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Shenai N, Fulmer V, Gowl C, See J, Peterson R, Van Deusen R. A Verbal De-escalation Standardized Patient Workshop for Third- and Fourth-Year Medical Students. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2024; 20:11417. [PMID: 39035103 PMCID: PMC11258212 DOI: 10.15766/mep_2374-8265.11417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/04/2024] [Indexed: 07/23/2024]
Abstract
Introduction Verbal de-escalation is an essential skill for physicians across specialties and is the first-line intervention for patients who present with agitation. Training in verbal de-escalation for medical students is less robust compared to other health care disciplines. We describe the creation and evaluation of a novel verbal de-escalation curriculum for third- and fourth-year medical students on their psychiatry clerkship rotation. Method We developed a simulation using standardized patient (SP) methodology and a dedicated reflection session, implementing it in the third-year psychiatry clerkship. Participants in the scenario received targeted feedback from their peers and SPs. The sessions were video recorded, and a random sample was selected and reviewed to identify key observations and themes from student performance. Results A total of 139 students participated in the encounter. One hundred twenty-two of 125 students (82%) stated the activity met the learning objectives, with 108 (86%) assigning the letter grade A to the activity. Written feedback indicated that the majority of students believed the activity to be realistic, instructive, and helpful but felt the SPs de-escalated too quickly. Video review of the encounters found that while the students effectively used the skills, many jumped to a quick fix, and some offered inappropriate choices to end the encounter. Discussion This SP activity was effective in allowing students to practice skills in a safe setting and was valued by students. In the future, adding another workshop in the fourth year could facilitate higher retention and practice of skills.
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Affiliation(s)
- Neeta Shenai
- Associate Professor of Psychiatry, University of Wisconsin School of Medicine and Public Health
| | - Valerie Fulmer
- Director of Standardized Patient Program, University of Pittsburgh School of Medicine
| | - Catherine Gowl
- Standardized Patient Program Manager, University of Pittsburgh School of Medicine
| | - Jordan See
- Assistant Professor of Medicine, University of Pittsburgh School of Medicine
| | - Ryan Peterson
- Assistant Professor of Psychiatry, University of Pittsburgh School of Medicine
| | - Reed Van Deusen
- Associate Professor of Medicine, University of Pittsburgh School of Medicine
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Shin J, San Gabriel MCP, Ho-Periola A, Ramer S, Kwon Y, Bang H. The impact of court-ordered psychiatric treatment on hospital length of stay: balancing legal and clinical concerns. JOURNAL OF KOREAN ACADEMY OF PSYCHIATRIC & MENTAL HEALTH NURSING 2022; 31:181-191. [PMID: 35891631 PMCID: PMC9311333 DOI: 10.12934/jkpmhn.2022.31.2.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 04/11/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE Psychiatric hospital length of stay (LOS) is not affected solely by socio-clinical factors but also by legal procedures. This study examined the associations between legal procedures and LOS. METHODS Data from 521 patients with psychiatric illnesses hospitalized over 2013-2015 were analyzed. Logistic regression was used to evaluate the predictors of longer (> 14 days) or prolonged (> 30) LOS with socio-clinical factors and legal procedures including court-ordered interventions (assisted outpatient treatment, medication over objection, and retention). RESULTS Longer LOS occurred in 246 patients and 99 had prolonged LOS. Legal procedures affected 57 patients, with 11 assisted outpatient treatments, 39 cases of medication over objection, and 16 retentions. Longer LOS was significantly associated with six factors including older age, unmarried status, non-Hispanic race, risk of violence, schizophrenia, and legal procedures. Legal procedures had the strongest association. Longer/prolonged LOS yielded qualitatively similar associations. CONCLUSION Among 521 psychiatric inpatients, approximately 11% were mandated to receive interventions/procedures by the courts. Court-ordered legal procedures were strongly associated with longer LOS. Mental health providers may consider legal procedures for patients at high treatment/medication noncompliance risk as early as patient admission to inpatient units to prevent, intervene or prepare for a longer or prolonged LOS.
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Affiliation(s)
- Jinah Shin
- Nurse Practitioner, Private Practice, Great Neck, NY, USA
| | - Maria Chona P. San Gabriel
- Attending Psychiatrist, Icahn School of Medicine at Mount Sinai – Health and Hospitals, Elmhurst, NY, USA
| | - Agnes Ho-Periola
- Director of Nursing Informatics, NYC Health and Hospitals, Elmhurst, NY, USA
| | - Sheryl Ramer
- Director of Health Science Library and Development, NYC Health and Hospitals, Elmhurst, NY, USA
| | - Youngihn Kwon
- Data Scientist, Insilicogen, Inc., Yongin-si, Gyeonggi-do, Korea
| | - Heejung Bang
- Professor, Division of Biostatistics, Department of Public Health Sciences, School of Medicine, University of California, Davis, CA, USA
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Mehta G, Lo B, Memarpour M, Chan A. Impact of Diabetes on Inpatient Length of Stay in Adult Mental Health Services in a Community Hospital Setting: A Retrospective Cohort Study. Can J Diabetes 2022; 46:S1499-2671(22)00075-2. [PMID: 35933315 DOI: 10.1016/j.jcjd.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 03/05/2022] [Accepted: 03/29/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Our aim in this study was to characterise the relationship between comorbid mental health diagnosis and diabetes type on inpatient length of stay (LOS). METHODS This retrospective, chart review study was conducted at a community hospital in Ontario, Canada. Individuals admitted to the inpatient mental health unit with a reported diagnosis of type 1 or type 2 diabetes were included in the analysis. Relevant data related to mental health conditions at admission and LOS were collected from the electronic health record. Analyses of variance and coviariance were used to determine the impact on LOS. RESULTS A total of 249 encounters were included in the analyses. Overall, individuals with type 2 diabetes (mean, 14.70 days; standard deviation, 15.75 days) had a significantly longer LOS than individuals with type 1 diabetes (mean, 8.01 days; standard deviation, 7.27 days). Upon including sociodemographic factors, individuals older in age and with a most recent admission of <1 year also had a longer LOS. There was no significant relationship between the most responsible mental health diagnosis and LOS. CONCLUSIONS Individuals with type 2 diabetes may be more likely to have a longer LOS in inpatient mental health settings than those with type 1 diabetes. More dedicated support would be beneficial for this population. Future work should focus on in-depth exploration of the challenges that lead to the observed LOS.
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Affiliation(s)
- Gaurav Mehta
- Southlake Regional Health Centre, Newmarket, Ontario, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Brian Lo
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Mahdi Memarpour
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Angela Chan
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
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Durns TA, O'Connell PH, Shvartsur A, Grey JS, Kious BM. Effects of temporary psychiatric holds on length of stay and readmission risk among persons admitted for psychotic disorders. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2021; 76:101695. [PMID: 33761439 DOI: 10.1016/j.ijlp.2021.101695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 03/10/2021] [Accepted: 03/10/2021] [Indexed: 06/12/2023]
Abstract
The practice of involuntary psychiatric commitment is central to the acute treatment of persons with severe mental illness and others in psychiatric crisis. Deciding whether a patient should be admitted involuntarily requires weighing respect for autonomy against beneficence, considering the clinical needs of the patient, and navigating ambiguous legal standards. The relative dearth of information about the impact of involuntary commitment on objective patient outcomes complicates matters ethically, legally, and clinically. To address this gap in the literature, we sought to determine the association between temporary psychiatric holds and length of stay and readmission rates among a retrospective sample of adult patients admitted to a large psychiatric hospital with diagnoses of schizophrenia, schizoaffective disorder, mania, and other psychotic disorders. In total, we identified 460 patients and 559 unique encounters meeting our inclusion criteria; 90 of the encounters were voluntary (involving a temporary psychiatric hold) and 469 were involuntary. Univariable and multivariable analyses suggested that temporary psychiatric holds were not significantly associated with either length of stay or readmission rate. These findings are relevant to clinicians who must decide whether to admit a patient involuntarily, as they suggest that making a patient involuntary is not associated with differences in length of stay or readmission risk.
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Affiliation(s)
- Tyler A Durns
- Department of Psychiatry, University of Utah, 501 Chipeta Way, Salt Lake City, UT, 84108, USA.
| | - Patrick H O'Connell
- University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT, 84132, USA.
| | - Anna Shvartsur
- University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT, 84132, USA.
| | - Jessica S Grey
- University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT, 84132, USA.
| | - Brent M Kious
- Department of Psychiatry, University of Utah, 501 Chipeta Way, Salt Lake City, UT, 84108, USA.
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Pott C, Stargardt T, Schneider U, Frey S. Do discontinuities in marginal reimbursement affect inpatient psychiatric care in Germany? THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2021; 22:101-114. [PMID: 33165668 PMCID: PMC7822769 DOI: 10.1007/s10198-020-01241-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 10/15/2020] [Indexed: 06/11/2023]
Abstract
This paper examines the behaviour of mental health care providers in response to marginal payment incentives induced by a discontinuous per diem reimbursement schedule with varying tariff rates over the length of stay. The analyses use administrative data on 12,627 cases treated in 82 psychiatric hospitals and wards in Germany. We investigate whether substantial reductions in marginal reimbursement per inpatient day led to strategic discharge behaviour once a certain length of stay threshold is exceeded. The data do not show gaps and bunches at the duration of treatment when marginal reimbursement decreases. Using logistic regression models, we find that providers did not react to discontinuities in marginal reimbursement by significantly reducing inpatient length of stay around the threshold. These findings are robust in terms of different model specifications and subsamples. The results indicate that if regulators aim to set incentives to decrease LOS, this might not be achieved by cuts in reimbursement over LOS.
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Affiliation(s)
- Clara Pott
- Hamburg Center for Health Economics (HCHE), University of Hamburg, Esplanade 36, 20354, Hamburg, Germany.
| | - Tom Stargardt
- Hamburg Center for Health Economics (HCHE), University of Hamburg, Esplanade 36, 20354, Hamburg, Germany
| | - Udo Schneider
- Techniker Krankenkasse, Bramfelder Straße 140, 22305, Hamburg, Germany
| | - Simon Frey
- Hamburg Center for Health Economics (HCHE), University of Hamburg, Esplanade 36, 20354, Hamburg, Germany
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Oh H, Lee J, Kim S, Rufino KA, Fonagy P, Oldham JM, Schanzer B, Patriquin MA. Time in treatment: Examining mental illness trajectories across inpatient psychiatric treatment. J Psychiatr Res 2020; 130:22-30. [PMID: 32768710 DOI: 10.1016/j.jpsychires.2020.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/03/2020] [Accepted: 07/01/2020] [Indexed: 12/12/2022]
Abstract
Early discharge or reduced length of stay for inpatient psychiatric patients is related to increased readmission rates and worse clinical outcomes including increased risk for suicide. Trajectories of mental illness outcomes have been identified as an important method for predicting the optimal length of stay but the distinguishing factors that separate trajectories remain unclear. We sought to identify the distinct classes of patients who demonstrated similar trajectories of mental illness over the course of inpatient treatment, and we explore the patient characteristics associated with these mental illness trajectories. We used data (N = 3406) from an inpatient psychiatric hospital with intermediate lengths of stay. Using growth mixture modeling, latent mental illness scores were derived from six mental illness indicators: psychological flexibility, emotion regulation problems, anxiety, depression, suicidal ideation, and disability. The patients were grouped into three distinct trajectory classes: (1) High-Risk, Rapid Improvement (HR-RI); (2) Low-Risk, Gradual Improvement (LR-GI); and (3) High-Risk, Gradual Improvement (HR-GI). The HR-GI was significantly younger than the other two classes. The HR-GI had significantly more female patients than males, while the LR-GI had more male patients than females. Our findings indicated that younger females had more severe mental illness at admission and only gradual improvement during the inpatient treatment period, and they remained in treatment for longer lengths of stay, than older males.
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Affiliation(s)
- Hyuntaek Oh
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd., Houston, TX, 77030, USA; The Menninger Clinic, 12301 S Main St, Houston, TX, 77035, USA.
| | - Jaehoon Lee
- Department of Educational Psychology and Leadership, College of Education, Texas Tech University, 3002 18th Street, Lubbock, TX, 79409, USA
| | - Seungman Kim
- Department of Educational Psychology and Leadership, College of Education, Texas Tech University, 3002 18th Street, Lubbock, TX, 79409, USA
| | - Katrina A Rufino
- The Menninger Clinic, 12301 S Main St, Houston, TX, 77035, USA; Department of Social Sciences, University of Houston - Downtown, One Main St, Houston, TX, 77002, USA
| | - Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College London, UK
| | - John M Oldham
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd., Houston, TX, 77030, USA; The Menninger Clinic, 12301 S Main St, Houston, TX, 77035, USA
| | - Bella Schanzer
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd., Houston, TX, 77030, USA; The Menninger Clinic, 12301 S Main St, Houston, TX, 77035, USA
| | - Michelle A Patriquin
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd., Houston, TX, 77030, USA; The Menninger Clinic, 12301 S Main St, Houston, TX, 77035, USA
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Silva M, Antunes A, Loureiro A, Azeredo-Lopes S, Saraceno B, Caldas-de-Almeida JM, Cardoso G. Factors associated with length of stay and readmission in acute psychiatric inpatient services in Portugal. Psychiatry Res 2020; 293:113420. [PMID: 32861099 DOI: 10.1016/j.psychres.2020.113420] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 11/20/2022]
Abstract
Assessing the factors that influence duration and number of hospitalizations may support mental health services planning and delivery. This study examines the factors associated with length of stay and readmission in Portuguese psychiatric inpatient services during 2002, 2007 and 2012. Data from all admissions were extracted from clinical files. Logistic regression models estimated the association between length of stay (<17 vs ≥17 days) and number of admissions per year (1 vs >1 admission) with sociodemographic, clinical, and contextual factors. Older age, a diagnosis of psychosis, and compulsory admission were associated with higher odds of longer length of stay. Being married, secondary education, suicide attempt, a diagnosis of substance use and "other mental disorders", being admitted in 2012, and two of the psychiatric inpatient services associated with lower odds of longer length of stay. Being retired (or others), a diagnosis of psychosis, compulsory admission, and psychiatric service were associated with increased odds of readmission. Older age, and secondary and higher education were associated with lower odds of readmission. The findings indicate that multiple factors influence length of stay and readmission. Identifying these factors provides useful evidence for clinicians and policy makers to design more targeted and cost-effective interventions.
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Affiliation(s)
- M Silva
- Comprehensive Health Research Centre (CHRC), Nova Medical School, Nova University of Lisbon, Rua do Instituto Bacteriológico, n°5, 1150-190 Lisbon, Portugal; Lisbon Institute of Global Mental Health, Lisbon, Portugal.
| | - A Antunes
- Comprehensive Health Research Centre (CHRC), Nova Medical School, Nova University of Lisbon, Rua do Instituto Bacteriológico, n°5, 1150-190 Lisbon, Portugal; Lisbon Institute of Global Mental Health, Lisbon, Portugal.
| | - A Loureiro
- Centre of Studies on Geography and Spatial Planning (CEGOT), Faculty of Arts and Humanities, Coimbra, Portugal
| | - S Azeredo-Lopes
- Nova Medical School, Nova University of Lisbon, Lisbon, Portugal.
| | - B Saraceno
- Comprehensive Health Research Centre (CHRC), Nova Medical School, Nova University of Lisbon, Rua do Instituto Bacteriológico, n°5, 1150-190 Lisbon, Portugal; Lisbon Institute of Global Mental Health, Lisbon, Portugal
| | - J M Caldas-de-Almeida
- Comprehensive Health Research Centre (CHRC), Nova Medical School, Nova University of Lisbon, Rua do Instituto Bacteriológico, n°5, 1150-190 Lisbon, Portugal; Lisbon Institute of Global Mental Health, Lisbon, Portugal
| | - G Cardoso
- Comprehensive Health Research Centre (CHRC), Nova Medical School, Nova University of Lisbon, Rua do Instituto Bacteriológico, n°5, 1150-190 Lisbon, Portugal; Lisbon Institute of Global Mental Health, Lisbon, Portugal
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Weissinger GM, Carthon JMB, Brawner BM. Non-psychiatric hospitalization length-of-stay for patients with psychotic disorders: A mixed methods study. Gen Hosp Psychiatry 2020; 67:1-9. [PMID: 32866772 PMCID: PMC7722147 DOI: 10.1016/j.genhosppsych.2020.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Patients with psychotic disorders experience higher rates of chronic and acute non-psychotic diseases and have frequent non-psychiatric hospitalizations which result in both longer and more varied length-of-stay (LoS) than other patients. This study seeks to use a patient-centered perspective to examine LoS. METHODS This article reports Phase Two of a mixed methods, exploratory sequential study on non-psychiatric hospitalizations for individuals with psychotic disorders. Patients' experiences were used to guide a quantitative analysis of LoS using a general linear model. RESULTS Medical comorbidities were the patient characteristics which had the largest effect on LoS. Certain processes of care highlighted by patients from Phase One were also associated with longer LoS, including: physical restraints (105%), psychiatric consults (20%) and continuous observation (133%). Only recent in-system outpatient appointments were associated with shorter LoS. Data integration highlighted that factors which were important to patients such as partner support, were not always quantitatively significant, while others like medical comorbidities and use of physical restraints were points of congruence. CONCLUSIONS Medical comorbidities were highly associated with LoS but processes relating to longer LoS are those that are used to manage symptoms of acute psychosis. Clinicians should develop policies and procedures that address psychosis symptoms effectively during non-psychiatric hospitalizations. Further research is needed to understand which patients with psychotic disorders are at highest risk of extended length-of-stay.
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Affiliation(s)
- Guy M Weissinger
- Drexel University, College of Nursing and Health Professions, 3020 Market Street, Suite 510, Philadelphia, PA 19104, United States of America; University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104, United States of America.
| | - J Margo Brooks Carthon
- University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104, United States of America
| | - Bridgette M Brawner
- University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104, United States of America
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Barroilhet SA, Pellegrini AM, McCoy TH, Perlis RH. Characterizing DSM-5 and ICD-11 personality disorder features in psychiatric inpatients at scale using electronic health records. Psychol Med 2020; 50:2221-2229. [PMID: 31544723 PMCID: PMC9980721 DOI: 10.1017/s0033291719002320] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Investigation of personality traits and pathology in large, generalizable clinical cohorts has been hindered by inconsistent assessment and failure to consider a range of personality disorders (PDs) simultaneously. METHODS We applied natural language processing (NLP) of electronic health record notes to characterize a psychiatric inpatient cohort. A set of terms reflecting personality trait domains were derived, expanded, and then refined based on expert consensus. Latent Dirichlet allocation was used to score notes to estimate the extent to which any given note reflected PD topics. Regression models were used to examine the relationship of these estimates with sociodemographic features and length of stay. RESULTS Among 3623 patients with 4702 admissions, being male, non-white, having a low burden of medical comorbidity, being admitted through the emergency department, and having public insurance were independently associated with greater levels of disinhibition, detachment, and psychoticism. Being female, white, and having private insurance were independently associated with greater levels of negative affectivity. The presence of disinhibition, psychoticism, and negative affectivity were each significantly associated with a longer stay, while detachment was associated with a shorter stay. CONCLUSIONS Personality features can be systematically and scalably measured using NLP in the inpatient setting, and some of these features associate with length of stay. Developing treatment strategies for patients scoring high in certain personality dimensions may facilitate more efficient, targeted interventions, and may help reduce the impact of personality features on mental health service utilization.
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Affiliation(s)
- Sergio A. Barroilhet
- Center for Quantitative Health, Division of Clinical Research and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Tufts University School of Medicine, Boston, MA, USA
- University Psychiatric Clinic, University of Chile Clinical Hospital, Santiago, Chile
| | - Amelia M. Pellegrini
- Center for Quantitative Health, Division of Clinical Research and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas H. McCoy
- Center for Quantitative Health, Division of Clinical Research and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Roy H. Perlis
- Center for Quantitative Health, Division of Clinical Research and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
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Olayinka O, Ojimba C, Alemu B, Olaolu O, Edomias D, Popoola O, Kallikkadan J, Tumenta T, Gayam V, Valbrun L, Olupona T, Hershberger J. Cannabis Use in Inpatients With Schizophrenia Spectrum Disorders at a Community Hospital. J Clin Med Res 2020; 12:243-250. [PMID: 32362972 PMCID: PMC7188370 DOI: 10.14740/jocmr4110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 03/03/2020] [Indexed: 12/14/2022] Open
Abstract
Background Cannabis is the second most used recreational drug in the United States and one of the most used substances in patients with schizophrenia spectrum disorder (SSD). Unfortunately, the increased use is likely to continue as more states legalize recreational use of cannabis. Although the association between cannabis and schizophrenia has been studied extensively, the understanding of the relationship is still evolving. In this study, we sought to determine the prevalence and potential factors associated with cannabis use (CU) among inpatients with SSD at a community teaching hospital. Methods We performed a retrospective review of the electronic medical charts of patients discharged from the psychiatric unit of our hospital from July 1, 2017 through October 31, 2017. Patients were included in this study if: 1) They were ≥ 18 years old; 2) They had discharge diagnosis of SSD; and 3) They had urine drug testing performed. Pertinent sociodemographic and clinical variables, including substance use status and hospital length of stay (LOS), were abstracted. Univariate frequencies and summary statistics were performed. Odds ratios (ORs) were determined by logistic regression analysis of bivariate and multivariate analyses. Results Three hundred sixty-five (52.2%) patients had a discharge diagnosis of SSD, and only 322 had urine toxicology result for cannabinoids and were included in analysis. Of the 322 patients, 41.5% (n = 133) screened positive for cannabinoids. Of the 133 patients, 78% were African American, 15% were Hispanic and 5% were White; 77% were male and the median age was 36 years. Bivariate analyses showed tobacco use (OR: 2.8, 95% confidence interval (CI): 1.7 - 4.6), alcohol use (OR: 3.4, 95% CI: 2.9 - 7.0), younger age (OR: 2.8, 95% CI: 1.8 - 4.5), male gender (OR: 2.9, 95% CI: 2.2 - 3.2), unemployment (OR: 3.91, 95% CI: 3.49 - 7.35), homelessness (OR: 3.18, 95% CI: 2.76 - 3.84) and LOS (OR: 3.46, 95% CI: 2.93 - 4.31) were significantly associated with CU. Result of multivariate analysis was similar to that found in bivariate analysis. Conclusions CU appears to be prevalent among patients with SSD. Clinicians and public health professionals are encouraged to understand the health implications of its use in patients with mental illness especially against the backdrop of current marijuana laws.
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Affiliation(s)
- Olaniyi Olayinka
- Department of Psychiatry and Behavioral Sciences, Interfaith Medical Center, Brooklyn, NY, USA
| | - Chiedozie Ojimba
- Department of Psychiatry and Behavioral Sciences, Interfaith Medical Center, Brooklyn, NY, USA
| | - Brook Alemu
- Integrated Health Sciences Program, School of Health Sciences, Western Carolina University, Cullowhee, NC, USA
| | - Olalekan Olaolu
- Department of Psychiatry and Behavioral Sciences, Interfaith Medical Center, Brooklyn, NY, USA
| | - Desta Edomias
- Department of Internal Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Olusegun Popoola
- Department of Psychiatry and Behavioral Sciences, Interfaith Medical Center, Brooklyn, NY, USA
| | - Jisha Kallikkadan
- Department of Psychiatry and Behavioral Sciences, Interfaith Medical Center, Brooklyn, NY, USA
| | - Terence Tumenta
- Department of Psychiatry and Behavioral Sciences, Interfaith Medical Center, Brooklyn, NY, USA
| | - Vijay Gayam
- Department of Internal Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Leon Valbrun
- Department of Psychiatry and Behavioral Sciences, Interfaith Medical Center, Brooklyn, NY, USA
| | - Tolu Olupona
- Department of Psychiatry and Behavioral Sciences, Interfaith Medical Center, Brooklyn, NY, USA
| | - Jason Hershberger
- Department of Psychiatry and Behavioral Sciences, Interfaith Medical Center, Brooklyn, NY, USA
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11
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Ignatyev Y, Mundt AP, von Peter S, Heinze M. Hospital length of stay among older people treated with flexible and integrative psychiatric service models in Germany. Int J Geriatr Psychiatry 2019; 34:1557-1564. [PMID: 31276239 DOI: 10.1002/gps.5165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 06/29/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Since 2012, a new law (§64b, Book V of the Social Security Code [SGB V]) regulates the implementation of flexible and integrative psychiatric treatment projects (FIT64b) in Germany. FIT64b allows rapid discharge of patients from inpatient to outpatient settings and cost reductions of hospital stays. Several psychiatric centres exclusively provide FIT64b; others provide FIT64b alongside with standard health care. The aim of the study was to assess the average hospital length of stay (AHLS) of older patients with mental illness included in FIT64b projects. METHODS A secondary data analysis was conducted using administrative data from eight German mental health centres providing FIT64b. The effects of gender, age, type of centre, and main diagnosis on AHLS were calculated for all older patients with age 65 years or older (n = 3495) treated in FIT64b in the year 2016. Data were analysed with descriptive statistics and robust multiway procedures. RESULTS The AHLS of older people with mental illness was 4.8 (SD = 11.5) days. The AHLS was shorter in centres exclusively providing FIT64b than in centres providing FIT64b alongside with standard health care: 3.2 (SD = 6.4) vs 8.4 (SD = 17.8) days, P = .001. This difference was particularly marked among patients with schizophrenia spectrum disorders, mood disorders, and neurotic, stress-related, and somatoform disorders. CONCLUSIONS FIT64b relates to very short AHLS even among older people. Centres using FIT64b alongside with standard health care usually provide standard care to most patients, which could lead to lower fidelity in the implementation of FIT64b.
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Affiliation(s)
- Yuriy Ignatyev
- Department of Psychiatry and Psychotherapy, Immanuel Klinik Rüdersdorf, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
| | - Adrian P Mundt
- Medical Faculty, Universidad Diego Portales, Santiago, Chile.,Medical School, Universidad San Sebastián, Puerto Montt, Chile
| | - Sebastian von Peter
- Department of Psychiatry and Psychotherapy, Immanuel Klinik Rüdersdorf, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
| | - Martin Heinze
- Department of Psychiatry and Psychotherapy, Immanuel Klinik Rüdersdorf, Brandenburg Medical School Theodor Fontane, Rüdersdorf, Germany
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Ragazan DC, Eberhard J, Ösby U, Berge J. Gender influence on the bipolar disorder inpatient length of stay in Sweden, 2005-2014: A register-based study. J Affect Disord 2019; 256:183-191. [PMID: 31177046 DOI: 10.1016/j.jad.2019.05.052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/03/2019] [Accepted: 05/27/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND The influence of gender on bipolar disorder is controversial and it is unclear if inpatient care differs between men and women. Here, we investigate for gender differences in the inpatient length of stay for Swedes admitted for bipolar disorder and explore other factors that could explain any observed association. METHODS Admission data were extracted from the Swedish National Patient Register and included all patients first admitted to a psychiatric inpatient unit with a bipolar disorder diagnosis, circa 2005-2014. Patients were then retrospectively followed for subsequent hospitalizations. Diagnostic subtypes were categorized by ICD-10 clusters: depressive, depressive with psychotic features, manic, manic with psychotic features, mixed, and other. Psychotropic therapies preceding the corresponding admissions were attained from the Prescribed Drug Register. Mixed-effects zero-truncated negative binomial regressions were employed to model the length of stay per admission. RESULTS Analysis included 39,653 admissions by 16,271 inpatients (60.0% women). Overall, when compared to men, women spent 7.5% (95% CI: 4.2-11.0%, p < 0.001) extra days hospitalized per admission. However, upon adjusting for candidate confounders, including the bipolar subtype, and selected comorbidities and psychotropics, the association weakened wherein women then spent 3.7% (95% CI: 0.1-6.9%, p = 0.028) extra days hospitalized per admission. LIMITATIONS The integrity of register data can be variable and the adherence to outpatient dispensed psychotropics could not be validated. CONCLUSION Although the influence of gender on the bipolar disorder inpatient length of stay is evident, other factors attenuate and better explain this crude observation.
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Affiliation(s)
- Dragos C Ragazan
- Lund University, Dept. of Clinical Sciences Lund, Division of Psychiatry, Baravägen 1, Psykiatriska kliniken, Lund, Sweden.
| | - Jonas Eberhard
- Lund University, Dept. of Clinical Sciences Lund, Division of Psychiatry, Baravägen 1, Psykiatriska kliniken, Lund, Sweden
| | - Urban Ösby
- Karolinska Institutet, Dept. of Clinical Neuroscience, Stockholm, Sweden
| | - Jonas Berge
- Lund University, Dept. of Clinical Sciences Lund, Division of Psychiatry, Baravägen 1, Psykiatriska kliniken, Lund, Sweden
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Borderline Personality Features in Inpatients with Bipolar Disorder: Impact on Course and Machine Learning Model Use to Predict Rapid Readmission. J Psychiatr Pract 2019; 25:279-289. [PMID: 31291208 DOI: 10.1097/pra.0000000000000392] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Earlier research indicated that nearly 20% of patients diagnosed with either bipolar disorder (BD) or borderline personality disorder (BPD) also met criteria for the other diagnosis. Yet limited data are available concerning the potential impact of co-occurring BPD and/or BPD features on the course or outcome in patients with BD. Therefore, this study examined this comorbidity utilizing the standardized Borderline Personality Questionnaire (BPQ). METHODS This study involved 714 adult patients with a primary diagnosis of BD per DSM-IV criteria who were admitted to the psychiatric unit at an academic hospital in Houston, TX between July 2013 and July 2018. All patients completed the BPQ within 72 hours of admission. Statistical analysis was used to detect correlations between severity of BD, length of stay (LOS), and scores on the BPQ. A machine learning model was constructed to predict the parameters affecting patients' readmission rates within 30 days. RESULTS Analysis revealed that the severity of certain BPD traits at baseline was associated with mood state and outcome measured by LOS. Inpatients with BD who were admitted during acute depressive episodes had significantly higher mean scores on 7 of the 9 BPQ subscales (P<0.05) compared with those admitted during acute manic episodes. Inpatients with BD with greater BPQ scores on 4 of the 9 BPQ subscales had significantly shorter LOS than those with lower BPQ scores (P<0.05). The machine learning model identified 6 variables as predictors for likelihood of 30-day readmission with a high sensitivity (83%), specificity (77%), and area under the receiver operating characteristic curve of 86%. CONCLUSIONS Although preliminary, these results suggest that inpatients with BD who have higher levels of BPD features were more likely to have depressive rather than manic symptoms, fewer psychotic symptoms, and a shorter LOS. Moreover, machine learning models may be particularly valuable in identifying patients with BD who are at the highest risk for adverse consequences including rapid readmission.
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Hielscher E, Diminic S, Harris M, Castle D, Lee YY, Kealton J, Whiteford H. Impact of the carer on length of hospital stay for mental health: Results from two Australian surveys. Int J Ment Health Nurs 2019; 28:436-447. [PMID: 30246493 DOI: 10.1111/inm.12543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2018] [Indexed: 11/30/2022]
Abstract
Informal carers play a vital role in supporting Australians living with a mental illness, including during the acute phases of illness; however, little is known about their impact on length of hospital stay. We aimed to investigate the impact of having a carer and of carer burden on length of hospital stay for mental health. Two Australian datasets were used. Data from the 2010 National Survey of High Impact Psychosis (n = 1825) were used to investigate the impact of having versus not having a carer on length of hospital stay for mental health. Data from the UQ Carer Survey 2016 (n = 105), a convenience sample of mental health carers, were used to investigate the impact of weekly hours of care (a measure of objective carer burden) on length of stay. Multiple logistic regression and correlation analyses were performed to investigate the association between carer status/burden and length of stay. Having a carer was associated with a significantly longer length of hospital stay; however, this relationship was no longer significant after adjusting for diagnosis, global functioning, depressive symptoms, deliberate self-harm, mental health outpatient contacts and type of admission. Weekly hours of care did not significantly impact on length of stay. Patients with carers had poorer functioning which may be related to longer stays. Our analysis was not able to look at subgroups of carers with different needs. Future work is required to determine other components of the admission and discharge process where having a carer is influential.
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Affiliation(s)
- Emily Hielscher
- Policy and Epidemiology Group, Queensland Centre for Mental Health Research (QCMHR), The Park Centre for Mental Health, Brisbane, Queensland, Australia.,School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Sandra Diminic
- Policy and Epidemiology Group, Queensland Centre for Mental Health Research (QCMHR), The Park Centre for Mental Health, Brisbane, Queensland, Australia.,School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Meredith Harris
- Policy and Epidemiology Group, Queensland Centre for Mental Health Research (QCMHR), The Park Centre for Mental Health, Brisbane, Queensland, Australia.,School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - David Castle
- University of Melbourne and St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Yong Yi Lee
- Policy and Epidemiology Group, Queensland Centre for Mental Health Research (QCMHR), The Park Centre for Mental Health, Brisbane, Queensland, Australia.,School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Jan Kealton
- Carer Consultant, Gold Coast, Queensland, Australia
| | - Harvey Whiteford
- Policy and Epidemiology Group, Queensland Centre for Mental Health Research (QCMHR), The Park Centre for Mental Health, Brisbane, Queensland, Australia.,School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Institute of Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
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15
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Fleury MJ, Fortin M, Rochette L, Grenier G, Huỳnh C, Pelletier É, Vasiliadis HM. Assessing quality indicators related to mental health emergency room utilization. BMC Emerg Med 2019; 19:8. [PMID: 30646847 PMCID: PMC6332534 DOI: 10.1186/s12873-019-0223-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 01/04/2019] [Indexed: 01/13/2023] Open
Abstract
Background This descriptive study compared 2014–15 to 2005–06 data on the quality of mental health services (MHS) in relation to emergency room (ER) use to assess the impact of the 2005 Quebec MH reform regarding access, continuity and appropriateness of care for patients with mental illnesses (PMI). Methods Data emanated from the Quebec Integrated Chronic Disease Surveillance System (Quebec/Canada). Participants (865,255 for 2014–15; 817,395 for 2005–06) were age 12 or over, with at least one MI, including substance use disorders (SUD), diagnosed during an ER visit, outpatient treatment or hospitalization. Variables included: access (ER use/frequency, hospitalization rates, outpatient consultations preceding an ER visit), care continuity (outpatient consultations following an ER visit/hospitalization, consecutive returns to the ERs), and care appropriateness (high ER use, recurrence of yearly ER visits, length of hospitalization). Frequency distributions were calculated on sex, age and geographic area for ER visits/hospitalizations in 2014–15, and between 2014 and 15 and 2005–06. Results PMI accounted for 12 % of the Quebec population in 2014–15 (n = 865,255), of whom 39% visited an ER for any reason. Amount and frequency of ER use and number/length of hospitalizations were almost twice as high for PMI versus patients without MI; 17% of PMI were also high/very high ER users and were frequently hospitalized. Among PMI, ER users were also frequent users of outpatient services despite a lack of follow-up appointments after ER visits or hospitalizations. Findings revealed some positive changes over time, such as decreased ER and hospitalization rates; yet overall access, continuity and appropriateness of care, as measured in this study, remained low. Conclusions This study demonstrated that the Quebec reform did not produce a substantial impact on ER use or substantially improved care, as hypothesized. Better access and continuity of care should be promoted to reduce the high prevalence of ER use among PMI. Quality improvement in MHS may be realized if ERs are supported by substantial and well-integrated community MH networks.
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Affiliation(s)
- Marie-Josée Fleury
- Department of Psychiatry, McGill University, Montreal, QC, Canada. .,Douglas Mental Health University Institute Research Centre, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada.
| | - Marilyn Fortin
- Douglas Mental Health University Institute Research Centre, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada
| | - Louis Rochette
- Quebec National Institute of Public Health, Quebec, QC, Canada
| | - Guy Grenier
- Douglas Mental Health University Institute Research Centre, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada
| | - Christophe Huỳnh
- Centre de recherche et d'expertise en dépendance, Montréal, QC, Canada.,Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Ile-de-Montréal, Montréal, QC, Canada
| | - Éric Pelletier
- Quebec National Institute of Public Health, Quebec, QC, Canada
| | - Helen-Maria Vasiliadis
- Département des sciences de la santé communautaires, Université de Sherbrooke, Sherbrooke, QC, Canada.,Centre de recherche de l'hôpital Charles LeMoyne, Longueuil, QC, Canada
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Edlinger M, Welte AS, Yalcin-Siedentopf N, Kemmler G, Neymeyer F, Fleischhacker WW, Hofer A. Trends in pharmacological emergency treatment of patients suffering from schizophrenia over a 16-year observation period. Int Clin Psychopharmacol 2018; 33:197-203. [PMID: 29664808 DOI: 10.1097/yic.0000000000000220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patients suffering from schizophrenia are often treated in locked psychiatric units because of psychomotor agitation, hostility and aggressive behavior, or suicidality. Because of legal conditions, investigations on these acutely ill patients are difficult, and many studies do not represent 'real-life psychiatry'. This retrospective survey was conducted at the Department of Psychiatry, Psychotherapy and Psychosomatics of the Medical University, Innsbruck, Austria. Data were collected from the records of all adult inpatients suffering from a schizophrenia spectrum disorder according to the International Classification of Diseases, 10th ed. (ICD-10) (F2x) who had been admitted to a locked unit in 1997, 2002, 2007, and 2012. In addition to demographic data, diagnoses at the time of admission, length of stay at the locked unit, and psychopharmacological treatment (3 h before and following admission) were recorded. The mean length of stay at a locked unit decreased significantly from 11.8±4.43 days (mean±SD) in 1997 to 8.5±12.96 days (mean±SD) in 2012. The use of antipsychotics decreased nonsignificantly from 1997 to 2012. Despite an increasing use of second compared with first-generation antipsychotic drugs over the course of time, haloperidol was the most frequently used single compound in all investigated years except 2012. The majority of medications were administered orally. The use of benzodiazepines did not change substantially over the course of time. All in all, pharmacological emergency treatment of patients suffering from schizophrenia spectrum disorders in locked units was in line with current treatment guidelines, which recommend the use of second-generation antipsychotic drugs, monotherapy, oral application, and cautious dosing.
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Affiliation(s)
- Monika Edlinger
- Department of Psychiatry, Psychotherapy and Psychosomatics, Division of Psychiatry I, Medical University Innsbruck, Innsbruck, Austria
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Carpar E, McCarthy G, Adamis D, Donmezler G, Cesur E, Fistikci N. Socio-demographic characteristics and factors associated with hospitalization in psychiatry of old age patients: an international comparison between Ireland and Turkey. Aging Clin Exp Res 2018; 30:651-660. [PMID: 28808907 DOI: 10.1007/s40520-017-0813-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 08/02/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Taking predictors of hospitalization characteristics into consideration internationally would broaden our understanding of this population on a local basis. AIMS We aimed to examine and compare socio-demographic profiles along with hospitalization characteristics including length of hospital stay (LOS), reasons for admission and diagnoses among older adult inpatients hospitalized in Ireland and Turkey, and to assess factors predicting these features. METHODS The admission charts of 356 psychiatric inpatients over 65 years of age who were admitted to two different acute psychiatric hospitals (Sligo/Ireland and Istanbul/Turkey) were analysed by means of descriptive modalities and logistic regression. RESULTS There were significant differences in several domains of socio-demographics, reasons of admission and diagnoses. LOS was significantly longer in Ireland. Living alone was the only significant predictor for longer LOS in both countries, whereas in addition to living alone, younger age was also a contributor for longer LOS in Turkey. DISCUSSION Given that the only factor predicting LOS both in Turkey and Ireland was living alone, helping to identify more acceptable ways of providing social support for living arrangements constitutes an important service to shorten LOS in old age psychiatric population. CONCLUSIONS It is possible to infer that independent from the cultural diversities, living arrangement is a consistent entity to influence length of hospital stay in older adult population.
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Affiliation(s)
- Elif Carpar
- Department of Psychiatry, Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Zuhuratbaba, 34147, Istanbul, Turkey.
| | - Geraldine McCarthy
- Departmant of Psychiatry, Sligo Leitrim South Donegal Mental Health Service, Sligo, Ireland
| | - Dimitrios Adamis
- Departmant of Psychiatry, Sligo Leitrim South Donegal Mental Health Service, Sligo, Ireland
| | - Gizem Donmezler
- Department of Psychiatry, Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Zuhuratbaba, 34147, Istanbul, Turkey
| | - Ender Cesur
- Department of Psychiatry, Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Zuhuratbaba, 34147, Istanbul, Turkey
| | - Nurhan Fistikci
- Department of Psychiatry, Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Zuhuratbaba, 34147, Istanbul, Turkey
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18
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Fornaro M, Iasevoli F, Novello S, Fusco A, Anastasia A, De Berardis D, Valchera A, de Bartolomeis A. Predictors of hospitalization length of stay among re-admitted treatment-resistant Bipolar Disorder inpatients. J Affect Disord 2018; 228:118-124. [PMID: 29245092 DOI: 10.1016/j.jad.2017.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/08/2017] [Accepted: 12/05/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hospitalization accounts for significant health care resource utilization for treatment-resistant Bipolar Disorder (BD), especially among frequent users of acute inpatient psychiatric units. Appraisal of the clinical features and predictive role of selected variables is therefore crucial in such population, representing the aim of the present research. METHODS A hundred and nineteen BD inpatients with an established history of pharmacological treatment resistance for either mania or bipolar depression were classified as long hospitalization cases (LOS+) and their controls and compared against each other for a number of demographic, clinical, and psychopathological features. RESULTS Overall, female sex, current second-generation atypical antipsychotic (SGA)/mood stabilizer other than lithium as well as antidepressant treatment at the admission occurred statistically more frequently among LOS+ cases, concordant with higher scores at the Hamilton scales for depression and anxiety. Lithium utilization at the time of hospitalization did not differ between cases and controls (LOS-, n = 81/119), as predominant affective temperament and other psychopathological rating did not. Overall, the time of admission, use of SGA, anticonvulsant (other than lithium), antidepressant, lifetime alcohol dependence, and BD Type (-I or -II), but not current mood polarity at the time of hospitalization, correctly predicted LOS+ grouping 68.2% of the times: Exp(B) = 3.151, p042. LIMITATIONS Post-hoc, cross-sectional study, relatively small sample size, recall and selection bias on some diagnoses. CONCLUSIONS Overall, LOS+ treatment-resistant BD inpatients characterize for higher severity and greater pharmaco-utilization use, which warrants replication studies to include additional predictors to shed further light on the matter.
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Affiliation(s)
- M Fornaro
- Unit on Treatment Resistant Disorders, Department of Neuroscience, Reproductive Sciences and Odontostomatology University School of Medicine Federico II, Naples, Via Pansini 5, 80131 Napoli, Italy.
| | - F Iasevoli
- Unit on Treatment Resistant Disorders, Department of Neuroscience, Reproductive Sciences and Odontostomatology University School of Medicine Federico II, Naples, Via Pansini 5, 80131 Napoli, Italy.
| | - S Novello
- Unit on Treatment Resistant Disorders, Department of Neuroscience, Reproductive Sciences and Odontostomatology University School of Medicine Federico II, Naples, Via Pansini 5, 80131 Napoli, Italy.
| | - A Fusco
- Unit on Treatment Resistant Disorders, Department of Neuroscience, Reproductive Sciences and Odontostomatology University School of Medicine Federico II, Naples, Via Pansini 5, 80131 Napoli, Italy.
| | - A Anastasia
- Unit on Treatment Resistant Disorders, Department of Neuroscience, Reproductive Sciences and Odontostomatology University School of Medicine Federico II, Naples, Via Pansini 5, 80131 Napoli, Italy.
| | - D De Berardis
- NHS, Department of Mental Health ASL Teramo, Psychiatric Service of Diagnosis and Treatment, Hospital 'G. Mazzini', Teramo, Italy.
| | - A Valchera
- Villa San Giuseppe Hospital, Hermanas Hospitalarias, Ascoli Piceno, Italy.
| | - A de Bartolomeis
- Unit on Treatment Resistant Disorders, Department of Neuroscience, Reproductive Sciences and Odontostomatology University School of Medicine Federico II, Naples, Via Pansini 5, 80131 Napoli, Italy.
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Wangen KR, Grepperud S. Supply factors as determinants of treatment costs: clinicians' assessments of a given set of referrals to community mental health centers in Norway. BMC Health Serv Res 2018; 18:60. [PMID: 29378666 PMCID: PMC5789684 DOI: 10.1186/s12913-018-2884-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 01/23/2018] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Previous works that uses patterns of prior spending to predict future mental health care expenses (utilization models) are mainly concerned with demand (need) variables. In this paper, we introduce supply variables, both individual rater variables and center variables. The aim is to assess these variables' explanatory power, and to investigate whether not accounting for such variables could create biased estimates for the effects of need variables. METHODS We employed an observational study design where the same set of referrals was assessed by a sample of clinicians, thus creating data with a panel structure being particularly relevant for analyzing supply factors. The referrals were obtained from Norwegian Community Mental Health Centers (outpatient services), and the clinicians assessed the referrals with respect to recommended treatment costs and health status. RESULTS Supply variables accounted for more than 10% of the total variation and about one third of the explained variation. Two groups of supply variables, individual rater variables and center variables (institutions) were equally important. CONCLUSIONS Our results confirm that supply factors are important but ignoring such variables, when analyzing demand variables, do not generally seem to produce biased (confounded) coefficients.
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Affiliation(s)
- Knut Reidar Wangen
- Department of Health Management and Health Economics, University of Oslo, P.O. box 1089, Blindern, 0318 Oslo, Norway
| | - Sverre Grepperud
- Department of Health Management and Health Economics, University of Oslo, P.O. box 1089, Blindern, 0318 Oslo, Norway
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20
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Predictors of length of stay in psychiatric inpatient units: Does their effect vary across countries? Eur Psychiatry 2018; 48:6-12. [PMID: 29331601 DOI: 10.1016/j.eurpsy.2017.11.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 11/10/2017] [Accepted: 11/10/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Previous studies in individual countries have identified inconsistent predictors of length of stay (LoS) in psychiatric inpatient units. This may reflect methodological inconsistencies across studies or true differences of predictors. In this study we assessed predictors of LoS in five European countries and explored whether their effect varies across countries. METHODS Prospective cohort study. All patients admitted over 14 months to 57 psychiatric inpatient units in Belgium, Germany, Italy, Poland and United Kingdom were screened. Putative predictors were collected from medical records and in face-to-face interviews and tested for their association with LoS. RESULTS Average LoS varied from 17.9days in Italy to 55.1days in Belgium. In the overall sample being homeless, receiving benefits, social isolation, diagnosis of psychosis, greater symptom severity, substance use, history of previous admission and being involuntarily admitted predicted longer LoS. Several predictors showed significant interaction effects with countries in predicting LoS. One variable, homelessness, predicted a different LoS even in opposite directions, whilst for other predictors the direction of the association was the same, but the strength of the association with LoS varied across countries. CONCLUSIONS The same patient characteristics have a different impact on LoS in different contexts. Thus, although some predictor variables related to clinical severity and social dysfunction appear of generalisable relevance, national studies on LoS are required to understand the complex influence of different patient characteristics on clinical practice in the given contexts.
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Laidi C, Prigent A, Plas A, Leboyer M, Fond G, Chevreul K. Factors associated with direct health care costs in schizophrenia: Results from the FACE-SZ French dataset. Eur Neuropsychopharmacol 2018; 28:24-36. [PMID: 29301707 DOI: 10.1016/j.euroneuro.2017.11.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 10/29/2017] [Accepted: 11/22/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION There is a lack of data on health care consumption of patients suffering from schizophrenia, as well as on the related health care costs. Factors associated with health care costs have not been widely studied, whereas knowledge on this topic would allow identifying risk factors and delineating strategies to improve patients' health and follow-up, likely to also decrease health care costs. The aim of this study was to estimate the average direct health care cost of patients with schizophrenia in France and to identify the factors associated with this cost. METHODS The study population included patients with schizophrenia enrolled in the FondaMental Advanced Centers of Expertise for Schizophrenia cohort. We accounted for the costs directly related to the treatment of schizophrenia. They included the costs of hospitalizations (full- and part-time), psychiatric ambulatory consultations and medications. We studied three categories of factors potentially associated with direct health care costs: demographic, socioeconomic and clinical characteristics. RESULTS Three hundred and ninety five patients with schizophrenia were included. The mean (median) annual direct health care cost per patient amounted to €14,995 (€3,435). A lower level of functioning and being single were associated with a higher cost. A significant association between the expert center of inclusion and the direct health care cost of schizophrenia was also highlighted. CONCLUSION Our results highlighted the significant cost of schizophrenia and suggest that improvement in patient care, based on well-validated targeted therapeutic interventions such as psycho-education and cognitive rehabilitation, could reduce worsening in symptom severity and therefore decrease health care costs.
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Affiliation(s)
- Charles Laidi
- Inserm, U955, Institut Mondor de la Recherche Biomédicale, Psychiatrie Translationnelle, Créteil, France; Fondation Fondamental, Créteil, France; Pôle de Psychiatrie, AP-HP, Faculté de Médecine de Créteil, DHU PePsy, Hôpitaux Universitaires Henri Mondor, France; AP-HP, URC Eco Ile-de-France, Paris F-75004, France
| | - Amélie Prigent
- AP-HP, URC Eco Ile-de-France, Paris F-75004, France; University Paris Diderot, Sorbonne Paris Cité, ECEVE, UMRS 1123, Paris F-75010, France
| | - Alice Plas
- AP-HP, URC Eco Ile-de-France, Paris F-75004, France; University Paris Diderot, Sorbonne Paris Cité, ECEVE, UMRS 1123, Paris F-75010, France
| | - Marion Leboyer
- Inserm, U955, Institut Mondor de la Recherche Biomédicale, Psychiatrie Translationnelle, Créteil, France; Fondation Fondamental, Créteil, France; Pôle de Psychiatrie, AP-HP, Faculté de Médecine de Créteil, DHU PePsy, Hôpitaux Universitaires Henri Mondor, France; AP-HP, URC Eco Ile-de-France, Paris F-75004, France
| | | | - Karine Chevreul
- AP-HP, URC Eco Ile-de-France, Paris F-75004, France; University Paris Diderot, Sorbonne Paris Cité, ECEVE, UMRS 1123, Paris F-75010, France; Inserm, ECEVE, U1123, Paris, F-75010, France. AP-HP, Robert-Debré University Hospital, Department of Public Health, Paris F-75019, France.
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Fleury MJ, Fortin M, Rochette L, Grenier G, Huỳnh C, Pelletier É, Lesage A, Vasiliadis HM. Utilisation de l’urgence au Québec des patients avec des troubles mentaux incluant les
troubles liés aux substances psychoactives. SANTE MENTALE AU QUEBEC 2018. [DOI: 10.7202/1058613ar] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Chen S, Collins A, Anderson K, McKenzie K, Kidd S. Patient Characteristics, Length of Stay, and Functional Improvement for Schizophrenia Spectrum Disorders: A Population Study of Inpatient Care in Ontario 2005 to 2015. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2017; 62:854-863. [PMID: 29194005 PMCID: PMC5714115 DOI: 10.1177/0706743716680167] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Schizophrenia and associated illnesses account for a large proportion of mental illness burden and health care expenditures, with the majority of expense involving inpatient care. To date, the literature exploring factors associated with length of stay (LOS) and functional improvement during inpatient care is underdeveloped. In response, this study examined the association between patient characteristics, LOS, and functional improvement using Ontario Mental Health Reporting System (OMHRS) data from 2005 to 2015. METHODS The associations of patient characteristics (including key demographics, psychosocial variables, reasons for admission, and service use history) and 2 outcome measures (LOS and Global Assessment of Functioning [GAF]) were analysed with generalised linear mixed modelling (GLMM). From 2005 to 2015, a total of 48,498 episodes for distinct patients from 18 psychiatric hospitals and 57 general hospitals in Ontario were included. RESULTS For psychiatric and general hospitals, mean LOS was 96.6 and 20.5 days, and mean GAF improvement was 14.8 and 16.1, respectively. The majority of associations probed demonstrated a high degree of significance with similar patterns across general and tertiary facility contexts. Older age and more recent readmission following a psychiatric discharge were associated with longer LOS and less GAF improvement. Recent experience of adverse life events and substance misuse were associated with shorter LOS. CONCLUSIONS While the findings of this exploratory cross-sectional analysis will require further inquiry with respect to validity and reliability, they suggest that a different service pathway is likely required for individuals with greater psychosocial challenge and extensive service use histories.
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Affiliation(s)
- Sheng Chen
- 1 Centre for Addiction and Mental Health, Toronto, Ontario
| | - April Collins
- 1 Centre for Addiction and Mental Health, Toronto, Ontario
| | - Kelly Anderson
- 2 Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario.,3 Department of Psychiatry, Schulich School of Medicine & Dentistry, Western University, London, Ontario
| | - Kwame McKenzie
- 1 Centre for Addiction and Mental Health, Toronto, Ontario.,4 Department of Psychiatry, University of Toronto, Toronto, Ontario
| | - Sean Kidd
- 1 Centre for Addiction and Mental Health, Toronto, Ontario.,4 Department of Psychiatry, University of Toronto, Toronto, Ontario
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Shinjo D, Tachimori H, Sakurai K, Ohnuma T, Fujimori K, Fushimi K. Factors affecting prolonged length of stay in psychiatric patients in Japan: A retrospective observational study. Psychiatry Clin Neurosci 2017; 71:542-553. [PMID: 28295856 DOI: 10.1111/pcn.12521] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 02/20/2017] [Accepted: 03/07/2017] [Indexed: 11/29/2022]
Abstract
AIM Hospital length of stay (LOS) is one of the stratified measures of health-care efficiency and is commonly used to assess performance of psychiatric care. The aim of this study was to identify risk factors for prolonged LOS of psychiatric patients. METHODS We retrospectively analyzed adult psychiatric patients (ICD-10; F00-F99) between April 2012 and March 2014 in the Japanese Diagnosis Procedure Combination database. We examined factors affecting prolonged LOS using multivariable logistic regression analysis. Subgroup analyses of the logistic regression were undertaken according to two diagnostic groups (F20-F29 and F30-F39). RESULTS A total of 34 326 patients admitted to and discharged from psychiatric beds were included. Older age, lower Global Assessment of Functioning score, involuntary commitment, several psychiatric services, certain other patient factors, academic hospitals, public hospitals, and higher density of psychiatric beds were significantly associated with prolonged LOS. Hospital patient volume was significantly associated with shorter LOS. In the subgroup analyses, most of these factors were consistent although some were not associated with prolonged LOS. CONCLUSION Not only clinical factors but also institutional characteristics were associated with prolonged LOS. Our study provided useful information for improvement in psychiatric services and indicated the need to consider the division of roles between healthcare/welfare institutions and psychiatric-related resource allocation. Interventions should be considered for achieving shorter LOS for psychiatric patients.
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Affiliation(s)
- Daisuke Shinjo
- Database Center of the National University Hospitals, University of Tokyo Hospital, Tokyo, Japan
| | - Hisateru Tachimori
- Department of Mental Health Policy and Evaluation, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Keiko Sakurai
- Database Center of the National University Hospitals, University of Tokyo Hospital, Tokyo, Japan
| | - Tetsu Ohnuma
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Kenji Fujimori
- Department of Health Administration and Policy, Tohoku University, Miyagi, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
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25
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Serrano-Blanco A, Rubio-Valera M, Aznar-Lou I, Baladón Higuera L, Gibert K, Gracia Canales A, Kaskens L, Ortiz JM, Salvador-Carulla L. In-patient costs of agitation and containment in a mental health catchment area. BMC Psychiatry 2017; 17:212. [PMID: 28583103 PMCID: PMC5460463 DOI: 10.1186/s12888-017-1373-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 05/26/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is a scarce number of studies on the cost of agitation and containment interventions and their results are still inconclusive. We aimed to calculate the economic consequences of agitation events in an in-patient psychiatric facility providing care for an urban catchment area. METHODS A mixed approach combining secondary analysis of clinical databases, surveys and expert knowledge was used to model the 2013 direct costs of agitation and containment events for adult inpatients with mental disorders in an area of 640,572 adult inhabitants in South Barcelona (Spain). To calculate costs, a seven-step methodology with novel definition of agitation was used along with a staff survey, a database of containment events, and data on aggressive incidents. A micro-costing analysis of specific containment interventions was used to estimate both prevalence and direct costs from the healthcare provider perspective, by means of a mixed approach with a probabilistic model evaluated on real data. Due to the complex interaction of the multivariate covariances, a sensitivity analysis was conducted to have empirical bounds of variability. RESULTS During 2013, 918 patients were admitted to the Acute Inpatient Unit. Of these, 52.8% were men, with a mean age of 44.6 years (SD = 15.5), 74.4% were compulsory admissions, 40.1% were diagnosed with schizophrenia or non-affective psychosis, with a mean length of stay of 24.6 days (SD = 16.9). The annual estimate of total agitation events was 508. The cost of containment interventions ranges from 282€ at the lowest level of agitation to 822€ when verbal containment plus seclusion and restraint have to be used. The annual total cost of agitation was 280,535€, representing 6.87% of the total costs of acute hospitalisation in the local area. CONCLUSIONS Agitation events are frequent and costly. Strategies to reduce their number and severity should be implemented to reduce costs to the Health System and alleviate patient suffering.
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Affiliation(s)
- Antoni Serrano-Blanco
- Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain
- Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Sant Boi de Llobregat, Spain
- Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Maria Rubio-Valera
- Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain
- Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Facultat de Farmàcia, Universitat de Barcelona, Barcelona, Spain
| | - Ignacio Aznar-Lou
- Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain
- Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Luisa Baladón Higuera
- Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Sant Boi de Llobregat, Spain
- Red de Investigación en Actividades Preventivas y Promoción de la Salud (RedIAPP), Barcelona, Spain
| | - Karina Gibert
- Statistics and Operations Research Department, Knowledge Engineering and Machine Learning group, Universitat Politècnica de Catalunya-Barcelona Tech, Barcelona, Spain
| | | | | | - José Miguel Ortiz
- Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Sant Boi de Llobregat, Spain
| | - Luis Salvador-Carulla
- Centre for Mental Health Research, Research School of Population Health, ANU College of Medicine, Biology & Environment, The Australian National University, Canberra, Australia
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Pauselli L, Verdolini N, Bernardini F, Compton MT, Quartesan R. Predictors of Length of Stay in an Inpatient Psychiatric Unit of a General Hospital in Perugia, Italy. Psychiatr Q 2017; 88:129-140. [PMID: 27167133 DOI: 10.1007/s11126-016-9440-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of this study was to understand which of a number of factors are most associated with psychiatric inpatient length of stay (LoS). We hypothesized that a longer LoS would be predicted by: older age, male gender, unmarried marital status, foreign nationality, more than one hospitalization, being hospitalized involuntarily, psychotic symptoms and behavioral dyscontrol at admission, discharge diagnosis of psychotic and personality disorders, not having a substance use disorder, treatment with more than one class of medications, and being discharged to a community residential facility. All admissions to the Psychiatric Inpatient Unit of Santa Maria della Misericordia, Perugia Hospital, Umbria, Italy, from June 2011 to June 2014, were included in a medical record review. Bivariate analyses were performed and a multiple linear regression model was built using variables that were associated (p < .05) with LoS in bivariate tests. The study sample included 1236 patients. In the final, most parsimonious regression model, five variables independently explained 18 % of variance in LoS: being admitted involuntarily, being admitted for thought disorders, not having a substance-related disorder, having had more than one hospitalization, and being discharged to a community residential facility. LoS on this inpatient psychiatric unit in Umbria was associated with a number of sociodemographic and clinical characteristics. Knowledge of these and other predictors of LoS will be increasingly important to, when possible, reduce the length of restrictive, costly hospitalizations and embrace community-based services.
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Affiliation(s)
- Luca Pauselli
- Scuola di Specializzazione in Psichiatria, Università degli Studi di Perugia, Piazzale Lucio Severi, Edificio Ellisse, 8 Piano, Sant'Andrea delle Fratte, 06132, Perugia, PG, Italy. .,Ospedale Santa Maria della Misericordia, Perugia, Italy.
| | - Norma Verdolini
- Scuola di Specializzazione in Psichiatria, Università degli Studi di Perugia, Piazzale Lucio Severi, Edificio Ellisse, 8 Piano, Sant'Andrea delle Fratte, 06132, Perugia, PG, Italy.,Ospedale Santa Maria della Misericordia, Perugia, Italy
| | - Francesco Bernardini
- Scuola di Specializzazione in Psichiatria, Università degli Studi di Perugia, Piazzale Lucio Severi, Edificio Ellisse, 8 Piano, Sant'Andrea delle Fratte, 06132, Perugia, PG, Italy.,Ospedale Santa Maria della Misericordia, Perugia, Italy
| | - Michael T Compton
- Department of Psychiatry, Lenox Hill Hospital, New York, NY, USA.,Department of Psychiatry, Hofstra Northwell School of Medicine, Hempstead, NY, USA
| | - Roberto Quartesan
- Ospedale Santa Maria della Misericordia, Perugia, Italy.,Sezione di Psichiatria, Dipartimento di Medicina, Università degli Studi di Perugia, Perugia, Italy
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McLaughlin P, Giacco D, Priebe S. Use of Coercive Measures during Involuntary Psychiatric Admission and Treatment Outcomes: Data from a Prospective Study across 10 European Countries. PLoS One 2016; 11:e0168720. [PMID: 28033391 PMCID: PMC5199011 DOI: 10.1371/journal.pone.0168720] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 12/05/2016] [Indexed: 11/18/2022] Open
Abstract
To assess the association between different types of coercive measures (forced medication, seclusion, and restraint) used during involuntary psychiatric admission and two treatment outcomes: retrospective views of patients towards their admission and length of inpatient stay. A secondary analysis was conducted of data previously gathered by the EUNOMIA study (n = 2030 involuntarily detained inpatients across 10 European countries, of whom 770 were subject to one or more coercive measures). Associations between coercive measures and outcomes were tested through multivariable regression models adjusted for patients' socio-demographic and clinical characteristics. Use of forced medication was associated with patients being significantly less likely to justify their admission when interviewed after three months. All coercive measures were associated with patients staying longer in hospital. When the influence of other variables was considered in a multi-variate analysis, seclusion remained as a significant predictor of longer inpatient stay, adding about 25 days to the average admission. Of the three coercive measures, forced medication appears to be unique in its significant impact on patient disapproval of treatment. While all coercive measures are associated with patients staying longer in hospital, only use of seclusion is associated with longer inpatient stays independently of coerced patients' having higher symptom scores at the time of admission.
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Affiliation(s)
- Paul McLaughlin
- Unit for Social & Community Psychiatry, WHO Collaborating Centre for Mental Health Services Development, East London NHS Foundation Trust and Queen Mary University of London, United Kingdom
- * E-mail:
| | - Domenico Giacco
- Unit for Social & Community Psychiatry, WHO Collaborating Centre for Mental Health Services Development, East London NHS Foundation Trust and Queen Mary University of London, United Kingdom
| | - Stefan Priebe
- Wolfson Institute, Queen Mary University of London, United Kingdom
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28
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Al-Sughayir MA. Effect of accreditation on length of stay in psychiatric inpatients: pre-post accreditation medical record comparison. Int J Ment Health Syst 2016; 10:55. [PMID: 27606002 PMCID: PMC5013634 DOI: 10.1186/s13033-016-0090-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 08/29/2016] [Indexed: 12/04/2022] Open
Abstract
Background An interest in hospital accreditation is growing rapidly among many countries to enhance the quality of health care services. The literature showed a positive association between accreditation and some processes of health care. One of the main factors that influence bed availability is the length of hospital stay (LOS), which is considered as an important indicator of the quality of inpatient psychiatric hospitalization. We aimed to investigate whether hospital accreditation drives improvements for the length of stay in psychiatric inpatients. Methods The study reviewed medical records of consecutive hospital admissions for pre- and post-accreditation comparisons of LOS in two acute mental health wards at a teaching general hospital in Riyadh, Saudi Arabia. Data obtained from the 12-month-post-accreditation period (July 2011 to June 2012) were compared with those from the 12-month-pre-accreditation period (July 2009 to June 2010). The adoption of accreditation program occurred over a 12-month period in the middle of the study (July 2010 to June 2011). Compiled information included demographics, diagnosis, assessment, and LOS. All identified charts were reviewed; there were no exclusion criteria. Patients were not contacted. Results Post-accreditation, the mean (SD) length of stay was 35.3 ± 18.5 days and the range was 3–113 days. Whereas in the pre-accreditation period the mean (SD) length of stay was 41.1 ± 29.5 days and the range was 1–167 days. The difference was statistically significant (P = 0.026). Conclusion Accreditation reduces excess LOS and contributes to improving the quality of psychiatric inpatient care and access to psychiatric beds.
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Affiliation(s)
- Mohammed Abdullah Al-Sughayir
- Psychiatry Department, College of Medicine, King Saud University, PO Box 21525, Riyadh, 11485 Kingdom of Saudi Arabia
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29
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Barros REM, Marques JMDA, Santos JLF, Zuardi AW, Del-Ben CM. Impact of length of stay for first psychiatric admissions on the ratio of readmissions in subsequent years in a large Brazilian catchment area. Soc Psychiatry Psychiatr Epidemiol 2016; 51:575-87. [PMID: 26801498 DOI: 10.1007/s00127-016-1175-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 01/10/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE This study aims to verify the impact that the length of stay has on the rates of readmission for patients who were first admitted to various inpatient psychiatric units in a large catchment area in a middle-income country. METHODS The study included all patients who were first admitted to the 108 acute psychiatric beds available in the catchment area of Ribeirão Preto, Brazil, for a period of 8 years. Demographic features, inpatient unit of discharge, diagnosis and length of stay were assessed by bivariate analysis. An analysis of the time span between first admission and readmission was also conducted using survival curves estimated by the Kaplan-Meier formula. For the analyses of the risk of readmissions, a logistic regression analysis was conducted. RESULTS From a total of 6261 patients admitted in the period of the survey, approximately one-third (2006) had at least one other readmission during the follow-up period. The rates per year of early readmission (within 90 days after discharge) varied from 16.1 to 20.9 %. The risk of readmission was higher immediately after discharge. The survival analysis showed that ultrashort length of stay (1-2 days) was associated with reduced odds of readmission, but multivariate logistic analysis showed no association between length of stay and the odds of readmissions. The predictors of early readmission included the diagnosis of depressive, bipolar, psychotic, and non-alcohol-related disorders, younger ages and unemployment. CONCLUSIONS Duration of the first psychiatric admission was not associated with a higher risk of readmissions. Predictors for early readmissions of first-time-admitted psychiatric patients seem to be more related to the severity of the psychiatric diagnosis and demographic characteristics.
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Affiliation(s)
- Regis Eric Maia Barros
- Departamento de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeirão Preto-USP, Ribeirão Preto Medical School, University of São Paulo, Avenida Bandeirantes 3900, Ribeirão Preto, SP, CEP: 14048-900, Brazil.
| | | | - Jair Lício Ferreira Santos
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Antonio Waldo Zuardi
- Departamento de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeirão Preto-USP, Ribeirão Preto Medical School, University of São Paulo, Avenida Bandeirantes 3900, Ribeirão Preto, SP, CEP: 14048-900, Brazil
| | - Cristina Marta Del-Ben
- Departamento de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeirão Preto-USP, Ribeirão Preto Medical School, University of São Paulo, Avenida Bandeirantes 3900, Ribeirão Preto, SP, CEP: 14048-900, Brazil
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Piccinelli M, Bortolaso P, Bolla E, Cioffi I. Typologies of psychiatric admissions and length of inpatient stay in Italy. Int J Psychiatry Clin Pract 2016; 20:116-20. [PMID: 27049814 DOI: 10.3109/13651501.2016.1166514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To describe admissions to an inpatient psychiatric unit in Italy over a two-year period and explore the influence of demographics, clinical variables and organisational and context-related factors on length of stay. METHODS Data were obtained from clinical records and recorded by a psychiatrist through a proper checklist. RESULTS Shorter admissions involved patients with personality disorders and substance use disorders. Greater illness severity and difficulties in setting a post-discharge programme were associated with longer admissions. CONCLUSIONS Clinical, organisational and context-related factors all had significant effects on length of stay.
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Affiliation(s)
- Marco Piccinelli
- a Psychiatric Unit - Verbano, Department of Mental Health , University Teaching Hospital of Varese , Varese , Italy
| | - Paola Bortolaso
- a Psychiatric Unit - Verbano, Department of Mental Health , University Teaching Hospital of Varese , Varese , Italy
| | - Emilio Bolla
- a Psychiatric Unit - Verbano, Department of Mental Health , University Teaching Hospital of Varese , Varese , Italy
| | - Isidoro Cioffi
- a Psychiatric Unit - Verbano, Department of Mental Health , University Teaching Hospital of Varese , Varese , Italy
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31
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Awareness of treatment needs and length of stay amongst psychiatric inpatients. Compr Psychiatry 2015; 63:65-70. [PMID: 26555493 DOI: 10.1016/j.comppsych.2015.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 06/24/2015] [Accepted: 08/04/2015] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Inpatient psychiatric units experience significant pressure from third party payers to keep length of stay (LOS) to a minimum despite having to treat more severely ill patients. However, there is a paucity of empiric data for guiding treatment decisions that maximize therapeutic outcome while minimizing LOS. We therefore endeavored to begin utilizing a newly created psychometric instrument that assesses patient psychological factors, which we propose will allow for LOS prediction and individualization of therapeutic outcome. MATERIALS AND METHODS The Goals Questionnaire (GQ), created to determine awareness of treatment needs, was administered to newly admitted patients. Linear regression analyses were conducted to ascertain the relationship between the GQ score and LOS, as well as the effects of confounding factors. RESULTS A significant and inverse relationship was found between the GQ score and LOS (β=-4.4; p=0.007) that was dependent upon (i.e., had a significant interaction with) age and substance use disorders. There was minimal confounding from common administrative, legal, and clinical factors. CONCLUSIONS The GQ may have utility for inpatient treatment teams, providing information that can be used to maximize and individualize therapeutic outcome while minimizing LOS.
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Wolff J, McCrone P, Patel A, Kaier K, Normann C. Predictors of length of stay in psychiatry: analyses of electronic medical records. BMC Psychiatry 2015; 15:238. [PMID: 26446584 PMCID: PMC4597607 DOI: 10.1186/s12888-015-0623-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 09/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Length of stay is a straightforward measure of hospital costs and retrospective data are widely available. However, a prospective idea of a patient's length of stay would be required to predetermine hospital reimbursement per case based on patient classifications. The aim of this study was to analyse the predictive power of patient characteristics in terms of length of stay in a psychiatric hospital setting. A further aim was to use patient characteristics to predict episodes with extreme length of stay. METHODS The study included all inpatient episodes admitted in 2013 to a psychiatric hospital. Zero-truncated negative binomial regression was carried out to predict length of stay. Penalized maximum likelihood logistic regressions were carried out to predict episodes experiencing extreme length of stay. Independent variables were chosen on the basis of prior research and model fit was cross-validated. RESULTS A total of 738 inpatient episodes were included. Seven patient characteristics showed significant effects on length of stay. The strongest increasing effects were found in the presence of affective disorders as main diagnosis, followed by severity of disease and chronicity of disease. The strongest decreasing effects were found in danger to others, followed by the presence of substance-related disorders as main diagnosis, the daily requirement of somatic care and male gender. The squared correlation between out-of-sample predictions and observed values was 0.14. The root-mean-square-error was 40 days. CONCLUSION Prospectively defining reimbursement per case might not be feasible in mental health because length of stay cannot be predicted by patient characteristics. Per diem systems should be used.
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Affiliation(s)
- Jan Wolff
- Institute of Psychiatry, Psychology & Neuroscience, King's Health Economics, King's College London, De Crespigny Park, SE5 8AF, London, United Kingdom. .,Department for Management and Controlling, Medical Centre-University of Freiburg, Hugstetter Strasse 49, 79106, Freiburg, Germany.
| | - Paul McCrone
- Institute of Psychiatry, Psychology & Neuroscience, King's Health Economics, King's College London, De Crespigny Park, SE5 8AF, London, United Kingdom.
| | - Anita Patel
- Institute of Psychiatry, Psychology & Neuroscience, King's Health Economics, King's College London, De Crespigny Park, SE5 8AF, London, United Kingdom. .,Barts and the London School of Medicine and Dentistry, Centre for Primary Care and Public Health, Queen Mary University of London, 58 Turner Street, E12AB, London, United Kingdom.
| | - Klaus Kaier
- Institute of Medical Biometry, Medical Centre-University of Freiburg, Hugstetter Strasse 49, 79106, Freiburg, Germany.
| | - Claus Normann
- Department of Psychiatry and Psychotherapy, Medical Centre- University of Freiburg, Hauptstrasse 5, 79106, Freiburg, Germany.
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Jacobs R, Gutacker N, Mason A, Goddard M, Gravelle H, Kendrick T, Gilbody S. Determinants of hospital length of stay for people with serious mental illness in England and implications for payment systems: a regression analysis. BMC Health Serv Res 2015; 15:439. [PMID: 26424408 PMCID: PMC4590310 DOI: 10.1186/s12913-015-1107-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 09/23/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Serious mental illness (SMI), which encompasses a set of chronic conditions such as schizophrenia, bipolar disorder and other psychoses, accounts for 3.4 m (7 %) total bed days in the English NHS. The introduction of prospective payment to reimburse hospitals makes an understanding of the key drivers of length of stay (LOS) imperative. Existing evidence, based on mainly small scale and cross-sectional studies, is mixed. Our study is the first to use large-scale national routine data to track English hospitals' LOS for patients with a main diagnosis of SMI over time to examine the patient and local area factors influencing LOS and quantify the provider level effects to draw out the implications for payment systems. METHODS We analysed variation in LOS for all SMI admissions to English hospitals from 2006 to 2010 using Hospital Episodes Statistics (HES). We considered patients with a LOS of up to 180 days and estimated Poisson regression models with hospital fixed effects, separately for admissions with one of three main diagnoses: schizophrenia; psychotic and schizoaffective disorder; and bipolar affective disorder. We analysed the independent contribution of potential determinants of LOS including clinical and socioeconomic characteristics of the patient, access to and quality of primary care, and local area characteristics. We examined the degree of unexplained variation in provider LOS. RESULTS Most risk factors did not have a differential effect on LOS for different diagnostic sub-groups, however we did find some heterogeneity in the effects. Shorter LOS in the pooled model was associated with co-morbid substance or alcohol misuse (4 days), and personality disorder (8 days). Longer LOS was associated with older age (up to 19 days), black ethnicity (4 days), and formal detention (16 days). Gender was not a significant predictor. Patients who self-discharged had shorter LOS (20 days). No association was found between higher primary care quality and LOS. We found large differences between providers in unexplained variation in LOS. CONCLUSIONS By identifying key determinants of LOS our results contribute to a better understanding of the implications of case-mix to ensure prospective payment systems reflect accurately the resource use within sub-groups of patients with SMI.
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Affiliation(s)
- Rowena Jacobs
- Centre for Health Economics, University of York, Heslington, York, UK.
| | - Nils Gutacker
- Centre for Health Economics, University of York, Heslington, York, UK.
| | - Anne Mason
- Centre for Health Economics, University of York, Heslington, York, UK.
| | - Maria Goddard
- Centre for Health Economics, University of York, Heslington, York, UK.
| | - Hugh Gravelle
- Centre for Health Economics, University of York, Heslington, York, UK.
| | - Tony Kendrick
- Primary Care and Population Sciences, University of Southampton, Southampton, UK.
| | - Simon Gilbody
- Department of Health Sciences, University of York, Heslington, York, UK.
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Nakanishi M, Niimura J, Tanoue M, Yamamura M, Hirata T, Asukai N. Association between length of hospital stay and implementation of discharge planning in acute psychiatric inpatients in Japan. Int J Ment Health Syst 2015; 9:23. [PMID: 26029254 PMCID: PMC4449576 DOI: 10.1186/s13033-015-0015-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 05/20/2015] [Indexed: 11/17/2022] Open
Abstract
Background Japan has introduced an acute psychiatric care unit to the public healthcare insurance program, but its requirement of a shorter length of stay could lead to discharges without proper discharge planning. The aim of this study was to examine the association between the implementation of discharge planning and the length of stay of acute psychiatric inpatients in Japan. Methods This retrospective cross-sectional study included 449 patients discharged from the ‘psychiatric emergency ward’ of 66 hospitals during a two-week period from March 7 to 20, 2011. The assigned nurse or nursing assistant for each patient provided information on the implementation of discharge planning in the hospital stay. Results Approximately one quarter of the 449 patients (n = 122) received no support for coordination with post-discharge community care resources. The 122 patients who had received no support for community care coordination had a significantly lower mean age at admission, a shorter length of stay, and a higher rate of either no follow-up or unidentified post-discharge outpatient service than the other 327 patients. Multilevel linear regression analysis demonstrated a significantly greater length of stay among patients who were older, those who had a primary diagnosis of schizophrenia, those who were admitted compulsorily, those who received hospital outpatient services, and those who received community care coordination support from the assigned nurse or nursing assistant. The implementation of support for community care coordination did not indicate a significant association with these factors, which have been related to an increased risk of psychiatric readmission. Conclusion Patients to whom the assigned nurse or nursing assistant provided support on community care coordination experienced a significantly greater length of hospital stay. The implementation of support for community care coordination did not indicate a significant association with these factors, which have been related to an increased risk of psychiatric readmission. The mental health policy should increase focus on discharge planning in the acute psychiatric setting to enhance a link between psychiatric inpatient care and post-discharge community care resources.
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Affiliation(s)
- Miharu Nakanishi
- Mental Health and Nursing Research Team, Tokyo Metropolitan Institute of Medical Science, Setagaya-ku, Tokyo, Japan
| | - Junko Niimura
- Mental Health and Nursing Research Team, Tokyo Metropolitan Institute of Medical Science, Setagaya-ku, Tokyo, Japan
| | - Michika Tanoue
- Mental Health and Psychiatric Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Motoe Yamamura
- Division of Nursing Sciences, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Arakawa-ku, Tokyo, Japan
| | - Toyoaki Hirata
- Chiba Psychiatric Medical Centre, Chiba-shi, Chiba Japan
| | - Nozomu Asukai
- Research Project for Mental Health Promotion, Tokyo Metropolitan Institute of Medical Science, Setagaya-ku, Tokyo, Japan
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Comas M, Valentino K, Bridgett DJ, Hayden LC. The direct and interactive effects of physical abuse severity and negative affectivity on length of psychiatric hospitalization: evidence of differential reactivity to adverse environments in psychiatrically high-risk youth. Child Psychiatry Hum Dev 2015; 45:220-8. [PMID: 23824554 DOI: 10.1007/s10578-013-0394-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The current study examined the interactive influence of multiple factors (i.e., physical abuse severity and negative affectivity) in predicting youth's inpatient psychiatric length of stay (LOS), extending previous research focused on identification of only single LOS predictors. Elevated physical abuse severity was hypothesized to predict longer youth LOS, and negative affectivity was anticipated to exacerbate this relationship. This study included 42 youth. Clinicians rated youth temperament, whereas physical abuse severity and LOS were coded from youth medical records. Controlling for other previously determined predictors of LOS (i.e., age, gender, and GAF), moderation analyses confirmed hypotheses, revealing a temperament by environment interaction. Specifically, physical abuse severity was positively associated with LOS only in the context of high negative affectivity. Findings highlighted the importance of disentangling the interactive effects of multiple factors in predicting LOS. Moreover, critical clinical implications involving prioritized trauma assessment and treatment for inpatient youth are discussed.
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Affiliation(s)
- Michelle Comas
- Center for Children and Families, Department of Psychology, University of Notre Dame, Notre Dame, IN, 46556, USA,
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Rubio-Valera M, Luciano JV, Ortiz JM, Salvador-Carulla L, Gracia A, Serrano-Blanco A. Health service use and costs associated with aggressiveness or agitation and containment in adult psychiatric care: a systematic review of the evidence. BMC Psychiatry 2015; 15:35. [PMID: 25881240 PMCID: PMC4356166 DOI: 10.1186/s12888-015-0417-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 02/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Agitation and containment are frequent in psychiatric care but little is known about their costs. The aim was to evaluate the use of services and costs related to agitation and containment of adult patients admitted to a psychiatric hospital or emergency service. METHODS Systematic searches of four electronic databases covering the period January 1998-January 2014 were conducted. Manual searches were also performed. Paper selection and data extraction were performed in duplicate. Cost data were converted to euros in 2014. RESULTS Ten studies met inclusion criteria and were included in the analysis (retrospective cohorts, prospective cohorts and cost-of-illness studies). Evaluated in these studies were length of stay, readmission rates and medication. Eight studies assessed the impact of agitation on the length of stay and six showed that it was associated with longer stays. Four studies examined the impact of agitation on readmission and a statistically significant increase in the probability of readmission of agitated patients was observed. Two studies evaluated medication. One study showed that the mean medication dose was higher in agitated patients and the other found higher costs of treatment compared with non-agitated patients in the unadjusted analysis. One study estimated the costs of conflict and containment incurred in acute inpatient psychiatric care in the UK. The estimation for the year 2014 of total annual cost per ward for all conflict was €182,616 and €267,069 for containment based on updated costs from 2005. CONCLUSIONS Agitation has an effect on healthcare use and costs in terms of longer length of stay, more readmissions and higher drug use. Evidence is scarce and further research is needed to estimate the burden of agitation and containment from the perspective of hospitals and the healthcare system.
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Affiliation(s)
- Maria Rubio-Valera
- Fundació Sant Joan de Déu, Esplugues de Llobregat, Spain. .,Primary Care Prevention and Health Promotion Research Network (RedIAPP), Barcelona, Spain. .,School of Pharmacy, Universitat de Barcelona, Barcelona, Spain. .,Research & Development Unit, Parc Sanitari Sant Joan de, 22 Déu. C/ Dr. Antoni Pujadas 42, 08830, Sant Boi de Llobregat, Barcelona, Spain.
| | - Juan V Luciano
- Fundació Sant Joan de Déu, Esplugues de Llobregat, Spain. .,Primary Care Prevention and Health Promotion Research Network (RedIAPP), Barcelona, Spain. .,Open University of Catalonia (UOC), Barcelona, Spain.
| | | | - Luis Salvador-Carulla
- Centre for Disability Research and Policy, Faculty of Health Sciences, and Mental Health Policy Unit, Brain and Mind Research Institute, University of Sydney, Sydney, Australia.
| | | | - Antoni Serrano-Blanco
- Primary Care Prevention and Health Promotion Research Network (RedIAPP), Barcelona, Spain. .,Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain.
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Archer SJ, Barna AE, Holper RM, Forsyth DM, Ellenbecker SM, Smith LK, Clobes JE, Meiers SJ, Malone C, Lapid MI. Associations among fluid intake, cognitive function, and length of stay in psychogeriatric inpatients. Perspect Psychiatr Care 2015; 51:52-6. [PMID: 24605762 DOI: 10.1111/ppc.12065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 01/08/2014] [Accepted: 01/16/2014] [Indexed: 11/29/2022] Open
Abstract
PURPOSE The purpose of this study was to examine differences, interactions, and associations among cognition, fluid intake, and demographic variables that may affect length of stay (LOS) for psychogeriatric inpatients aged 65 years or older. DESIGN AND METHODS Descriptive, comparative, correlational secondary analysis of data from a primary study of 202 inpatients. FINDINGS Older adults with and without cognitive impairment had different fluid intake over time (F = 3.50; p = .03), but had no difference in LOS in relation to cognitive functioning (p = .23); additional factors may predict LOS. PRACTICE IMPLICATIONS Care providers must monitor the fluid intake of elderly patients with and without cognitive impairment throughout their hospitalization.
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Affiliation(s)
- Sarah J Archer
- Department of Nursing, Winona State University-Rochester Center, Rochester, Minnesota, USA
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Emons B, Haussleiter IS, Kalthoff J, Schramm A, Hoffmann K, Jendreyschak J, Schaub M, Armgart C, Juckel G, Illes F. Impact of social-psychiatric services and psychiatric clinics on involuntary admissions. Int J Soc Psychiatry 2014; 60:672-80. [PMID: 24336088 DOI: 10.1177/0020764013511794] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Germany provides a wide range of highly developed mental health care to its citizens. The aim of this study was to identify factors influencing the voluntariness of admissions to psychiatric hospitals. Especially the impact of demographic factors of the region, characteristics of the psychiatric hospitals and characteristics of the psychosocial services was analyzed. METHOD A retrospective analysis of hospital admission registers from 13 German adult psychiatric hospitals in 2009 was conducted. Public data on the regional psychiatric accommodation and demographic situation were added. Hospitals were dichotomously divided according to their index of involuntary admissions. Group comparisons were performed between the clinics with low and high involuntary admission indices. Analysis was conducted with clinical, psychiatric provision and demographic data related to inpatients in the Landschaftsverbands Westfalen-Lippe (LWL)-PsychiatryNetwork. RESULTS Especially the range of services provided by the social-psychiatric services in the region such as number of supervised patients and home visits had an influence on the proportion of involuntary admissions to a psychiatric hospital. Some demographic characteristics of the region such as discretionary income showed further influence. Contrary to our expectations, the characteristics of the individual hospital seem to have no influence on the admission rate. CONCLUSION Social-psychiatric services show a preventive impact on involuntary acute psychiatry interventions. Sociodemographic factors and patient variables play a role with regard to the number of involuntary hospitalizations, whereas characteristics of hospitals seemed to play no role.
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Affiliation(s)
- Barbara Emons
- LWL-Institute of Mental Health, LWL-University Hospital Bochum, Germany
| | | | - Jörg Kalthoff
- Social-Psychiatric Service, Health Authority Bochum, Germany
| | - Anja Schramm
- Department of Psychiatry, LWL-University Hospital Bochum, Germany
| | - Knut Hoffmann
- Department of Psychiatry, LWL-University Hospital Bochum, Germany
| | | | - Markus Schaub
- LWL-Institute of Mental Health, LWL-University Hospital Bochum, Germany
| | - Carina Armgart
- Department of Psychiatry, LWL-University Hospital Bochum, Germany
| | - Georg Juckel
- LWL-Institute of Mental Health, LWL-University Hospital Bochum, Germany Department of Psychiatry, LWL-University Hospital Bochum, Germany
| | - Franciska Illes
- Department of Psychiatry, LWL-University Hospital Bochum, Germany
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Abstract
The current study sought to evaluate the validity and reliability of a brief measure of overall functioning for adolescents. Clinicians were asked to complete the Overall Functioning Scale (OFS) for 72 adolescents consecutively admitted to the adolescent psychiatric inpatient service of a community safety net medical center. The results revealed that this new measure is related to the patients' length of stay, clinician-rated measures of social cognition and object relations, Global Assessment of Functioning (GAF) score at admission, as well as global rating of engagement in individual psychotherapy. The results also showed that the OFS was related to the patients' history of nonsuicidal self-harm as well as treatment outcome as assessed by measures of psychological health and well-being as well as symptoms. Hierarchical regressions reveal that the OFS shows incremental validity greater than the admission GAF score in predicting length of stay. The results also showed that the OFS demonstrates interrater reliability in the excellent range (intraclass correlation coefficient(1,2)) of 0.88. Clinical implications of the use of this tool and areas of future research are discussed.
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40
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Compton MT, Kelley ME, Ionescu DF. Subtyping first-episode non-affective psychosis using four early-course features: potentially useful prognostic information at initial presentation. Early Interv Psychiatry 2014; 8:50-8. [PMID: 23343467 PMCID: PMC3672389 DOI: 10.1111/eip.12026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 07/31/2012] [Indexed: 11/29/2022]
Abstract
AIM Heterogeneity of symptoms, course and outcomes in primary psychotic disorders complicates prognosis, treatment and diverse aspects of research. This study aimed to identify interpretable subtypes of first-episode non-affective psychosis based on four early-course features (premorbid academic functioning, premorbid social functioning, duration of the prodrome and age at onset of psychosis). METHODS Data from 200 well-characterized patients hospitalized in public-sector inpatient units for first-episode non-affective psychosis were used in latent profile analyses. Derived subtypes were then compared along a number of clinical dimensions using analyses of variance. RESULTS Using four early-course features, three classes were derived. A good premorbid/short prodrome subtype was characterized by a lower severity of positive symptoms, better social/occupational/global functioning, and a shorter duration of untreated psychosis; a poor premorbid/early onset subtype demonstrated greater negative and preoccupation symptoms, as well as greater psychosocial problems; and a long prodrome/late onset subtype was characterized by greater dysphoric symptoms. CONCLUSIONS Findings indicate a need for further research with first-episode samples on the utility of subtyping based on early-course (premorbid, prodromal and onset-related) characteristics. Such efforts could enhance the parsing of heterogeneity, thereby advancing clinical practice and research.
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Affiliation(s)
- Michael T. Compton
- The George Washington University School of Medicine and Health Sciences, Department of Psychiatry and Behavioral Sciences, Washington, D.C., U.S.A. 20037
| | - Mary E. Kelley
- Rollins School of Public Health of Emory University, Department of Biostatistics and Bioinformatics, Atlanta, Georgia, U.S.A. 30322
| | - Dawn Flosnik Ionescu
- National Institute of Mental Health, Experimental Therapeutics & Pathophysiology Branch, Bethesda, Maryland, U.S.A. 20892
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Clinical outcome and length of stay in an Italian Psychiatric Emergency Service. Soc Psychiatry Psychiatr Epidemiol 2013; 48:1013-20. [PMID: 23689863 DOI: 10.1007/s00127-012-0607-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Accepted: 10/08/2012] [Indexed: 10/27/2022]
Abstract
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.
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Chung W, Chang HS, Oh SM, Yoon CW. Factors associated with long-stay status in patients with schizophrenia: an analysis of national databases covering the entire Korean population. Int J Soc Psychiatry 2013; 59:207-16. [PMID: 22222848 DOI: 10.1177/0020764011431794] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Admissions lasting over six months (long-stay) occur frequently among patients with schizophrenia in South Korea. AIMS To identify some patient-level and institution-level factors associated with long-stay status of patients with schizophrenia. METHODS This is a retrospective cross-sectional study. We analysed a nationwide population-based reimbursement claims data set consisting of 496,338 claims for 58,287 patients with schizophrenia between 1 January 2005 and 30 June 2006. A two-level random effects logistic regression model was used to identify those factors. RESULTS Age (<20 years (ref), 60-69 (OR 2.000, 95% CI: 1.640-2.438), ≥ 70 (2.068, 1.682-2.543)), male gender (1.192, 1.144-1.242), type of national health insurance plan (national health insurance (ref), Medical Care Aid Type 1 (4.299, 4.024-4.593)), secondary diagnosis (none (ref), psychiatric diagnosis (0.719, 0.666-0.777), non-psychiatric diagnosis (0.918, 0.850-0.991)) and type of institution (clinic (ref), psychiatric hospital (2.769, 1.507-5.087)) were associated with likelihood of long-stay status. Institutional variable associated with long-stay status included a higher number of beds (1.073, 1.013-1.137). The number of professionals (0.752, 0.646-0.876) showed negative association with long-stay status. CONCLUSIONS Researchers could improve their assessment of long-stay status of patients with schizophrenia by using a two-level analysis including patient-level and institution-level factors. This study suggests that mental health interventions to reduce the long stay of patients with schizophrenia focus on older male patients, those enrolled in a national medical care aid programme and those admitted to psychiatric hospitals.
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Affiliation(s)
- Woojin Chung
- Department of Health Policy and Management, Graduate School of Public Health, Yonsei University, South Korea
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Richmond JS, Berlin JS, Fishkind AB, Holloman GH, Zeller SL, Wilson MP, Rifai MA, Ng AT. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med 2012; 13:17-25. [PMID: 22461917 PMCID: PMC3298202 DOI: 10.5811/westjem.2011.9.6864] [Citation(s) in RCA: 240] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 09/06/2011] [Accepted: 09/26/2011] [Indexed: 01/23/2023] Open
Abstract
Agitation is an acute behavioral emergency requiring immediate intervention. Traditional methods of treating agitated patients, ie, routine restraints and involuntary medication, have been replaced with a much greater emphasis on a noncoercive approach. Experienced practitioners have found that if such interventions are undertaken with genuine commitment, successful outcomes can occur far more often than previously thought possible. In the new paradigm, a 3-step approach is used. First, the patient is verbally engaged; then a collaborative relationship is established; and, finally, the patient is verbally de-escalated out of the agitated state. Verbal de-escalation is usually the key to engaging the patient and helping him become an active partner in his evaluation and treatment; although, we also recognize that in some cases nonverbal approaches, such as voluntary medication and environment planning, are also important. When working with an agitated patient, there are 4 main objectives: (1) ensure the safety of the patient, staff, and others in the area; (2) help the patient manage his emotions and distress and maintain or regain control of his behavior; (3) avoid the use of restraint when at all possible; and (4) avoid coercive interventions that escalate agitation. The authors detail the proper foundations for appropriate training for de-escalation and provide intervention guidelines, using the “10 domains of de-escalation.”
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Affiliation(s)
- Janet S Richmond
- Tufts University School of Medicine, Department of Psychiatry, Boston, Massachusetts
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Hunt GE, O'Hara-Aarons M, O'Connor N, Cleary M. Why are some patients admitted to psychiatric hospital while others are not? A study assessing risk during the admission interview and relationship to outcome. Int J Ment Health Nurs 2012; 21:145-53. [PMID: 22039923 DOI: 10.1111/j.1447-0349.2011.00778.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of this study was to determine what patient characteristics are used to decide whether a patient is or is not admitted to a psychiatric hospital, and what happens to those not admitted. A further aim was to determine if high levels of risk on admission predict seclusions, length of stay, or readmission within 28 days. Data were collected prospectively on consecutive presentations to an admission office via case notes and electronic databases. Eighty percent (100/127) of the adults presenting to the admission office over a typical month were admitted to hospital. Patients were more likely to be admitted if they were experiencing psychosis or exacerbation of schizophrenia, referred by other doctors or mental health teams, had a legal reason for referral, or if they were homeless. There was no association between risk for violence or suicide and seclusion rates, length of stay, or being readmitted within 28 days. It was reassuring to find that 85% of those not admitted were referred to other mental health providers, and none required admission over the following month. This study found high rates of seclusion and readmissions within 1 year, which requires further study to find strategies to reduce these rates.
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Affiliation(s)
- Glenn E Hunt
- Department of Psychiatry, University of Sydney, Australia
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Barbato A, Parabiaghi A, Panicali F, Battino N, D'Avanzo B, de Girolamo G, Rucci P, Santone G. Do patients improve after short psychiatric admission?: a cohort study in Italy. Nord J Psychiatry 2011; 65:251-8. [PMID: 21062122 DOI: 10.3109/08039488.2010.533387] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Information on outcomes of acute inpatient care in routine psychiatric practice is scant. In particular, it is uncertain to what extent short hospitalization can produce clinically meaningful changes. AIM Our aim was to estimate the symptomatic outcome in a representative sample of patients admitted for short treatment to general hospital psychiatric units in Italy. METHODS Patients were assessed at admission and discharge using 24-item Brief Psychiatric Rating Scale (BPRS). Reliable change index was calculated to estimate the proportion of change attributable to measurement error and a cut-off score of 38 was adopted to identify the patients who showed clinically significant change. RESULTS Average length of stay was 5.7 days. Mean BPRS score dropped from 53.2 on admission to 41.5 at discharge, showing statistically significant improvement with an effect size of 0.80. However, reliable change was achieved by 24.7% of patients and clinically meaningful change by 13.6%. CONCLUSIONS Reliance on statistical significance and effect size overestimates treatment effects, whereas reliable and clinically significant change index provides a conservative way to assess outcome. Few patients showed relevant improvement after a brief admission.
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Affiliation(s)
- Angelo Barbato
- Epidemiology and Social Psychiatry Unit, Mario Negri Institute for Pharmacological Research, Milan, Italy.
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Pertile R, Donisi V, Grigoletti L, Angelozzi A, Zamengo G, Zulian G, Amaddeo F. DRGs and other patient-, service- and area-level factors influencing length of stay in acute psychiatric wards: the Veneto Region experience. Soc Psychiatry Psychiatr Epidemiol 2011; 46:651-60. [PMID: 20473480 DOI: 10.1007/s00127-010-0231-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Accepted: 04/26/2010] [Indexed: 11/29/2022]
Abstract
PURPOSE This study aimed to identify services-related and area-based measures together with socio-demographic factors that could improve diagnosis-related groups in explaining length of stay variability in general hospital psychiatric units in Veneto Region (North East of Italy). METHODS Data were collected from the regional hospital discharge records database. A hierarchical multiple regression model with only diagnosis-related groups as predictors of actual and ln-transformed length of stay was compared with a second model in which patient-, service- and area-level variables were included. Local health district was used as group-level in the hierarchical multiple regression analysis. RESULTS The only diagnosis explains 6.4% of actual length of stay total variance (14.8% for ln-transformation). In the second model length of stay resulted related also to gender, age, severity of hospitalization, patient's local health district, number of psychiatrists, psychologists, hospital attendants/nurses, social workers and educators in the general hospital psychiatric units, number of outpatients in each local health district and percentages of divorced and single people, with almost a 2% point increase on actual length of stay in explained variance (5% point increase for ln-transformation). CONCLUSIONS For the first time the hospital discharge card regional survey of all public acute inpatient psychiatric facilities in Veneto Region were used. The innovative aspect of this study was the attempt to investigate the relationship between length of stay and other indexes, characterizing not only the inpatient facilities, but also the resident population structure in each area. The information about factors that influence length of stay can be useful to inform service planning and resource allocation.
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Affiliation(s)
- Riccardo Pertile
- Section of Psychiatry and Clinical Psychology, Department of Public Health and Community Medicine, University of Verona, Policlinico G.B. Rossi, Piazzale L.A. Scuro 10, 37134 Verona, Italy.
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Tulloch AD, Fearon P, David AS. Length of Stay of General Psychiatric Inpatients in the United States: Systematic Review. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2010; 38:155-68. [DOI: 10.1007/s10488-010-0310-3] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Fanniff AM, Otto RK, Petrila J. Competence to proceed in SVP commitment hearings: Irrelevant or fundamental due process right? BEHAVIORAL SCIENCES & THE LAW 2010; 28:647-670. [PMID: 20878661 DOI: 10.1002/bsl.957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Sexually Violent Predator (SVP) civil commitment, intended to incapacitate offenders and protect the public, has been implemented in 21 jurisdictions. While respondents in traditional civil commitment proceedings need not be competent to proceed, SVP commitment may present a greater deprivation of liberty and therefore greater procedural protections may be merited. Statutes and case law regarding competence in this context address two issues: competence to challenge unproven sexual offense allegations and competence to participate in the SVP commitment process. Of the 14 states that have addressed the issue, one concluded that respondents must be competent to challenge unproven allegations and one concluded that all SVP respondents must be competent to participate in the commitment process. Differences between SVP and traditional civil commitment, the rationale underlying the competence requirement, and decisions regarding competence in SVP commitment are reviewed to inform debate regarding whether SVP respondents must be competent to proceed with the commitment process.
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Affiliation(s)
- Amanda M Fanniff
- Department of Mental Health Law and Policy, University of South Florida, Tampa, FL 33612, USA.
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Stellwagen KK, Kerig PK. Relation of callous-unemotional traits to length of stay among youth hospitalized at a state psychiatric inpatient facility. Child Psychiatry Hum Dev 2010; 41:251-61. [PMID: 19949974 DOI: 10.1007/s10578-009-0164-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We examined the association of callous-unemotional (C/U) traits with length of psychiatric hospitalization among two samples each with 50 participants: a group of 7-11 year-olds (39 males and 11 females) receiving services on a children's unit, and a group of 12-17 year-olds (27 males and 23 females) receiving services on an adolescent unit. Our analyses focused on the additionally predictive value of C/U traits above and beyond the influence of pre-established risk factors for length of stay, including age, gender, ethnicity, overall levels of functioning and psychopathology, and the diagnosis of a Conduct Disorder or Oppositional Defiant Disorder. In both samples, hierarchic regression analyses indicated that C/U traits were associated with longer lengths of stay, whereas none of the previously identified risk factors were significant. The discussion of these results focuses on the importance of developing non-coercive and non-confrontational therapeutic treatment regimens for youth with C/U traits receiving inpatient psychiatric services.
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Affiliation(s)
- Kurt K Stellwagen
- Department of Psychology, Eastern Washington University, 526 5th Street, Cheney, WA 99004, USA.
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Barros REM, Marques JMDA, Carlotti IP, Zuardi AW, Del-Ben CM. Short admission in an emergency psychiatry unit can prevent prolonged lengths of stay in a psychiatric institution. ACTA ACUST UNITED AC 2009; 32:145-51. [PMID: 20027489 DOI: 10.1590/s1516-44462009005000014] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 09/29/2009] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Characterize and compare acute psychiatric admissions to the psychiatric wards of a general hospital (22 beds), a psychiatric hospital (80) and of an emergency psychiatry unit (6). METHOD Survey of the ratios and shares of the demographic, diagnostic and hospitalization variables involved in all acute admissions registered in a catchment area in Brazil between 1998 and 2004. RESULTS From the 11,208 admissions, 47.8% of the patients were admitted to a psychiatric hospital and 14.1% to a general hospital. The emergency psychiatry unit accounted for 38.1% of all admissions during the period, with a higher variability in occupancy rate and bed turnover during the years. Around 80% of the hospital stays lasted less than 20 days and in almost half of these cases, patients were discharged in 2 days. Although the total number of admissions remained stable during the years, in 2004, a 30% increase was seen compared to 2003. In 2004, bed turnover and occupancy rate at the emergency psychiatry unit increased. CONCLUSION The increase in the number of psychiatric admissions in 2004 could be attributed to a lack of new community-based services available in the area beginning in 1998. Changes in the health care network did affect the emergency psychiatric service and the limitations of the community-based network could influence the rate of psychiatric admissions.
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Affiliation(s)
- Régis Eric Maia Barros
- Department of Neurosciences and Behavior, Faculty of Medicine of Ribeirão Preto, Universidade de São Paulo, Avenida Bandeirantes 3900, Ribeirão Preto, SP, Brazil.
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