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Otis M, Barber S, Amet M, Nicholls D. Models of integrated care for young people experiencing medical emergencies related to mental illness: a realist systematic review. Eur Child Adolesc Psychiatry 2023; 32:2439-2452. [PMID: 36151355 PMCID: PMC9510153 DOI: 10.1007/s00787-022-02085-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 09/10/2022] [Indexed: 11/30/2022]
Abstract
Mental illness heightens risk of medical emergencies, emergency hospitalisation, and readmissions. Innovations for integrated medical-psychiatric care within paediatric emergency settings may help adolescents with acute mental disorders to get well quicker and stay well enough to remain out of hospital. We assessed models of integrated acute care for adolescents experiencing medical emergencies related to mental illness (MHR). We conducted a systematic review by searching MEDLINE, PsychINFO, Embase, and Web of Science for quantitative studies within paediatric emergency medicine, internationally. We included populations aged 8-25 years. Our outcomes were length of hospital stay (LOS), emergency hospital admissions, and rehospitalisation. Limits were imposed on dates: 1990 to June 2021. We present a narrative synthesis. This study is registered on PROSPERO: 254,359. 1667 studies were screened, 22 met eligibility, comprising 39,346 patients. Emergency triage innovations reduced admissions between 4 and 16%, including multidisciplinary staffing and training for psychiatric assessment (F(3,42) = 4.6, P < 0.05, N = 682), and telepsychiatry consultations (aOR = 0.41, 95% CI 0.28-0.58; P < 0.001, N = 597). Psychological therapies delivered in emergency departments reduced admissions 8-40%, including psychoeducation (aOR = 0.35, 95% CI 0.17-0.71, P < 0.01, N = 212), risk-reduction counselling for suicide prevention (OR = 2.78, 95% CI 0.55-14.10, N = 348), and telephone follow-up (OR = 0.45, 95% CI 0.33-0.60, P < 0.001, N = 980). Innovations on acute wards reduced readmissions, including guided meal supervision for eating disorders (P = 0.27), therapeutic skills for anxiety disorders, and a dedicated psychiatric crisis unit (22.2 vs 8.5% (P = 0.008). Integrated pathway innovations reduced readmissions between 8 and 37% including family-based therapy (FBT) for eating disorders (X2(1,326) = 8.40, P = 0.004, N = 326), and risk-targeted telephone follow-up or outpatients for all mental disorders (29.5 vs. 5%, P = 0.03, N = 1316). Studies occurred in the USA, Canada, or Australia. Integrated care pathways to psychiatric consultations, psychological therapies, and multidisciplinary follow-up within emergency paediatric services prevented lengthy and repeat hospitalisation for MHR emergencies. Only six of 22 studies adjusted for illness severity and clinical history between before- and after-intervention cohorts and only one reported socio-demographic intervention effects.
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Affiliation(s)
- Michaela Otis
- Imperial College London, South Kensington, London, SW7 2BX UK
- NIHR Applied Research Collaboration (ARC) Northwest London, London, UK
- Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Susan Barber
- Imperial College London, South Kensington, London, SW7 2BX UK
- NIHR Applied Research Collaboration (ARC) Northwest London, London, UK
- Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Mona Amet
- Imperial College London, South Kensington, London, SW7 2BX UK
| | - Dasha Nicholls
- Imperial College London, South Kensington, London, SW7 2BX UK
- NIHR Applied Research Collaboration (ARC) Northwest London, London, UK
- Chelsea and Westminster NHS Foundation Trust, London, UK
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Connell SK, To T, Arora K, Ramos J, Haviland MJ, Desai AD. Perspectives of Parents and Providers on Reasons for Mental Health Readmissions: A Content Analysis Study. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2021; 48:830-838. [PMID: 33876319 DOI: 10.1007/s10488-021-01134-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 11/28/2022]
Abstract
Pediatric hospitalizations for mental health conditions are rapidly increasing, with readmission rates for mental health conditions surpassing those for non-mental health conditions. The objective of this study was to identify reasons for pediatric mental health readmissions from the perspectives of parents and providers. We performed a retrospective content analysis of surveys administered to parents and providers of patients with a 14-day readmission to an inpatient pediatric psychiatry unit between 5/2017 and 8/2018. Open-ended survey items assessed parent and provider perceptions of readmission reasons. We used deductive coding to categorize survey responses into an a priori coding scheme based on prior research. We used inductive coding to identify and categorize responses that did not fit into the a priori coding scheme. All data were recoded using the revised schema and reliability of the coding process was assessed using kappa statistics and consensus building. We had completed survey responses from 89 (64%) of 138 readmission encounters (56 parent surveys; 61 provider surveys). The top three readmission reasons that we identified from parent responses were: discordant inpatient stay expectations with providers (41%), discharge hesitancy (34%), and treatment plan failure (13%). Among providers, the top readmission reasons that we identified were: access to outpatient care (30%), treatment adherence (13%), and a challenging home (11%) and social environment (11%). We identified inpatient stay expectations, discharge hesitancy, and suboptimal access to outpatient care as the most prominent reasons for mental health readmissions, which provide targets for future quality improvement efforts.
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Affiliation(s)
- Sarah K Connell
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Research Institute, 2001 8th Ave., Seattle, WA, USA. .,Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, USA.
| | - Tony To
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | - Kashika Arora
- Psychiatry and Behavioral Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Jessica Ramos
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | - Miriam J Haviland
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | - Arti D Desai
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Research Institute, 2001 8th Ave., Seattle, WA, USA.,Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, USA
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McConachie SM, Raub JN, Yost R, Monday L, Agrawal S, Tannous P. Evaluation of a multidisciplinary approach to reduce internal medicine readmissions using a readmission prediction index. Am J Health Syst Pharm 2020; 77:950-957. [DOI: 10.1093/ajhp/zxaa078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Purpose
Readmission prediction indices are used to stratify patients by the risk of hospital readmission. We describe the integration of a 30-day hospital readmission prediction index into the electronic medical record (EMR) and its impact on pharmacist interventions during transitions of care (TOC).
Methods
A retrospective cohort study was conducted to compare 30-day readmission rates between adult internal medicine inpatients admitted by a multidisciplinary team providing TOC services (the TOC group) and those who received usual care (the control group). Interventions by a pharmacist serving on the TOC team were guided by an EMR-integrated readmission index, with patients at the highest risk for readmission receiving targeted pharmacist interventions. Inpatient encounters (n = 374) during the 5-month study period were retrospectively identified. Chi-square and Mann-Whitney U tests were performed to analyze differences in nominal and nonparametric continuous variables, respectively. Logistic regression was performed to identify variables associated with 30-day readmissions. The log-rank test was used to analyze hazard ratios for readmission outcomes in the 2 cohorts.
Results
Thirty-day readmission rates did not differ significantly in the TOC group and the control group (20.9% vs 18.3%, P = 0.52). However, patients who received additional direct pharmacist interventions, as guided by use of a hospital readmission index, had a lower 30-day readmission rate than patients who did not (11.4% vs 21.7%, P = 0.04). The readmission index score was significantly associated with the likelihood of 30-day readmission (odds ratio for readmission, 1.25; 95% confidence interval, 1.16-1.34; P < 0.01). The difference in unadjusted log-rank scores at 30 days with and without pharmacist intervention was not significant (P = 0.05). A mean of 4.5 medication changes were identified per medication reconciliation performed by the TOC pharmacist.
Conclusion
A multidisciplinary TOC team approach did not reduce the 30-day readmission rate on an internal medicine service. However, patients who received additional direct pharmacist interventions guided by a readmission prediction index had a reduced readmission rate.
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Affiliation(s)
- Sean M McConachie
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, and Beaumont Hospital, Dearborn, Dearborn, MI
| | - Joshua N Raub
- Department of Pharmacy Services, Detroit Medical Center, Detroit, MI, and Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI
| | - Raymond Yost
- Department of Pharmacy Services, Detroit Medical Center, Detroit, MI, and Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI
| | - Lea Monday
- Department of Internal Medicine, Detroit Medical Center, Detroit, MI, and Wayne State University School of Medicine, Detroit, MI
| | - Shivani Agrawal
- Department of Internal Medicine, Detroit Medical Center, Detroit, MI, and Wayne State University School of Medicine, Detroit, MI
| | - Pierre Tannous
- Department of Internal Medicine, Detroit Medical Center, Detroit, MI, and Wayne State University School of Medicine, Detroit, MI
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Phillips MS, Steelesmith DL, Campo JV, Pradhan T, Fontanella CA. Factors Associated With Multiple Psychiatric Readmissions for Youth With Mood Disorders. J Am Acad Child Adolesc Psychiatry 2020; 59:619-631. [PMID: 31170443 PMCID: PMC7561034 DOI: 10.1016/j.jaac.2019.05.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 03/22/2019] [Accepted: 05/29/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Inpatient psychiatric readmission rates are increasingly considered indicators of quality of care. This study builds upon prior research by examining patient-, hospital-, and community-level factors associated with single and multiple readmissions for youth. METHOD A retrospective cohort study was conducted using Medicaid claims data from four states supplemented with the American Hospital Association survey, the Area Resource File, and the National Survey of Mental Health Treatment Services. Multinomial logistic regression examined patient-, hospital-, and community-level factors that were associated with inpatient psychiatric readmission for 6,797 Medicaid-eligible youth with a primary diagnosis of mood disorder using a three-level nominal dependent variable coded as no readmission, one readmission, and two or more readmissions within 6 months after discharge. RESULTS Six months after initial discharge, 941 youth (13.8%) were readmitted once and 471 (6.9%) were readmitted two or more times. The odds of single or multiple readmissions were significantly higher (p < .05) for youth classified as disabled or in foster care, those with multiple psychiatric comorbidities, medical comorbidity, and prior psychiatric hospitalization. Treatment in hospitals with high percentage of Medicaid discharges and a high number of beds was associated with lower odds of readmission. There was a significant interaction between length of stay and outpatient mental health follow-up within 7 days of discharge. CONCLUSION Patient- and hospital-level factors are associated with likelihood of both single and multiple youth inpatient psychiatric readmissions, suggesting potential risk markers for psychiatric readmission.
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Affiliation(s)
- Matthew S. Phillips
- College of Medicine and Wexner Medical Center, The Ohio State University, Columbus
| | | | - John V. Campo
- West Virginia University School of Medicine, Morgantown.; West Virginia University Rockefeller Neuroscience Institute, Morgantown
| | - Taniya Pradhan
- The West Virginia University School of Medicine, Morgantown
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