Length of hospitalisation for people with severe mental illness

The Impact of 90-day Physician Follow-up Care on the Risk of Readmission Following a Psychiatric Hospitalization

AIMS

This study measures the impact of 90-day physician follow-up care after psychiatric hospitalization among 3,311 adults and youth, with risk of subsequent readmission within six months.

METHODS

A 5-year investigation was conducted based on Quebec (Canada) medical administrative databases. Cox proportional-hazards regression was performed, with 90-day follow-up care as the main independent variable, controlling for various sociodemographic, clinical, and other service use variables.

RESULTS

Within the 90-day follow-up period after patient discharge, or in the first 30 days, receiving at least one consultation per month as opposed to no consultation was associated with a reduced risk of psychiatric readmission. Women showed an increased readmission risk compared to men, while those living in less materially deprived areas a decreased risk as opposed to more deprived areas. Patients hospitalized for suicide attempt or schizophrenia spectrum and other psychotic disorders, and those with co-occurring mental and substance-related disorders or chronic physical illnesses, especially illnesses high on the severity index, also presented a heightened risk of hospitalization. Patients hospitalized for personality disorders or receiving a high continuity of physician care showed a reduced risk of readmission.

CONCLUSION

This study demonstrates that follow-up care, if provided within the first 30 days of discharge or monthly during the 90-day follow-up period, decreased the risk of readmission, as did having a high continuity of physician care prior to and within the 90-day follow-up period. However, few patients in this study had received such high-quality care, indicating that the Quebec system needs to considerably improve its discharge planning processes.

Duration of hospital admission in severe mental illness: is longer better?

A Cochrane review has compared short-stay hospital admission with long-stay/standard admission of patients with severe mental illness for a number of outcomes in a total 2030 participants from 6 randomised trials. It reached the conclusion, supported by limited evidence, that short admissions in mental health units do not increase the risk of death, readmission or worsening of mental state, and pose less risk of delayed discharge and patient's unemployment. This commentary examines the available evidence from previous studies and discusses its relevance to current practice.

Number of long-term inpatients in Japanese psychiatric care beds: trend analysis from the patient survey and the 630 survey

BACKGROUND

The number of psychiatric care beds and the mean length of stay in psychiatric care beds in Japan have decreased over the past 10 years. However, as has long been indicated here and elsewhere, Japan lags behind other countries in terms of deinstitutionalization. Furthermore, the population of inpatients in psychiatric care beds is aging dramatically. In addition to the diversification of mental illness, the question of what measures to implement going forward regarding current psychiatric bed resources has emerged as a new challenge.

METHODS

Using data from the Patient Survey and the 630 Survey, we examined trends in the number of long-term inpatients in psychiatric care beds in Japan through 2040. Population estimation was used for estimating long-term hospital bed demand because of small fluctuations in the admission and discharge of long-term inpatients.

RESULTS

In 2017, nearly one-third of all long-term hospitalized patients were aged ≥75 years, and an estimated 47% of the total are expected to die by 2040. Thus, the overall demand for long-term hospitalization is forecast to decrease sharply due to aging of currently hospitalized long-term inpatients. The number of long-term inpatients in 2017 was 167,579, and this is projected to decrease to 103,141 in 2040.

CONCLUSIONS

We believe it is necessary to adopt a multifaceted approach to promote hospital discharge and transition to the community, and to address the diversification of mental illness and the issue of psychiatric care bed supply/availability, which are forecast to decrease due to the natural decrease in long-term inpatients.

Use of psychiatric hospitals and social integration of patients with psychiatric disorders: a prospective cohort study in five European countries

PURPOSE

Long lengths of stay (LoS) in psychiatric hospitals or repeated admission may affect the social integration of patients with psychiatric disorders. So far, however, studies have been inconclusive. This study aimed to analyse whether long LoS or repeated admissions in psychiatric wards were associated in different ways with changes in the social integration of patients.

METHODS

Within a prospective cohort study, data were collected on 2181 patients with a main ICD-10 diagnosis of psychotic, affective, or anxiety disorder, hospitalised in the UK, Italy, Germany, Poland, and Belgium in 2015. Social integration was measured at baseline and 1 year after admission using the SIX index, which includes four dimensions: employment, housing, family situation, and friendship. Regression models were performed to test the association between LoS, the number of admissions, and the change in social integration over the study period, controlling for patients' characteristics (trial registration ISRCTN40256812).

RESULTS

A longer LoS was significantly associated with a decrease in social integration (β = - 0.23, 95%CI - 0.32 to - 0.14, p = 0.03), particularly regarding employment (OR = 2.21, 95%CI 1.18-3.24, p = 0.02), housing (OR = 3.45, 95%CI 1.74-5.16, p < 0.001), and family situation (OR = 1.94, 95%CI 1.10-2.78, p = 0.04). In contrast, repeated admissions were only associated with a decrease in friendship contacts (OR = 1.15, 95CI% 1.08-1.22, p = 0.03).

CONCLUSIONS

Results suggest that a longer hospital LoS is more strongly associated with a decrease in patients' social integration than repeated admissions. Special attention should be paid to helping patients to find and retain housing and employment while hospitalised for long periods.

The 23-Hour Observation Unit Admissions Within the Emergency Service at a National Tertiary Psychiatric Hospital: Clarifying Clinical Profiles, Outcomes, and Predictors of Subsequent Hospitalization

OBJECTIVE

We examined health care utilization, clinical profiles (such as sociodemographic features, clinical severity), and outcomes (inpatient admission, revisit within 24 hours of discharge) of patients who were admitted to a 23-hour observation unit within the emergency service of a tertiary psychiatric hospital and hypothesized that a specific clinical profile (greater clinical severity, lower psychosocial functioning) predicted subsequent inpatient hospitalization.

METHOD

The medical records of all patients admitted to the observation unit from February 5, 2007, to February 4, 2012 (N = 2,158) were assessed for relevant data. Clinical severity and level of psychosocial functioning were assessed using Clinical Global Impressions-Severity (CGI-S) and Global Assessment of Functioning (GAF) scales, respectively.

RESULTS

Overall, the patients seen were predominantly Chinese males > 36 years old who had diagnoses including stress-related, anxiety, affective spectrum, and psychotic disorders. The clinical severity score (CGI-S) improved significantly following discharge from the observation unit (t 1,1848 = 23.316; P < .001). Logistic regression analyses revealed that self-referred (P = .001), older patients (P = .007) with past psychiatric history (P = .019), lower GAF scores (P = .025), and less improvement of CGI-S scores (P = .001) were associated with inpatient admission after a 23-hour stay in the observation unit.

CONCLUSIONS

Our study findings affirmed our hypothesis and supported the utility of the observation unit in monitoring the overall clinical status of patients, which was linked with subsequent inpatient admissions. Better management of these patients at the outpatient level can potentially decrease unnecessary hospitalization and reduce health care cost as well as illness burden on patients and caregivers.

Length of hospitalisation for people with severe mental illness

BACKGROUND

In high-income countries, over the last three decades, the length of hospital stays for people with serious mental illness has reduced drastically although considerable variation remains. In lower-income countries this variation may be greater. Some argue that reduction in hospital stay leads to 'revolving door admissions' and worsening mental health outcomes despite apparent cost savings, whilst others suggest longer stays may be more harmful by institutionalising people to hospital care.

OBJECTIVES

To evaluate the effect of short stay/brief admission hospital care with long stay/standard in-patient care in people with serious mental illness.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's register of trials, July 2007 and updated this search in May 2012.

SELECTION CRITERIA

We included all randomised controlled trials comparing planned short/brief with long/standard hospital stays for people with serious mental illnesses.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated risk ratios (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based using a fixed-effect model. For continuous data, had we identified such data, we planned to calculate fixed-effect mean differences (MD). We assessed risk of bias for included studies and rated quality of evidence using GRADE.

MAIN RESULTS

We included six relevant trials undertaken between 1969 and 1980. We found no significant difference in death (n = 175, 1 RCT, RR in the longer term 0.42, CI 0.10 to 1.83, very low quality evidence). In the long term, there was no difference in improvement of mental state (n = 61, 1 RCT, RR 3.39, CI 0.76 to 15.02, very low quality evidence). There was no difference in readmission to hospital (n = 651, 4 RCTs, RR by the long term 1.26, CI 1.00 to 1.57, low quality evidence). Data for leaving the study prematurely by the longer term showed no difference (n = 229, 2 RCTs, (RR 0.77, CI 0.34 to 1.77, low quality evidence). There was a significant difference favouring short stay (P = 0.01) in numbers of participants with delayed discharge from hospital exceeding the time planned in study (n = 404, 3 RCTs, RR in the longer term 0.54, CI 0.33 to 0.88, low quality evidence). There was no difference in numbers of participants lost to follow-up (n = 404, 3 RCTs, RR by the longer term 1.07, CI 0.70 to 1.62, low quality evidence). Finally, there was a significant difference favouring short-stay hospitalisation for social functioning, including unemployment, unable to housekeep, or unknown employment status (n = 330, 2 RCTs, RR by longer term 0.61, CI 0.50 to 0.76, very low quality evidence).

AUTHORS' CONCLUSIONS

The effects of hospital care and the length of stay is important for mental health policy. We found limited low and very low quality data which were all over 30 years old. Outcomes from these studies do suggest that a planned short-stay policy does not encourage a 'revolving door' pattern of admission and disjointed care for people with serious mental illness. More large, well-designed and reported trials are justified especially where a short-stay policy is not routine care.

Clinical outcome and length of stay in an Italian Psychiatric Emergency Service

PURPOSE

The aims of the present study were to analyze outcome and to evaluate diagnosis-specific pattern of improvement during a brief hospitalization in a Psychiatric Emergency Service (PES) in a catchment area in Turin, Italy.

METHODS

A sample of 848 acute patients, consecutively hospitalized between January 2007 and December 2008 in the PES of the San Giovanni Battista Hospital, with diagnoses of non-affective psychosis-affective psychosis, depressive disorder and mania-and personality disorder (DSM-IV-TR) was recruited. All patients were assessed with the Brief Psychiatric Rating Scale (BPRS). One-way analysis of variance was used to measure patients' individual reliable and clinically significant change speed between BPRS assessments, in which change speed was referred to the division of the gap between admission and discharge scores over the number of days of length of stay (LOS).

RESULTS

The overall sample showed a significant improvement of BPRS total score and each domain during a brief hospitalization (mean LOS 10.5 days), with a different pattern between the diagnostic groups. A significant difference in change speed of BPRS resulted in the whole sample and in each diagnostic groups; patients with mania showed a significantly faster improvement.

CONCLUSIONS

A brief hospitalization in our service was shown to be highly effective. A different and diagnosis-specific patients' individual reliable and clinically significant change speed was observed, with a significantly faster improvement in patients with mania.

Day hospital versus admission for acute psychiatric disorders

BACKGROUND

Inpatient treatment is an expensive way of caring for people with acute psychiatric disorders. It has been proposed that many of those currently treated as inpatients could be cared for in acute psychiatric day hospitals.

OBJECTIVES

To assess the effects of day hospital versus inpatient care for people with acute psychiatric disorders.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (June 2010) which is based on regular searches of MEDLINE, EMBASE, CINAHL and PsycINFO. We approached trialists to identify unpublished studies.

SELECTION CRITERIA

Randomised controlled trials of day hospital versus inpatient care, for people with acute psychiatric disorders. Studies were ineligible if a majority of participants were under 18 or over 65, or had a primary diagnosis of substance abuse or organic brain disorder.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted and cross-checked data. We calculated risk ratios (RR) and 95% confidence intervals (CI) for dichotomous data. We calculated weighted or standardised means for continuous data. Day hospital trials tend to present similar outcomes in slightly different formats, making it difficult to synthesise data. We therefore sought individual patient data so that we could re-analyse outcomes in a common format.

MAIN RESULTS

Ten trials (involving 2685 people) met the inclusion criteria. We obtained individual patient data for four trials (involving 646 people). We found no difference in the number lost to follow-up by one year between day hospital care and inpatient care (5 RCTs, n = 1694, RR 0.94 CI 0.82 to 1.08). There is moderate evidence that the duration of index admission is longer for patients in day hospital care than inpatient care (4 RCTs, n = 1582, WMD 27.47 CI 3.96 to 50.98). There is very low evidence that the duration of day patient care (adjusted days/month) is longer for patients in day hospital care than inpatient care (3 RCTs, n = 265, WMD 2.34 days/month CI 1.97 to 2.70). There is no difference between day hospital care and inpatient care for the being readmitted to in/day patient care after discharge (5 RCTs, n = 667, RR 0.91 CI 0.72 to 1.15). It is likely that there is no difference between day hospital care and inpatient care for being unemployed at the end of the study (1 RCT, n = 179, RR 0.88 CI 0.66 to 1.19), for quality of life (1 RCT, n = 1117, MD 0.01 CI -0.13 to 0.15) or for treatment satisfaction (1 RCT, n = 1117, MD 0.06 CI -0.18 to 0.30).

AUTHORS' CONCLUSIONS

Caring for people in acute day hospitals is as effective as inpatient care in treating acutely ill psychiatric patients. However, further data are still needed on the cost effectiveness of day hospitals.

Outcome and length of stay in psychiatric hospitalization, the experience of the University Clinic of Turin

BACKGROUND

Given the current tendency to shorten psychiatric hospitalization and change its organization, an issue could be raised regarding its outcomes.

PURPOSE

To analyze features related to length of stay in a short-term inpatient treatment, to study outcomes and to evaluate the diagnosis-specific effects of hospitalization.

METHOD

A sample of 310 consecutive hospitalized patients, with psychotic disorder, depressive disorder and bipolar disorder (DSM IV-TR), was recruited at the University Psychiatric Clinic, Service for Cognitive Disorders, Department of Neuroscience, University of Turin. Severity of illness was rated using the brief psychiatry rating scale (BPRS). We evaluated relations between length of stay and clinical and socio-demographic features (linear regression) and possible differences confronting BPRS scores at admission and discharge in the different diagnostic subgroups (ANOVA for repeated measures).

RESULTS

All the sample of patients showed a significant improvement in symptomatology during hospitalization. Worse symptomatology in anxiety-depression domain of BPRS at admission in the whole sample was positively correlated with length of stay. A longer length of stay was also shown in patients with diagnosis of depressive disorder. Finally, a different pattern of improvement of BPRS (total score and domains) was shown between the different diagnostic groups.

CONCLUSION

Brief hospitalization in our service was shown to be highly effective. Different diagnostic groups had different response to hospitalization, showing faster improvement in characteristic symptomatology, but the anxiety-depression domain showed the highest percentage of change for all the diagnostic groups. We therefore suppose that hospitalization has two effects: a specific (due to tailored therapies) and a non-specific one (due to non-specific therapy and to a placebo-like effect).

Determinants of length of stay for psychiatric inpatients: analysis of a national database covering the entire Korean elderly population

OBJECTIVE

In a rapidly aging society, inappropriately long geropsychiatric inpatient hospitalization is a challenging concern for mental health policy-makers and researchers. This study aimed to investigate patient and institutional factors affecting geropsychiatric inpatient length of stay (LOS), providing an overview of current geropsychiatric health care system in South Korea.

METHODS

This retrospective, population-based, cross-sectional study analysed nationwide reimbursement claim databases covering the entire elderly population of Korea between January 2005 and June 2006. Given the nested structure of the data, a multivariate multilevel regression analysis was performed.

RESULTS

The average LOS was 128 days. Males, patients with schizophrenia, and those enrolled in a National Medical Care Aid program tended to have longer hospital stays. Patient age was negatively related to LOS. Institutional variables related to longer hospitalizations included a psychiatric hospital, a higher number of beds, fewer human resource employees, a higher proportion of male, oldest old, and patients with dementia.

CONCLUSIONS

Our results suggest that policies targeting geropsychiatric patients diagnosed with schizophrenia, enrolled in National Medical Care Aid programs, and admitted to psychiatric hospitals could reduce LOS. Additionally, the impact of the patient composition of a medical institution on LOS needs to be closely investigated.