Factors associated with multiple re-admission to a psychiatric hospital

Early and Frequent Psychiatric Readmissions in a Brazilian Cohort of Hospitalized Patients Between 2001 and 2013

OBJECTIVE

To characterize the profile of patients who were readmitted for mental and behavioral disorders, in the Brazilian Unified Health System, from 2001 to 2014, and the factors associated with early and frequent readmission.

METHOD

A retrospective, non-concurrent cohort study of patients admitted with a primary diagnosis of mental or behavioral disorders, from 2001 to 2014. This study selected demographic variables and clinical variables, as well as variables related to the characteristics of the hospitals. Poisson Regression methods with a robust variance estimator were used to estimate the incidence rate ratio (IRR) for each of the outcomes.

RESULTS

Early readmission occurred for 6.8% of the patients and frequent readmission for 8.3%. Characteristics such as being male, younger, with a diagnosis of a bipolar disorder, and admitted to a specialized hospital show a higher IRR for early readmission. The occurrence of early readmission was the most heavily associated characteristic with an increased rate of early readmission, and the magnitude of this increase depends on the patient's age.

CONCLUSION

Early and frequent readmissions are linked to patients' demographics, clinical information and health system's organization. Early readmission should be a priority in treatment planning to prevent frequent readmissions due to its strong association.

Effects of the Mental Health and Welfare Law revision on schizophrenia patients in Korea: an interrupted time series analysis

Background

High rates of involuntary hospitalization and long lengths of stay have been problematic in Korea. To address these problems, the Mental Health and Welfare Law was revised in 2016, mainly to protect patient rights by managing involuntary admissions. The aim of this study was to evaluate the impact of the revised Mental Health and Welfare Law on deinstitutionalization by using routinely collected data from hospital admissions and continuity of mental health service use after hospital discharge as proxy measures of deinstitutionalization.

Methods

We used monthly-aggregated claims-based data with a principal or secondary diagnosis of schizophrenia from 2012 to 2019, collected by the National Health Insurance Service. Outcome variables included rates of first admission; discharges; re-admissions within 7, 30, and 90 days; outpatient visits after discharge within 7 and 30 days; and continuity of visits, at least once a month for 6 months after discharge. Using interrupted time series analysis, we estimated the change in levels and trends of the rates after revision, controlling for baseline level and trend.

Results

There was no significant change in first admission and discharge rates after the revision. Immediately after the revision, however, the rates of re-admission within 7 and 30 days dropped significantly, by 2.24% and 1.99%, respectively. The slopes of the re-admission rate decreased significantly, by 0.10% and 0.14%, respectively. The slopes of the re-admission rate within 90 days decreased (0.001%). The rates of outpatient visits within 7 and 30 days increased by 1.98% and 2.72%, respectively. The rate of continuous care showed an immediate 4.0% increase.

Conclusions

The revision had slight but significant effects on deinstitutionalization, especially decreasing short-term re-admission and increasing immediate outpatient service utilization.

Searching for factors associated with the "Revolving Door phenomenon" in the psychiatric inpatient unit: A 5-year retrospective cohort study

The revolving door (RD) phenomenon refers to subjects who undergo frequent rehospitalizations in psychiatric units. The main aim of this study was to analyze clinical factors associated with RD in acute inpatient psychiatric ward. In a 5-year cohort study, subjects hospitalized three or more times in 12 months (revolving door subjects-RDS) were identified. A total of 1,324 subjects were hospitalized. RDS represented 6.3% (n = 84) of the entire sample with a total of 337 RD hospitalizations (revolving door hospitalizations-RDH) (16.7% of all admissions). RDS were younger, unmarried, with comorbid substance related disorders, with mood or psychotic disorders and affected by comorbid medical conditions. After controlling for age, sex and marital status, the most strongly associated variable with RDH was the comorbidity between mood and substance use disorders. Other associated factors were the presence of a comorbid medical condition and a longer length of stay. The commitment to community residential facilities and the treatment with a first generation long-acting antipsychotic were also associated with RDH. On the contrary, admissions to the psychiatric unit for manic/hypomanic episode or for self-directed harmful behavior were inversely associated with RDH. Attention should be given to these clinical variables in order to reduce RD.

Rehospitalization and "Revolving Door" in Anorexia Nervosa: Are There Any Predictors of Time to Readmission?

Objective: Anorexia nervosa (AN) is a severe psychiatric illness with multifactorial etiology and unsatisfactory treatment outcomes. Hospitalization is required for a substantial number of patients, and readmission (RA) commonly occurs. Some individuals need multiple hospitalizations sometimes over a short amount of time, thus, delineating the "revolving door" (RD) phenomenon. However, very little is known about readmissions and their frequency in AN. Therefore, we aimed to longitudinally investigate readmissions in AN in order to: (a) characterize patients with AN who need readmission (i.e., RA-AN), sometimes rapidly (RD-AN); (b) ascertain differences between RA-AN and non-RA-AN groups during baseline hospitalization; (c) investigate as to whether clinical or psychometric parameters worsened on RA; and (d) analyze predictors of time-to-readmission in AN. Methods: A total of 170 inpatients with AN were enrolled at their baseline hospitalization; all their subsequent rehospitalizations were recorded with a longitudinal design by which each patient has been observed for 3 years. Patients were classified as RD-AN if requiring a readmission <12 months since last discharge. Clinical characteristics were measured upon admission and discharge for each hospitalization, and at all time points, patients completed questionnaires assessing eating and general psychopathology, and body shape concerns. Results: Sixty-seven patients (39.4%) needed at least one readmission and 62 (92.5% of RA-AN) reported RD. Compared with non-RA-AN, those with RA-AN were younger, reported a shorter duration of illness, and were more frequently diagnosed with AN-BP. Also, greater severity of anxious and depressive symptoms and body shape concerns emerged in the RA-AN group. The outcome of baseline hospitalization did not differ between groups, and only depressive symptoms worsened at readmission. Shorter duration of AN and low weight gain during baseline hospitalization predicted early readmission but did not survive statistical control. In contrast, high scores on drive for thinness upon baseline hospital entry robustly predicted a shorter time to readmission even after statistical control. Discussion: Individuals with AN who require readmission do so over a short period notwithstanding a positive treatment outcome during their baseline hospitalization. Shorter time-to-readmission can be predicted mostly in case of marked drive for thinness and poor weight gain at baseline hospital admission.

Factors Associated With High Use of Hospital Psychiatric Services in Málaga, Spain: Analysis of First Admissions

The early prediction of patients at risk may facilitate the efficient use of interventions that have been demonstrated to reduce readmissions. The aim of the study was to analyze variables during first admissions associated with further high use of an inpatient hospitalization psychiatric unit in Málaga, Spain. The risk of having three or more psychiatric admissions was analyzed in a sample of 1535 first-time admissions with multivariate Cox regression. In the multivariate model, the variables associated with the risk of high use were age at admission (p < 0.001), length of stay (p < 0.001), place of residence (p < 0.001), and previous history with mental health services (p < 0.001). The results suggest that there are several easily accessible characteristics at first admission that are potentially useful in detecting patients at risk.

Factors Associated with Rapid Readmission Among Nevada State Psychiatric Hospital Patients

Rapid readmission (RR) of psychiatric patients within 30 days of discharge places a costly burden on state psychiatric facilities and may indicate suboptimal service provisions. Information regarding variables associated with RR of psychiatric patients is limited, particularly in Nevada. This study attempts to identify factors associated with RR at a Nevada state psychiatric hospital. Participants included 7177 patients admitted between May 2012 and April 2014. Using logistic regression, all admissions were reviewed and rapid readmits compared to counterparts who were not readmitted within 30 days. Nevada suffers from budget cuts in mental health care spending because of recent economic crisis and severe lack of bed space. This study demonstrates that it may be possible to reduce rates of costly RR by focusing on those with a history of RR and modifiable factors including social and financial support, as well as reliable and stable housing.

A patient perspective on recurrent or prolonged contact with psychiatric inpatient care for affective disorder

Background

The aim of this qualitative study was to explore why some patients receive recurrent or prolonged psychiatric inpatient care, based on the experiences of the patients themselves.

Methods

The participants were recruited at an outpatient clinic at the department of psychiatry for patients with affective disorders at Sahlgrenska University Hospital, Sweden. Ten patients, nine women and one man, aged 22–61 years, agreed to participate. A semi-structured interview guide was used during the interviews, which were audiotaped, transcribed, and analyzed using interpretative phenomenological analysis.

Results

The four themes that emerged were Difficulties in affective regulation, where the informants reported difficulty in managing their emotions, with the possible consequence of admission to inpatient care; Relational sensitivity, concerning a sensitivity to relationships with healthcare professionals and a need for a secure therapeutic rapport; Resignation, characterized by passivity and depression; and Ambivalence towards responsibility, where ambivalence about their responsibility could lead to failure to initiate change.

Conclusions

More options beside inpatient care should be available in cases of an urgent need for help. A stable care structure, good cooperation, and long-term planning based on individual needs are pivotal. In the planning of psychiatric care, consideration must be given to the patient’s relational sensitivity. By encouraging patients to actively seek help, we can counteract their resistance and achieve a more effective contact with psychiatric services.

Factors Associated with Length of Stay in Psychiatric Inpatient Services in London, UK

The purpose of this research was to identify factors associated with lengthy stays in psychiatric hospital in a UK mental health trust. A multiple regression using a multiple imputation method to deal with missing data was performed on inpatient admissions data over a four-year period for 7653 individuals. Factors associated with a longer length of stay included gender (being male), ethnicity (being Asian/Asian British, Black/Black British, or having a mixed background compared to being White/White British), accommodation status (being homeless, or in accommodation with support), primary diagnostic group of psychosis (F20-29), and number of care coordinators. Marital status was not found to be associated with length of stay in this sample. Length of stay is likely to be multifactorially determined, and more similar studies examining factors associated with length of hospital stay are needed to understand the operation of psychiatric services.

The ‘revolving door’: a profile of acute admissions at a South African psychiatric hospital

This paper reports admission rates within the acute service at a major South African tertiary psychiatric facility, Lentegeur Psychiatric Hospital (LPH) in Cape Town.

Rapid and frequent psychiatric readmissions: associated factors

OBJECTIVE

This article aims to examine the impact of clinical and demographic factors on both rapid readmission (being readmitted within 30 d) and frequent readmission (experiencing three or more admissions) in a London mental health trust.

METHODS

A four-year study period with a sample of 7648 inpatients were examined with chi-square or Mann-Whitney U tests, and binary logistic regressions to assess the associations and possible predictors of rapid (readmitted within 30 d) and frequent (admitted at least three times) readmission.

RESULTS

Frequent admitters were more likely to be unemployed, have more care-coordinators, be living in accommodation with support, be Black or Black British, and to have certain diagnoses. Binary logistic regression revealed that our variables of interest explained between 36.1 and 60.9% of the variation in number of readmissions (±3 admissions), and between 3.7 and 4.2% of the variation in time to readmission (±30 d).

CONCLUSIONS

Identifying factors that are associated with rehospitalisation and understanding their importance is necessary to reduce the risk of readmission. This study suggests that particular demographic, clinical and treatment factors require consideration to tackle the seemingly wide range of factors that could be affecting readmission to inpatient services.

High utilization of inpatient detoxification: predictors among US veterans

BACKGROUND

Readmissions are among the most problematic and expensive problems in the treatment of substance use disorders.

OBJECTIVE

To evaluate the characteristics associated with four or more inpatient medically managed detoxification admissions in FY 2012, when all had post-discharge appointments within 7 days.

METHODS

A retrospective case control study. A total of 38 (6.0%) of 623 unique veterans had four or more detoxification admissions (high utilizers). A random sample of 42 was selected from the remaining 585 people (comparison group). In all, 264 detoxification and 70 hospital admissions for other reasons were reviewed.

RESULTS

The high utilizers had more alcohol use disorder (AUD, 82% versus 59%, p = 0.03) of significantly longer duration (mean 28.9 years [SD = 17] vs. 19.6 [SD = 13.4], p = 0.01). AUD increased the odds of being a high utilizer three-fold [OR = 3.0, 95% CI 1.1, 8.4], and every additional year of AUD, increased the number of admissions 1.3%, p = 0.0006. The high utilizers did not differ from the comparison group with regards to either number of hospitalizations for other reasons (mean 1.2 [SD = 1.9] vs. 0.57 [SD = 0.8], p = 0.06) or rate of 7 day post discharge appointments kept (46.9% vs. 49.3%, p = 0.82).

CONCLUSIONS

High utilizers were a small percentage of patients (6.0%) who accounted for a disproportionate number (23%) of 977 detoxification admissions. They had greater disease severity as manifest by more years of AUD. They were not more likely to have hospitalizations for other reasons or less likely to keep post discharge appointments. These patients may warrant different services tailored to prevent hospital readmissions for detoxification.

Impact of socio-economic status on hospital length of stay following injury: a multicenter cohort study

BACKGROUND

Injury is second only to cardiovascular disease in terms of acute care costs in North America. One key to improving injury care efficiency is to generate knowledge on the determinants of resource use. Socio-economic status (SES) is a documented risk factor for injury severity and mortality but its impact on length of stay (LOS) for injury admissions is unknown. This study aimed to examine the relationship between SES and LOS following injury. This multicenter retrospective cohort study was based on adults discharged alive from any trauma center (2007-2012; 57 hospitals; 65,486 patients) in a Canadian integrated provincial trauma system. SES was determined using ecological indices of material and social deprivation. Mean differences in LOS adjusted for age, gender, comorbidities, and injury severity were generated using multivariate linear regression.

RESULTS

Mean LOS was 13.5 days. Patients in the highest quintile of material/social deprivation had a mean LOS 0.5 days (95 % CI 0.1-0.9)/1.4 days (1.1-1.8) longer than those in the lowest quintile. Patients in the highest quintiles of both social and material deprivation had a mean LOS 2.6 days (1.8-3.5) longer than those in the lowest quintiles.

CONCLUSIONS

Results suggest that patients admitted for traumatic injury who suffer from high social and/or material deprivation have longer acute care LOS in a universal-access health care system. The reasons behind observed differences need to be further explored but may indicate that discharge planning should take patient SES into consideration.

Post-inpatient attrition from care "as usual" in veterans with multiple psychiatric admissions

Disengagement from outpatient care following psychiatric hospitalization is common in high-utilizing psychiatric patients and contributes to intensive care utilization. To investigate variables related to treatment attrition, a range of demographic, diagnostic, cognitive, social, and behavioral variables were collected from 233 veterans receiving inpatient psychiatric services who were then monitored over the following 2 years. During the follow-up period, 88.0 % (n = 202) of patients disengaged from post-inpatient care. Attrition was associated with male gender, younger age, increased expectations of stigma, less short-term participation in group therapy, and poorer medication adherence. Of those who left care, earlier attrition was predicted by fewer prior-year inpatient psychiatric days, fewer lifetime psychiatric hospitalizations, increased perceived treatment support from family, and less short-term attendance at psychiatrist appointments. Survival analyses were used to analyze the rate of attrition of the entire sample as well as the sample split by short-term group therapy attendance. Implications are discussed.

Rehabilitation between institutional and non-institutional forensic psychiatric care: important influences on the transition process

All patients cared for in forensic psychiatric care (FPC) have some kind of psychiatric disorder and most of them have committed one or more criminal acts. One part of the patient's rehabilitation is the transition from institutional to non-institutional FPC, but a number of patients do not succeed. The aim of this study was to elucidate different caregivers' experiences of aspects that influence the patients' ability to manage this rehabilitation. A qualitative approach was chosen. Data were collected by interviews in two focus groups, each group comprising of six caregivers representing both institutional and non-institutional FPC. The transcribed interviews were analysed using a qualitative content analysis. Important aspects influencing the patients' transition described were a well-planned care plan, together with a suitable non-institutional dwelling and a tailored occupation. Other important areas were having a well-functioning and trusting social network and a good relationship with a contact person/advocate. A major barrier to a successful transition was whether the patients managed their own finances or not. It was stated that it is important that the patients participate in the care and that different authorities create individual conditions and flexible solutions. All of these factors are important to focus on when caring for patients during their stay in the institutional FPC.

The ‘revolving door’: a profile of acute admissions at a South African psychiatric hospital

This paper reports admission rates within the acute service at a major South African tertiary psychiatric facility, Lentegeur Psychiatric Hospital (LPH) in Cape Town.

Predictors of rehospitalization in high-utilizing patients in the VA psychiatric medical system

233 high-service-utilizing (HSU) psychiatric patients were recruited during an inpatient psychiatric treatment. They completed a questionnaire related to their treatment beliefs and were tracked via computerized medical records over 2 years. During the follow-up period, 79.8% were readmitted for additional inpatient psychiatric treatment. Survival analysis techniques were used to examine patients' rates of readmittance during the follow-up period. Number of previous year inpatient psychiatric days served as a significant predictor of readmittance status and time to readmission. The survival plot was split by previous-year inpatient days to examine the effect of this variable on readmission. Implications of findings are discussed.

Fostering a culture of engagement: an evaluation of a 2-day training in solution-focused brief therapy for mental health workers

The focus of mental health care has changed considerably in recent years, from an almost exclusive inpatient system of care to one where the majority of care is being delivered within the community. Arguably this has contributed to a reduction in the length of inpatient admissions. Therefore, there is a need to understand the ramifications that shorter admissions have on inpatient care and nursing practice. This paper reports on a study designed to test the knowledge and skill acquisition and self-reported application of solution-focused brief therapy by staff following a 2-day training. The study adopted a repeated measures design where participants' baseline knowledge was measured prior to the 2-day training and then at 3 and 6 months post-training. This study has demonstrated that the 2-day training was effective in increasing participants' reported knowledge and understanding of solution-focused brief therapy and their self-reported use of the techniques in routine clinical practice. In conclusion, this study has established that staff from a variety of professional and non-professional backgrounds can make good skill acquisition from a fairly modest training. Additionally, the current study has also highlighted the need for well-conducted large-scale trials of this potentially important technology.