ECT Among Older Medicare Beneficiaries
Background: Electroconvulsive therapy (ECT) is an important therapy for treatment-resistant depression and is especially effective for elderly individuals with depression. This is the first US nationally representative description of ECT in the elderly.
Methods: Using 2014-2015 Medicare claims data, we compared elderly individuals with major depressive disorder (using ICD-9 and ICD-10 codes) who received ECT with those who did not on demographic and clinical measures. We characterized treatment patterns by setting and the proportion of individuals receiving index and continuation/maintenance courses, subtherapeutic courses of ECT, and post-ECT follow-up care.
Results: Of all Medicare beneficiaries aged 65 years and older diagnosed with depression in 2014-2015, 7,817 (0.41%) received 1 or more ECT sessions. Compared to the general population of elderly Medicare beneficiaries with depression, recipients of ECT were slightly younger and more likely to be male, non-Hispanic, and white and live in a zip code with a higher median income. Among those who received any ECT, 33.7% received < 5 total treatments. Of those who received an index ECT treatment, 33.7% received a continuation/maintenance course of ECT, while 60.9% received some form of post-ECT follow-up treatment (additional ECT or new psychotropic medication). Receipt of psychotherapy was the strongest predictor of those who received ≥ 5 ECT treatments (adjusted odds ratio = 1.43; 95% CI, 1.22 to 1.67).
Conclusions: Despite substantial evidence of efficacy, ECT use remains rare among elderly patients with depression. Findings suggest a potential need for efforts to increase the proportion of patients receiving adequate courses of ECT and evidence-based post-ECT follow-up care.
And from the text:
Inpatient versus outpatient use. Most individuals (2,938; 71.2%) who received ECT began in the inpatient setting, with approximately half (50.7%) receiving only inpatient ECT. Approximately one-third (33.7%) received ECT in both inpatient and outpatient settings and 18.8% received only outpatient ECT (Table 3)
Preliminary studies investigating barriers to ECT implementation have identified several possible modifiable barriers. For example, some providers have cited that a lack of adequate space can restrain the expansion of existing services. Despite the passage of the Mental Health Parity and Addiction Equity Act, psychiatric services are reimbursed at relatively low rates compared with services provided by other specialties. Hence, ECT providers have reported that, in a busy hospital setting, times allotted for ECT can diminish if other, more profitable services have higher patient volumes. Currently, the Center for Medicaid/Medicare Services will not reimburse for ECT services performed outside of a hospital setting (for instance, in an outpatient, ambulatory surgical center), despite the fact that ECT is reported to be among the safest procedures involving general anesthesia with respect to peri-procedural mortality. The creation of billing codes for ECT outside of hospital settings may allow for expansion of services, shifting the space constraint to a “buyer’s market” and allowing ECT practitioners to expand services when clinical demand is high. Other potential approaches to enhancing the implementation of ECT include modifying educational curriculum requirements (currently, requirements for ECT didactics among psychiatrists in training are limited), reforms of legal restrictions, and education for the public as well as for practicing psychiatrists who potentially refer patients for ECT (“gatekeepers”).
These data are useful and very important. As I have mentioned before, we in the USA are at a disadvantage compared with many European countries when it comes to accurate national data on ECT utilization. The data here document extreme underuse of ECT (annual rate of 0.3% of medicare beneficiaries with depression who received ECT) . The data on number of ECT received are harder to interpret, but suggest undertreatment (referred to as "subtherapeutic ECT treatment" by these authors) in some patients (although I stress the need to individualize treatment courses...) and underuse of continuation/maintenance ECT and other modalities.
The authors' point about CMS not recognizing reimbursement codes for ECT done outside a hospital setting is a critical one that I have remarked on many times before. This should be changed and hopefully will be accomplished in the not-too-distant future.
This article was picked up by Healio News on 7/14/2020 and a short article sent around by blast email.
Since the article is in J Clin Psych, it will be widely read. I encourage all to read this manuscript in full, as it has many important details about the use of ECT in the USA.
CK
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