The Effect of Centers for Medicare and Medicaid's Inpatient Psychiatric Facility Quality Reporting Program on the Use of Restraint and Seclusion

A systematic review of interventions to reduce mechanical restraint in adult mental health inpatient settings

Mechanical restraint is a commonly used restrictive practice worldwide, although reducing its use is an international priority. Interventions to reduce mechanical restraint are needed if reducing mechanical restraint is to succeed. Therefore, this systematic review aimed to examine evaluated evidence-based interventions that seek to reduce the incidence of and/or time in mechanical restraint in adult mental health inpatient settings. The JBI framework was used to guide this systematic review. The search strategy included peer-reviewed primary research literature published between 1999 and 2023. Two authors independently conducted the systematic search, selection process and data extraction process. Forty-one studies were included in this review. Using content analysis, we grouped interventions into four categories: (I) calm-down methods, (II) staff resources, (III) legal and policy changes and (IV) changing staff culture. Interventions to reduce mechanical restraint in adult mental health inpatient settings have shown some promise. Evidence suggests that a range of interventions can reduce the incidence of and/or time in mechanical restraint. However, controlled trials were lacking and consensus was lacking across studies. Furthermore, specific findings varied widely, and reporting was inconsistent, hampering the development of interventions for this issue. Further research is needed to strengthen the evidence base for reducing mechanical restraint in mental health inpatient settings.

Rural-Urban Disparities in Quality of Inpatient Psychiatric Care

OBJECTIVE

Rural residents have higher rates of serious mental illness than urban residents, but little is known about the quality of inpatient psychiatric care available to them locally or how quality may have changed in response to federal initiatives. This study aimed to examine differences and changes in the quality of inpatient psychiatric care in rural and urban hospitals.

METHODS

This national retrospective study of 1,644 facilities examined facility-level annual quality-of-care data from the Inpatient Psychiatric Facility Quality Reporting program, 2015-2019. Facility location was categorized as urban, large rural, or small or isolated rural on the basis of zip code-level rural-urban commuting area codes. Generalized regression models were used to assess rural-urban differences in care quality (five continuity-of-care and two patient experience measures) and changes over time.

RESULTS

Rural inpatient psychiatric units performed better than urban units in nearly all domains. Improvements in quality of care (excluding follow-up care) were similar in rural and urban units. Rates of 30- and 7-day postdischarge follow-up care decreased in all hospitals but faster in rural units. Timely transmission of transition records was more frequent in small or isolated rural versus urban units (mean marginal difference=22.5, 95% CI=6.3-38.8). Physical restraint or seclusion use was less likely in rural than in urban units (OR=0.6, 95% CI=0.5-0.8).

CONCLUSIONS

Rural psychiatric units had better care quality at baseline (better follow-up care, better timely transmission of transition records, and lower rates of physical restraint use) than urban units, but during 2015-2019, follow-up care performance decreased overall and more in rural than urban units.

Former Inpatient Psychiatric Patients' Past Experiences With Traditional Frontline Staff and Their Thoughts on the Benefits of Peers as Part of Frontline Staff

Little is known about how integrating peers into frontline staff might improve the quality of inpatient psychiatric care. In the current study, we interviewed 18 former adult patients of inpatient psychiatric facilities using semi-structured interviews. We first asked about positive and negative past experiences with traditional staff. We then asked participants to share their opinions on the potential benefits of peers as part of frontline staff. We identified themes through a joint inductive and deductive approach. Participants reported past positive experiences with traditional staff as being (a) personable and caring, (b) validating feelings and experiences, (c) de-escalating, and (d) providing agency. Past negative experiences included (a) not sharing information, (b) being inattentive, (c) not providing agency, (d) being dehumanizing/disrespectful, (e) incompetency, (f) escalating situations, and (g) being apathetic. Participants believed that peers as part of frontline staff could champion emotional needs in humanizing and nonjudgmental ways, help navigate the system, and disrupt power imbalances between staff and patients. Further research is needed to understand financial, organizational, and cultural barriers to integrating peers into frontline staff. [Journal of Psychosocial Nursing and Mental Health Services, 60(3), 15-22.].

Patient Characteristics Associated With Admission to Low-Safety Inpatient Psychiatric Facilities: Evidence for Racial Inequities

OBJECTIVE

The author examined patient demographic, clinical, payment, and geographic factors associated with admission to low-safety inpatient psychiatric facilities.

METHODS

Massachusetts all-payer 2017 discharge data (N=39,128 psychiatric patients) were linked to facility-level indicators of safety (N=38 facilities). A composite of safety was created by averaging standardized measures of restraint and seclusion as well as 5-year averages of overall, substantiated, and abuse-related (i.e., verbal, physical, or sexual) complaints per 1,000 discharges (α=0.73). This composite informed quintile groups of safety performance. A series of multinomial regression models were fit, with payment and geography added separately.

RESULTS

Notable factors independently associated with admission to low-safety facilities were belonging to a racial or ethnic minority group compared with being a White patient (for non-Hispanic Black, relative risk ratio [RRR]=1.71, p<0.01; for non-Hispanic Asian, RRR=5.60, p<0.01; for non-Hispanic "other" race, RRR=2.17, p<0.01; and for Hispanic-Latinx, RRR=1.29, p<0.01) and not having private insurance (for self-pay or uninsured, RRR=2.40, p<0.01; for Medicaid, RRR=1.80, p<0.01; and for Medicare, RRR=1.31, p<0.01).

CONCLUSIONS

To the best of the author's knowledge, this is the first study to examine differences in admission to low-safety inpatient psychiatric facilities. Even after accounting for potential clinical, geographic, and insurance mediators of structural racism, stark racial and ethnic inequities were found in admission to low-safety inpatient psychiatric facilities. In addition to addressing safety performance, policy makers should invest in gaining a better understanding of how differences in community-based referrals, mode of transport (e.g., police or self), and deliberate or unintentional steering and selection affect admissions and outcomes.

Effects of the CMS' Public Reporting Program for Inpatient Psychiatric Facilities on Targeted and Nontargeted Safety: Differences Between For-Profits and Nonprofits

The Centers for Medicare and Medicaid Services implemented the Inpatient Psychiatric Facility Quality Reporting Program in 2012, which publicly reports facilities' performance on restraint and seclusion (R-S) measures. Using data from Massachusetts, we examined whether nonprofits and for-profits responded differently to the program on targeted indicators, and if the program had a differential spillover effect on nontargeted indicators of quality by ownership. Episodes of R-S (targeted), complaints (nontargeted), and discharges were obtained for 2008-2017 through public records requests to the Commonwealth of Massachusetts. Using difference-in-differences estimators, we found no differential changes in R-S between for-profits and nonprofits. However, for-profits had larger increases in overall complaints, safety-related complaints, abuse-related complaints, and R-S-related complaints compared with nonprofits. This is the first study to examine the effects of a national public reporting program among psychiatric facilities on nontargeted measures. Researchers and policymakers should further scrutinize intended and unintended consequences of performance-reporting programs.