 months for the patients with and without HHS, respectively.

^b Use of HHS was identified during the 24 months following the index date, based on place of service, provider type, and relevant procedure codes.

^c Mental health-related HRU was identified using the following International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes: 290.xx–319.xx.

^d The number of medical-related absenteeism days was imputed based on length of stay for inpatient visits or a half day each for ED, outpatient, and other visits.

HHS related HRU has been bolded to highlight the specific outcomes.

Table 3. Follow-up direct and indirect healthcare costs in the TRD cohort, the non-TRD MDD, and non-MDD cohorts, stratified by HHS use^a.

Healthcare cost (US $2015) per-patient-per-year (PPPY); mean ± SD [median]	TRD cohort (N = 6411)		Non-TRD MDD cohort (N = 33,068)		Non-MDD cohort (N = 149,884)
	With HHS	Without HHS	With HHS	Without HHS	With HHS	Without HHS
	N = 1152 (18.0%)	N = 5259 (82.0%)	N = 4084 (12.4%)	N = 28,984 (87.6%)	N = 9743 (6.5%)	N = 140,141 (93.5%)
Direct costs
All-cause pharmacy and medical	40,040 ± 64,248 [19,543]	12,272 ± 20,315 [6346]	28,767 ± 62,786 [10,849]	7227 ± 18,886 [3183]	22,340 ± 58,614 [7582]	3479 ± 11,768 [791]
Pharmacy	5605 ± 9802 [2720]	2997 ± 7209 [1490]	3458 ± 8850 [1193]	1534 ± 4618 [480]	3115 ± 9895 [549]	895 ± 4810 [44]
Inpatient	15,387 ± 48,543 [0]	2085 ± 8731 [0]	11,382 ± 44,153 [0]	1174 ± 9585 [0]	8837 ± 39,798 [0]	591 ± 5785 [0]
ED	1991 ± 4856 [382]	821 ± 2550 [19]	1275 ± 3949 [140]	465 ± 1682 [0]	728 ± 3159 [0]	189 ± 1013 [0]
Outpatient	14,454 ± 24,335 [7633]	5623 ± 11,589 [2749]	10,907 ± 26,973 [4761]	3748 ± 12,936 [1593]	8134 ± 21,095 [2921]	1724 ± 6780 [374]
Other	2602 ± 7730 [572]	745 ± 4023 [16]	1745 ± 7617 [345]	306 ± 2165 [0]	1526 ± 11,780 [253]	80 ± 612 [0]
HHS^b^,^c	1419 ± 6106 [303]	0 ± 0 [0]	1175 ± 6665 [199]	0 ± 0 [0]	1223 ± 11,222 [173]	0 ± 0 [0]
Mental health-related pharmacy and medical costs^d	9519 ± 32,232 [2874]	5152 ± 12,929 [2086]	5285 ± 26,509 [1012]	2089 ± 7223 [691]	1070 ± 13,564 [0]	167 ± 1940 [0]
Psychiatric pharmacy^e	1462 ± 2582 [699]	1164 ± 1892 [524]	484 ± 1050 [131]	391 ± 950 [90]	180 ± 968 [0]	59 ± 547 [0]
Inpatient	4700 ± 30,547 [0]	1095 ± 4809 [0]	3265 ± 25,729 [0]	403 ± 3990 [0]	695 ± 13,279 [0]	35 ± 1489 [0]
ED	353 ± 1264 [0]	215 ± 911 [0]	160 ± 1096 [0]	98 ± 609 [0]	33 ± 479 [0]	11 ± 204 [0]
Outpatient	2431 ± 6369 [795]	2108 ± 8323 [740]	1158 ± 3281 [404]	1012 ± 3991 [326]	137 ± 969 [0]	55 ± 889 [0]
Other	574 ± 2884 [0]	570 ± 3956 [0]	219 ± 2347 [0]	185 ± 2050 [0]	25 ± 739 [0]	6 ± 265 [0]
HHS^b^,^c	128 ± 910 [0]	0 ± 0 [0]	54 ± 498 [0]	0 ± 0 [0]	167 ± 9884 [0]	0 ± 0 [0]
Indirect costs
Employee with available work loss data, n (%)	336 (29.2)	1572 (29.9)	1259 (30.8)	9106 (31.4)	3093 (31.7)	46,177 (33.0)
All cause
Total work loss-related	6342 ± 14,818 [1343]	4199 ± 10,020 [1033]	3452 ± 6803 [1162]	2451 ± 7841 [752]	2368 ± 5317 [943]	837 ± 3685 [258]
Medical-related absenteeism^f	895 ± 753 [760]	817 ± 780 [634]	915 ± 735 [776]	755 ± 838 [558]	915 ± 1003 [678]	454 ± 718 [229]
Disability	5446 ± 14,907 [0]	3382 ± 10,057 [0]	2537 ± 6824 [0]	1696 ± 7845 [0]	1453 ± 5295 [0]	383 ± 3630 [0]
Mental health-related^d
Total work loss-related	2761 ± 12,127 [254]	2359 ± 7041 [404]	829 ± 3022 [177]	1177 ± 4747 [217]	66 ± 923 [0]	42 ± 694 [0]
Medical-related absenteeism^f	312 ± 457 [204]	435 ± 574 [267]	280 ± 408 [142]	348 ± 589 [167]	38 ± 194 [0]	26 ± 174 [0]
Disability	2448 ± 12,140 [0]	1924 ± 7015 [0]	550 ± 2966 [0]	829 ± 4704 [0]	28 ± 894 [0]	16 ± 669 [0]

Abbreviations. ED, Emergency department; HHS, Home health services; MDD, Major depressive disorder; SD, Standard deviation; TRD, Treatment-resistant depression.

^a The observation period was restricted to a maximum of 2 years following index date (all patients were required to have an observation period of at least 6 months). In the TRD cohort, the mean observation period was 21.8 and 20.8 months for the patients with and without HHS, respectively. In the non-TRD MDD cohort, the mean observation period was 21.2 and 19.8 months for the patients with and without HHS, respectively. In the non-MDD cohort, the mean observation period was 19.6 and 17.7 months for the patients with and without HHS, respectively.

^b Use of HHS was identified during the 24 months following index date, based on place of service, provider type and relevant procedure codes.

^c HHS costs and other medical cost categories are not mutually exclusive.

^d Mental health-related costs were defined as all costs during a visit with any of the following International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), diagnostic codes: 290.xx–319.xx.

^e Psychiatric pharmacy costs include the following classes of agents (generic product identifier (GPI) prefix): anxiolytics (“57”), antidepressants (“58”), antipsychotics/antimanics (“59”), anticonvulsants (“7299”, “721”, “726”), and other mood stabilizers (e.g. lithium).

^f The medical-related absenteeism costs were imputed based on the time absent from work related to full day wage equivalent for inpatient visits and a half day wage equivalent each for ED, outpatient, and other visits.

HHS related costs have been bolded to highlight the specific outcomes.

Figure 3. Work-loss costs (the observation period was restricted to a maximum of 2 years following index date (all patients were required to have an observation period of at least 6 months)) in the TRD cohort, the unmatched non-TRD MDD, and non-MDD cohorts stratified by HHS use (use of HHS was identified during the 24 months following index date, based on place of service, provider type and relevant procedure codes). Abbreviations. HHS, Home health services; MDD, Major depressive disorder; PPPY, Per-patient-per-year; TRD, Treatment-resistant depression; US, United States.

Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43(11):1130-1139.

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Data availability

The data that support the findings of this study are available from OptumHealth Care Solutions, Inc. but restrictions apply to the availability of these data, which were used under license for the current study, and are not publicly available.