Alternatives to DRGs: research issues

Legislative mandates for the development of prospective payment methodologies for reimbursing inpatient care have spurred the psychiatric community into its own independent effort, applying both clinical and service research, to develop schemes which are fair to psychiatric patients, their providers and payers. Many of the issues involved in the development of an equitable prospective payment system (PPS) for psychiatric care are not new to the field, namely, problems of limited diagnostic accuracy, a limited knowledge of the outcomes of clearly defined treatment protocols, and a lack of integration, efficiency and efficacy in a highly differentiated service system. The research community needs to respond to these problems in the context of cost containment with an awareness that its response will influence care for psychiatric patients for the remainder of this century. In this paper, we will describe the background issues that have brought the psychiatric community to the present point in its response to PPS, and discuss some of the research problems posed by the need for a PPS with the right incentives for clinical effectiveness and efficiency.

Severe alcoholism in the mental health sector: I. A cost analysis of treatment

In a country in which the public mental health sector provides services to alcoholics, the costs of direct care to alcoholics were compared with those of other mental health patients. Costs were developed for a 1-yr cohort of patients who had received inpatient care but who had recently come from the community and returned to the community. The costs were based on inpatient and outpatient utilization within 2 yr of follow-up, commencing at discharge from inpatient care. Alcoholics represented the largest single diagnostic group in the cohort (39%), although their cost of care was only 22% of total costs. This is so despite the facts that similar percentages of alcoholics and nonalcoholics required rehospitalization in the 2 yr of follow-up and both groups exhibited similar patterns in the number of readmissions. Alcoholics have lower costs than other patients because they use cumulatively fewer inpatient days and receive fewer days of the most expensive outpatient service of full-day treatment. On the average, the cost to serve alcoholic patients is less than half the cost to serve nonalcoholic patients.

Severe alcoholism in the mental health sector: II. Effects of service utilization on readmission

A follow-up study of a cohort of suburban alcoholics who are comprehensively served by the public mental health sector used a Cox survival time analyses to examine the relationship of patient characteristics, receipt of outpatient services and readmission to inpatient care. Patients were followed up until their first readmission to inpatient care or for 2 yr subsequent to an inpatient episode. As expected, established chronicity was associated with short "survival" in the community, as were youth and living alone. For first admissions, the receipt of aftercare was associated with a decreased likelihood of readmission, especially in conjunction with inpatient stays of treatment that included rehabilitation services. Patients who had established a pattern of chronicity, however, appeared resistant to the effect of these services. The transition from inpatient to aftercare services was identified as a crucial point in treatment. Aftercare patients who did not receive services beyond 6 months in the community were likely to be readmitted, suggesting that this period is also an important focus for treatment planning.

Evaluation of a computerized drug review system: impact, attitudes, and interactions

A study was carried out across 11 psychiatric and mental retardation, and developmental disabilities facilities to investigate the impact of a computerized drug prescription monitoring system on clinicians' prescribing behavior, knowledge of pharmacotherapy, attitudes toward computers, and the relationships between their attitudes and changes in their prescribing practices. The results document that surveillance systems can improve prescribing practices. The tangible feedback provided by the exception report, although in the form of a surveillance mechanism, also increased user acceptance to computer technology. However, the findings also suggest that user acceptance is not necessarily required to see positive effects, which in environments where clinical and fiscal accountability are paramount, may override some clinicians' concerns. Attention to human factors components may help to alleviate some negativism.

Deficits in sensory gating in schizophrenic patients and their relatives. Evidence obtained with auditory evoked responses

A deficit in inhibitory gating of auditory evoked responses was examined in 15 schizophrenic patients, their first-degree relatives, and normal subjects, using a conditioning-testing paradigm with the P50 wave of the auditory evoked response. This paradigm demonstrates inhibition by presenting paired stimuli to the subject; the P50 wave evoked by the second stimulus is reduced because of inhibitory mechanisms activated during the response to the first stimulus. In normal subjects, the mean amplitude of the second P50 response was reduced to less than 20%. In the schizophrenics, the mean amplitude of the second response was more than 85% of the first, a result that replicates our previous finding of a deficit in inhibition in schizophrenia. Approximately half the first-degree relatives, generally including at least one parent, had a similar deficit. Presence of this deficit in the parents was associated with a family history of schizophrenia. Family members with this deficit also had significantly higher scores on several scales of the Minnesota Multiphasic Personality Inventory than did family members without the deficit. Despite the deficit in inhibition, other characteristics of the P50 wave were normal in the relatives, in contrast to unmedicated schizophrenics, who showed additional abnormalities in wave latency and amplitude.

The dynamics of hospitalization in a defined population during deinstitutionalization

In a sample of 1,032 psychiatric inpatients studied for 1 year, chronic patients (more than 6 months' inpatient stay) represented 17.4%, almost half of whom were discharged during a 2-year follow-up; an additional 19.4% died. The incidence of "new" long-stay patients was 8.6/100,000 population, which, if constant over time, would result in a net increase of long-stay patients. Most chronic long-stay patients had a diagnosis of schizophrenia or organic brain syndrome. The two diagnostic groups had strikingly different patterns of deinstitutionalization. Alcoholic patients and those with "other" diagnoses demonstrated chronic dependence on the hospital, characterized by short inpatient stays and high readmission rates.

Mortality in the era of deinstitutionalization

The authors examined the 3 1/2-year mortality rate of 1,033 psychiatric patients who had received inpatient treatment during a 1-year period, using standardized mortality ratios to identify heightened risk. Deaths due to accidents or suicides and pneumonia occurred more frequently than expected. Deaths due to cancer occurred primarily among alcoholics; nonalcoholic patients had a significantly lower cancer mortality risk. The risk associated with age was greatest for young patients in general, but male schizophrenic patients and female alcoholics died at particularly young ages. The highest mortality risk associated with diagnosis was for male patients with affective disorders. The authors discuss the implications of these findings.

The relationship between socioeconomic class and prevalence of schizophrenia, alcoholism, and affective disorders treated by inpatient care in a suburban area

This study relates inpatient-treated prevalence of the three mental illnesses most often requiring inpatient treatment--schizophrenia, alcoholism, and affective disorders--to social class in a suburban area. Rates were developed for the total population, including those living in domiciliary care, for those living in households only, and for first-admission patients living in households. Log-linear models supported the finding that low socioeconomic status was related to a high prevalence of alcoholism and affective disorders. In contrast, socioeconomic status was not related to the prevalence of schizophrenia among those living in households or among first-admission patients living in households.

A comparison of work activities of mental health professionals among disciplines and environments

Due to fiscal constraints on health care providers, the utilization of time of mental health professionals has come under close examination. The authors conducted a study of the work habits of 193 psychiatrists, psychologists, nurses, rehabilitation therapists, social workers, and mental health workers in 1976 and 1977. The clinicians worked at 18 facilities that offered inpatient, outpatient, partial hospital, or a mix of partial and outpatient services. Their work activities were observed over a two-week period. The data were analyzed for each clinical type and for each service modality across three funding sources--state, private, and mixed. The data, in part, show that a substantial amount of time was spent in all types of facilities in indirect patient care activities, particularly use of psychiatric records. Privately funded inpatient facilities devoted a much greater amount of time to direct patient care than did state inpatient facilities, which spent more time on administration and use of records. Staff of outpatient or partial-mixed facilities spent much more time on individual or other therapies, while inpatient staff spent more time on patient management and informal contacts with patients.

Fluoride supplementation in Harris County, Texas

We sent questionnaires to 421 physicians in Harris County, Texas, to determine the use of oral fluoride supplementation. The response rate was 56%. Although 95% of the physicians practice in fluoride-deficient areas (less than 0.7 ppm), 36% of those responding stated that the fluoride content of the water was adequate; 25% were unsure. Of those who thought that the fluoride content was adequate, 79% stated that the actual fluoride content was less than 0.7 ppm or were unsure. Only 35% of the responding physicians prescribed fluoride, only 45% knew the correct dose. Only 50% of the responders made routine dental referrals in the 3- and 4-year age group. More physician education is needed to ensure oral fluoride supplementation in communities with inadequately fluoridated water supplies.

Automated review system for orders of psychotropic drugs

A computerized drug-review system both reviews drug orders and notifies clinicians of orders that are considered exceptions to some clinical guidelines. The impact of this system in a psychiatric center in which it has been used since December 1975 is examined in terms of the reduction of the percentage of orders of psychotropic drugs that involve polypharmacy or dose-range exceptions. The results show a substantial reduction in orders in exception since the implementation of the system.

Problems in the care of the infant diabetic patient

The unique problems of three infants who developed diabetes mellitus at 13 months of age or younger are discussed. These problems include: the administration of small doses of insulin; the difficulty in attaining control; and the evaluation of urinary sugar content. Suggestions for care are made.

Quantitative care norms for a psychiatric ambulatory population in a county medical assistance program

An approach for developing quantitative care norms for outpatient acute psychiatric patients is presented. Both the methodological concept of the norming procedure and its application to the needs of Medicaid in Rockland County, New York are given. The methodology is totally general in that it could be applied to concerns related to characterization of services rendered in a wide variety of applications ranging from planning to utilization review. The norms developed relate both to monthly quantity of services rendered and length of active treatment period. Further, the impact of a review rule is discussed in terms of its implication to number of cases reviewed.

An evaluative paradigm for community mental health centers using an automated data system

A methodology is presented for the evaluation of community mental health centers using data routinely collected by an automated patient management system (Multistate Information System). Four community mental health centers whose catchment areas were widely diverse in composition participated in the study. A generalized evaluation paradigm was developed with measures and objectives formulated to analyze various stages of care as patients progressed through the community mental health center system. The stages covered were admission, initial modality of service, service delivery in terms of types and amounts of services rendered and termination. Each other was analyzed independently of the others and it was ascertained that the methodology produced useful and informative evaluative data across all four centers.

Matched-pairs study of reserpine use and breast cancer

This paper reports on an analysis of psychiatric population. 55 female patients with breast cancer were matched with non-cancer patients on age, year of admission, psychiatric diagnosis, race, and religion. Reserpine use was examined for yearly use by each year preceding the diagnosis of breast cancer, by cumulative yearly use, and by other defined time periods. Regardless of the definition of reserpine user, there were no significant increased relative risks of breast cancer for those women on reserpine. There was a fairly low proportion of patients from each group who were on the drug in any given year, and a fairly wide range of total dosage received. Over half of the women used reserpine at some time during their hospital stay.