Effect of mental health staffing inputs on initiation of care among recently separated Veterans
利用美国退伍军人健康管理局数据，采用工具变量法估计心理健康人员配置对新患者开始治疗时间的影响，发现增加人员配置能显著加快治疗启动，尤其在人员配置较低的机构效果更明显。
OBJECTIVE: To estimate a causal relationship between mental health staffing and time to initiation of mental health care for new patients. DATA SOURCES AND STUDY SETTING: As the largest integrated health care delivery system in the United States, the Veterans Health Administration (VHA) provides a unique setting for isolating the effects of staffing on initiation of mental health care where demand is high and out-of-pocket costs are not a relevant confounder. We use data from the Department of Defense and VHA to obtain patient and facility characteristics and health care use. STUDY DESIGN: To isolate exogenous variation in mental health staffing, we used an instrumental variables approach-two-stage residual inclusion with a discrete time hazard model. Our outcome is time to initiation of mental health care after separation from active duty (first appointment) and our exposure is mental health staffing (standardized clinic time per 1000 VHA enrollees per pay period). DATA COLLECTION/EXTRACTION METHODS: Our cohort consists of all Veterans separating from active duty between July 2014 and September 2017, who were enrolled in the VHA, and had at least one diagnosis of post-traumatic stress disorder, major depressive disorder, and/or substance use disorder in the year prior to separation from active duty (N = 54,209). PRINCIPAL FINDINGS: An increase of 1 standard deviation in mental health staffing results in a higher likelihood of initiating mental health care (adjusted hazard ratio: 3.17, 95% confidence interval: 2.62, 3.84, p < 0.001). Models stratified by tertile of mental health staffing exhibit decreasing returns to scale. CONCLUSIONS: Increases in mental health staffing led to faster initiation of care and are especially beneficial in facilities where staffing is lower, although initiation of care appears capacity-limited everywhere.