The dynamics of hospitalization in a defined population during deinstitutionalization

Long-term hospitalizations for schizophrenia in the Czech Republic 1998-2012

Deinstitutionalization has not been pursued in the post-communist Europe until recently. The population of psychiatric patients institutionalized in the regional mental hospitals is, however, largely understudied. The aim of this study is to assess discharges of long-term inpatients with schizophrenia from Czech psychiatric hospitals and to analyse re-hospitalizations within this group. The nationwide register of all-cause inpatient hospitalizations was merged with the nationwide register of all-cause deaths on an individual level basis. Descriptive statistics, survival analysis and logistic regression were performed. 3601 patients with schizophrenia previously hospitalized for more than a year were discharged from Czech mental hospitals between 1998 and 2012. This included 260 patients hospitalized for >20years. Nearly one fifth (n=707) of the long-term patients died during the hospitalization; and discharges of 19.36% (n=697) were only administrative in their nature. Out of 2197 truly discharged patients, 14.88% (n=327) were re-hospitalized within 2weeks after the discharge. The highest odds of rehospitalization were associated with being discharged against medical advice (OR 5.27, CI: 3.77-7.35, p<0.001). These data are important for the ongoing mental health care reforms in the Czech Republic and other countries in the Central and Eastern Europe.

The state of the state mental hospital at the turn of the century

There is a core of services whose specific content varies from place to place that still appears to belong to the state mental hospital.

The Qualyop Project. 1: Monitoring the dismantlement of Italian public psychiatric hospitals. Characteristics of patients scheduled for discharge

OBJECTIVES

Monitoring and evaluating the Italian psychiatric hospitals closure process, stated by the law to be concluded by 31 December 1996, and then postponed to 31 March 1998, identifying characteristics related to the possibility of discharge in 4493 patients living in twenty-two public psychiatric hospitals.

METHOD

Sociodemographic and clinical data, information on impairment and functioning and plans for discharge in the subsequent twelve months of all patients were collected at baseline using a standard questionnaire.

RESULTS

Discharge was planned within twelve months for 11% of the patients: 4% to other psychiatric or non-psychiatric institutions and 7% to community settings. Severely disabled patients and patients with some behavioural problems were more frequently scheduled to go to institutional settings. For both types of discharge, an adequate network of social relationships was an important determinant. Patients were more frequently planned for discharge if they resided in hospitals with a higher care providers/patients ratio, and in Emilia Romagna and Rome, than in Lombardy and Liguria.

CONCLUSION

Frequency of planned discharge depended partly on the patients' personal characteristics related to independence and functioning, but the effect of these factors on frequency of planned discharge was influenced by characteristics of the hospitals where the patients lived.

A national audit of new long-stay psychiatric patients. I: Method and description of the cohort

BACKGROUND

This first report of a national audit of new long-stay (NLS) psychiatric patients conducted in 1992 describes the survey method and characteristics of the cohort.

METHOD

Psychiatrists from 59 UK mental health services returned data on 905 patients, aged 18-64 on admission, who had been in hospital for between six months and three years.

RESULTS

Two particular sub-groups were observed. Younger NLS patients (aged 18-34) were predominantly single men with schizophrenia; 43% of these had a history of serious violence, dangerous behaviour or admission to a Special Hospital and over one-third were formally detained. Older NLS patients (aged 55-67) were predominantly married or previously married women, more often with a diagnosis of affective disorder or dementia and with poor personal and social functioning; over half were at moderate or severe risk of non-deliberate self-harm.

CONCLUSIONS

Despite the continued policy of bed closures and focus on care in the community, some patients admitted recently to psychiatric units in the UK still have protracted hospital stays.

A thirty-year retrospective study of hospitalization among severely mentally ill patients

This study examines the effects of deinstitutionalization policies on psychiatric hospitalization rates over a thirty-year period. It is based on a retrospective study of successive hospitalizations in severely disabled patients. The data indicate that in any five-year period these patients still spend over 20% of their time in hospital. For patients who have stayed for a total of more than one year every five years in hospital, the average length of stay has been decreasing far less rapidly in the last fifteen years than it had previously. Patients who were first admitted after 1971 spent proportionally as much time in hospital as those whose first stay was earlier. These results show that the groups primarily affected by deinstitutionalization are those who were first hospitalized prior to the 1970s and those who are the heaviest hospital users. However, the data from the patients admitted since the seventies seem to reveal that the process of change may have reached its limits.

Chronic or long-term psychiatric patients: potential subjects for longitudinal research

The frequently admitted "revolving door" chronic psychiatric patient presents significant ethical, scientific, and practical challenges to mental health nurses. This article highlights ethical issues relevant to their participation in longitudinal research and describes methods implemented to successfully follow a cohort of such patients over a 2-year period.

Some factors relating to satisfactory post-discharge community maintenance of chronic psychotic patients

The length of time a group of 70 psychiatric patients could be maintained in the community following discharge from a provincial hospital was found to be significantly related to post-discharge compliance with medication and to the level of discharge planning (well planned versus unplanned, or patient prematurely self-discharged against medical advice). Various demographic and clinical variables were unrelated to the length of post-discharge survival in the community.

Deinstitutionalisation--from hospital closure to service development

The necessary components of a comprehensive service of local non-institutional forms of care for the seriously mentally ill have been researched separately in pilot trials, but not within integrated programmes for defined populations. Reported outcomes are at least as favourable as for traditional long-term hospital care, but alternative provisions are no less costly. A case manager system may allow co-ordinated formal and informal services to meet the individual needs of chronically ill patients. Poorly integrated programmes will expose discharged patients to disadvantages.

Paranoid schizophrenia: prognosis under DSM-II and DSM-III-R

DSM-III-R subtype-specific criteria and Tsuang-Winokur demographic criteria for paranoid schizophrenia were applied to records of discharged schizophrenic inpatients diagnosed according to DSM-II. Those meeting DSM-III-R subtype-specific criteria for paranoid schizophrenia and those who did not, ie, they received more hopeful diagnoses, had equally good prognoses. Good outcome was associated with the presence of prior affective symptomatology, absence of formal thought disorder, or other negative-type symptoms as well as Tsuang-Winokur demographic criteria of onset after age 25, married or employed status, and/or absence of family history. Patients with particularly poor outcome were identified by the coexistence of unsystematized or poorly developed persecutory ideation, symptoms of thought disorder, and/or disorganized behavior. The clinical and demographic descriptors discussed in this report may be particularly useful in creating homogeneous patient groupings for both clinical and rate-setting payment classifications.

Patterns of care in a district general hospital psychiatric department

A survey of all admissions of patients under the age of 65 during the first 6 years of a District General Psychiatric Department without mental-hospital support is reported. Three high-uptake groups of in-patients were defined; the long-stay (12 months or more), the medium-stay (6-12 months), and the revolving-door group (more than three admissions in any period of 12 months). Identifying characteristics which distinguish between these groups were examined. During a 7-year period there was no accumulation of long-stay patients, and a striking lack of schizophrenic patients who remained in hospital for more than 6 months or who had more than three admissions in any twelve-month period. This was not accounted for by drift of the high-uptake groups out of contact with the service, but may be related both to the style of service provision and to the socially cohesive nature of the area under study. Local variation should be given due importance when community services are being developed.

[The psychiatric hospital: from yesterday to tomorrow]

A study carried out in a psychiatric hospital in the Montreal region reveals that in spite of deinstitutionalization, long-term stay remains an important factor in the use of beds. For some patients the hospital remains a permanent home, either from their first admission or from the time they are institutionalized after multiple admissions. For both in- and out-patients, return to the hospital and long-term care are almost inevitable. Generally speaking, the services of the hospital are used by the same long-term patients, and this to the extent that the hospital cannot provide services to other establishments or play its second-line role. This is frustrating for other institutions in the network, even though they accept the inevitability of the situation given the lack of adequate community resources for these patients. One of the primary functions of a psychiatric hospital also seems to be to fill in the gaps in the service network. In this regard, its expertise in the field of intervention in chronic psychiatric patients must not be overlooked. Given the current situation, the hospital's responsibility in regard to second-line services cannot be clarified until it has been determined just how much of the responsibility for care of psychiatric patients can be assumed by the community itself.

Alternatives to DRGs: research issues

Legislative mandates for the development of prospective payment methodologies for reimbursing inpatient care have spurred the psychiatric community into its own independent effort, applying both clinical and service research, to develop schemes which are fair to psychiatric patients, their providers and payers. Many of the issues involved in the development of an equitable prospective payment system (PPS) for psychiatric care are not new to the field, namely, problems of limited diagnostic accuracy, a limited knowledge of the outcomes of clearly defined treatment protocols, and a lack of integration, efficiency and efficacy in a highly differentiated service system. The research community needs to respond to these problems in the context of cost containment with an awareness that its response will influence care for psychiatric patients for the remainder of this century. In this paper, we will describe the background issues that have brought the psychiatric community to the present point in its response to PPS, and discuss some of the research problems posed by the need for a PPS with the right incentives for clinical effectiveness and efficiency.