Predicting readmission to the psychiatric hospital in a managed care environment: implications for quality indicators

Dynamic risk factors of psychiatric readmission for major depressive disorder: A longitudinal study on patients treated with mono-antidepressant

In this comprehensive study, we sought to unravel the risk factors for recurrence in Major Depressive Disorder (MDD), uniquely focusing on patients undergoing mono-antidepressant treatment. By considering psychiatric readmission as a direct indicator of MDD recurrence, we meticulously analyzed the records of 1,456 inpatients from a Chinese mental health center from 2012 to 2020. Our follow-up periods, spanning 90, 180, and 365 days post-discharge, allowed for a nuanced understanding of the recurrence dynamics. We identified four critical risk factors: thyroid function (FT3 and TSH), high-density lipoprotein (HDL) levels, and region of residence. Notably, the study revealed an increasing risk of readmission associated with decreased FT3 and HDL over time, while elevated TSH and residing in another province 's impact diminished. The antidepressant type did not significantly alter readmission risks, providing a unique perspective on MDD management. This research contributes to the field by offering a deeper understanding of how demographic and biochemical factors influence the likelihood of MDD recurrence, guiding more effective treatment approaches.

Comparison of Resilience, Personal Recovery, and Quality of Life Measures Pre- and Post-Discharge from Inpatient Mental Health Units in Alberta: Analysis of Control Group Data from a Randomized Trial

Background: The transition from hospital to community settings for most mental health service users is often hindered by challenges that affect community adjustment and continuity of care. The first few weeks and days after discharge from mental health inpatient units represent a critical phase for many service users. This paper aims to evaluate the changes in the resilience, personal recovery, and quality of life status of individuals with mental health challenges recently discharged from acute mental health care into the community. Methods: Data for this study were collected as part of a pragmatic stepped-wedge cluster-randomized, longitudinal approach in Alberta. A paired sample t-test and Chi-squared/Fisher test were deployed to assess changes from baseline to six weeks in the recovery assessment scale (RAS), brief resilience scale (BRS), and EuroQol-5d (EQ-5D), using an online questionnaire. Results: A total of 306 service users were recruited and 88 completed both baseline and six weeks, giving a response rate of 28.8%. There was no statistically significant change in the level of resilience, recovery and quality of life as measured with the brief resilience scale, recovery assessment scale and EQ-5D from baseline to six weeks (p > 0.05). Conclusions: The study showed that there was neither an improvement nor deterioration in resilience, recovery, or quality of life status of service users six weeks post-discharge from inpatient mental health care. The lack of further progress calls into question whether the support available in the community when patient's leave inpatient care is adequate to promote full recovery. The results justify investigations into the effectiveness of innovative and cost-effective programs such as peer and text-based supportive interventions for service users discharged from inpatient psychiatric care.

Independent Predictors of 30-Day Readmission to Acute Psychiatric Wards in Patients With Mental Disorders: A Systematic Review and Meta-Analysis

Psychiatric readmissions have long been considered significant indicators for healthcare planning. The aim of this study was to identify factors influencing early (30-day) readmissions to acute psychiatric wards. A meta-analysis and systematic review were conducted according to Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Comprehensive database searching was conducted using online databases, including PubMed and Google Scholar, to search for articles identifying factors associated with early (30-day) readmissions to acute psychiatric wards. Keywords used to search for relevant articles included "Mental illness," "readmission," and factors along with their synonyms and Medical Subject Headings (MeSH) terms. The search included studies published between 2011 and June 2023. A total of 13 studies were included in this meta-analysis. The pooled rate of the 30-day readmission was 16% (95% confidence interval: 13%-20%). A pooled analysis showed that factors significantly associated with an unplanned hospital readmission included gender, length of stay, and insurance status as predictors of the unplanned hospital readmission among individuals with psychiatric illness. Additionally, we also found that the rate of 30-day unplanned admissions was greater in patients with schizophrenia, followed by personality disorder, bipolar disorder, depression, and substance use. This study highlights the importance of providing targeted interventions and support for individuals with these conditions to reduce the risk of readmissions.

Predictors of behavioral health unit readmission within 30 days of discharge: A retrospective study

Several studies have aimed to describe associated demographic and psychiatric risk factors that would lead to readmission to a behavioral health unit within 30 days of discharge. Here we considered 1,095 patients that were discharged from Millcreek Community Hospital (MCH) in Erie, Pennsylvania between June 2018 and June 2019. We extracted electronic medical data and analyzed various risk factors using a SPSS software and performed Chi square analysis to determine significance. We determined that patients between the age 30–39 that were diagnosed with major depressive disorder or bipolar disorder, and patients that had 12 or more previous behavioral health admissions were significantly more likely to be readmitted within 30 days of discharge. By analyzing risk factors that lead to a higher percentage of readmission rates, physicians can be more readily equipped and prepared while treating inpatient psychiatric patients. These physicians can take more precautionary measures when discharging patients with specific characteristic profiles to prevent the risk of being readmitted within 30 days of discharge.

Individualized prediction of psychiatric readmissions for patients with major depressive disorder: a 10-year retrospective cohort study

Patients with major depressive disorder (MDD) are at high risk of psychiatric readmission while the factors associated with such adverse illness trajectories and the impact of the same factor at different follow-up times remain unclear. Based on machine learning (ML) approaches and real-world electronic medical records (EMR), we aimed to predict individual psychiatric readmission within 30, 60, 90, 180, and 365 days of an initial major depression hospitalization. In addition, we examined to what extent our prediction model could be made interpretable by quantifying and visualizing the features that drive the predictions at different follow-up times. By identifying 13,177 individuals discharged from a hospital located in western China between 2009 and 2018 with a recorded diagnosis of MDD, we established five prediction-modeling cohorts with different follow-up times. Four different ML models were trained with features extracted from the EMR, and explainable methods (SHAP and Break Down) were utilized to analyze the contribution of each of the features at both population-level and individual-level. The model showed a performance on the holdout testing dataset that decreased over follow-up time after discharge: AUC 0.814 (0.758-0.87) within 30 days, AUC 0.780 (0.728-0.833) within 60 days, AUC 0.798 (0.75-0.846) within 90 days, AUC 0.740 (0.687-0.794) within 180 days, and AUC 0.711 (0.676-0.747) within 365 days. Results add evidence that markers of depression severity and symptoms (recurrence of the symptoms, combination of key symptoms, the number of core symptoms and physical symptoms), along with age, gender, type of payment, length of stay, comorbidity, treatment patterns such as the use of anxiolytics, antipsychotics, antidepressants (especially Fluoxetine, Clonazepam, Olanzapine, and Alprazolam), physiotherapy, and psychotherapy, and vital signs like pulse and SBP, may improve prediction of psychiatric readmission. Some features can drive the prediction towards readmission at one follow-up time and towards non-readmission at another. Using such a model for decision support gives the clinician dynamic information of the patient's risk of psychiatric readmission and the specific features pulling towards readmission. This finding points to the potential of establishing personalized interventions that change with follow-up time.

Effects of temporary psychiatric holds on length of stay and readmission risk among persons admitted for psychotic disorders

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.

Hospital Competition and Unplanned Readmission: Evidence from a Systematic Review

Competition has been widely introduced among hospitals in the hope of improving health-care quality. However, whether competition leads to higher-quality health care is a topic of considerable debate. We conducted a systematic review to assess the impact of hospital-market competition on unplanned readmission. We searched six electronic databases (PubMed, EmBase, Wiley Online Library, Web of Science, Scopus, and JSTOR) and reference lists of screened articles for relevant studies, and strictly followed methods proposed by the Cochrane Collaboration. Finally, nine observational studies with 2,241,767 patients were included. For the primary outcome, pooled results of three studies showed that it was uncertain whether or not hospital competition reduces readmission (β=0.02, P=0.06; very low certainty of evidence, as they were all observational studies with high heterogeneity). Inconsistent results were found in the remaining six studies, and they were assessed as very low–certainty evidence, downgraded for either inconsistency or indirectness or both. As for secondary outcomes, seven of the nine studies reported on the impact of competition on the risk of mortality, and two reported on length of stay (LOS). It was uncertain whether competition had an effect on mortality or LOS. The relevant studies were limited and of very low certainty, which means there is currently no reliable evidence showing that hospital competition reduces quality of health care in terms of readmission/mortality/LOS. There is a need for rigorous studies to assess the impact of hospital competition on the quality of health care.

Do discontinuities in marginal reimbursement affect inpatient psychiatric care in Germany?

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.

Modeling socio-demographic and clinical factors influencing psychiatric inpatient service use: a comparison of models for zero-Inflated and overdispersed count data

BACKGROUND

Psychiatric disorders may occur as a single episode or be persistent and relapsing, sometimes leading to suicidal behaviours. The exact causes of psychiatric disorders are hard to determine but easy access to health care services can help to reduce their severity. The aim of this study was to investigate the factors associated with repeated hospitalizations among the patients with psychiatric illness, which may help the policy makers to target the high-risk groups in a more focused manner.

METHODS

A large linked administrative database consisting of 200,537 patients with psychiatric diagnosis in the years of 2008-2012 was used in this analysis. Various counts regression models including zero-inflated and hurdle models were considered for analyzing the hospitalization rate among patients with psychiatric disorders within three months follow-up since their index visit dates. The covariates for this study consisted of socio-demographic and clinical characteristics of the patients.

RESULTS

The results show that the odds of hospitalization are significantly higher among registered Indians, male patients and younger patients. Hospitalization rate depends on the patients' disease types. Having previously visited a general physician served a protective role for psychiatric hospitalization during the study period. Patients who had seen an outpatient psychiatrist were more likely to have a higher number of psychiatric hospitalizations. This may indicate that psychiatrists tend to see patients with more severe illnesses, who require hospital-based care for managing their illness.

CONCLUSIONS

Providing easier access to registered Indian people and youth may reduce the need for hospital-based care. Patients with mental health conditions may benefit from greater and more timely access to primary care.

Factors associated with psychiatric readmission of children and adolescents in the U.S.: A systematic review of the literature

OBJECTIVE

A systematic review of research assessing factors associated with inpatient psychiatric readmission of children and adolescents.

METHODS

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we searched 8 databases (1994-2018) to identify relevant articles on factors associated with youth psychiatric readmission. Selected articles addressed one or more factors associated with psychiatric readmission for children and adolescents (≤21 years of age) admitted to a psychiatric hospital in the United States for a primary mental health diagnosis. Two authors independently reviewed article abstracts, titles, and text.

RESULTS

Of 7903 retrieved articles, 30 studies met inclusion criteria. Analyzed variables were categorized according to child demographic and clinical characteristics; family, provider, and community characteristics; and treatment and aftercare characteristics. Available studies were markedly heterogeneous in methodology and outcomes. Factors associated with an increased risk of readmission included greater symptom severity, clinical diagnoses such as psychosis and affective disorders, suicidal behavior and self-injury, poor family functioning, and longer lengths of index hospital stay.

CONCLUSIONS

Controlled trials of interventions to improve care and reduce recidivism for psychiatrically hospitalized youth are needed. Future research will benefit from a guiding theoretical framework, more representative samples, and standardized exposure/outcome measures.

Predictors of 30-day Postdischarge Readmission to a Multistate National Sample of State Psychiatric Hospitals

BACKGROUND

Early discharge from psychiatric inpatient care may pose challenges for the patient's recovery and may incite a rapid return to the hospital. This study identified demographic, clinical, and the continuing of care characteristics associated with rapid readmission into a sample of psychiatric inpatient hospitals.

METHODS

Cross-sectional analysis of 60,254 discharges from state psychiatric hospitals. Logistic regression explored the relationship between predictors of rapid readmission.

RESULTS

Eight percent of discharges were readmitted to the same hospital within 30 days after discharge. Factors significantly related with rapid readmission included white (odds ratio, 1.23; 95% confidence interval, 1.13-1.34), non-Hispanic (1.48, 1.26-1.73), not married (1.53, 1.32-1.76), voluntarily admitted (1.18, 1.05-1.33), with length of stay (LOS) ≤ 7 days (3.52, 3.04-4.08), or LOS 8-31 days (3.20, 2.79-3.66), or LOS 32-92 days (1.91, 1.65-2.22), with a schizophrenia or other psychotic disorders (1.69, 1.46-1.96) or personality disorder (1.76, 1.50-2.06), referred to a setting different from the outpatient (1.27, 1.16-1.40), or with a living arrangement different from private residence (1.54, 1.40-1.68).

CONCLUSIONS

Disparities in rapid readmission rates exist among state psychiatric hospitals. A national overview of the individuals with mental illness at risk of being prematurely discharged may suggests insights into quality initiatives aimed at reducing rapid readmissions into psychiatric inpatient care.

Post-discharge outcomes for mothers and the mother-infant relationship following admission to a psychiatric Mother-Baby Unit

Mother-Baby Unit research has focussed on maternal psychopathology over the course of an admission. Less is known about the baby's well-being, the shared relationship, or the mother's recovery. In an initial sample of 45 women, we describe discharge and post-discharge outcomes for maternal psychopathology (using maternal report and the Global Assessment of Function, GAF) and the mother-infant relationship (using the Child and Adult Relational Experimental Index, CARE Index). Three months post-discharge, one third of women described themselves as "completely recovered," one third were experiencing significant deterioration and 17% were readmitted to inpatient care. Poorer GAF scores were associated with a clinical diagnosis of comorbid personality disorder, antenatal presence of the index illness, partner illicit substance use, maternal perception of her bond, infant social withdrawal, and child protection concern. Post-discharge, the mother-infant relationship results were concerning. Only 17% were regarded as adequate. Improvement was observed across this period in 56% but relational deterioration occurred for 35%. Maternal and relational outcomes were weakly correlated at discharge (r² = 0.29, p = 0.07) but this was lost post-discharge (r² = 0.03, p = 0.89). The shared relationship and infant mental health should both be targets for intervention; both during MBU admission, and post-discharge.

Predicting Patients' Readmission: Do Clinicians Outperform a Statistical Model? An Exploratory Study on Clinical Risk Judgment in Mental Health

This study explores whether clinicians or a statistical model can better identify patients at risk of early readmission and investigates variables potentially associated with clinicians' risk judgment. We focus on a total of 142 patients discharged from acute psychiatric wards in the Verona Mental Health Department (Italy). Psychiatrists assessed patients' risk of readmission at 30 and 90 days postdischarge, predicted their postdischarge compliance, and assessed their Global Assessment of Functioning (GAF) score at admission and discharge. Clinicians' judgment outperformed the statistical model, with the difference reaching statistical significance for 30-day readmission. Clinicians' readmission risk judgment, both for 30 and 90 days, was found to be statistically associated with predicted compliance with community treatment and GAF score at discharge. Clinicians' superior performance might be explained by their risk judgment depending on nonmeasurable factors, such as experience and intuition. Patients with a poorer GAF score at discharge and poor assumed compliance were predicted to have a higher risk of readmission.

Factors Associated With Multiple Psychiatric Readmissions for Youth With Mood Disorders

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.

Psychiatric Readmission of Children and Adolescents: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate predictors of psychiatric hospital readmission of children and adolescents, a systematic review and meta-analysis was conducted.

METHODS

Following PRISMA statement guidelines, a systematic literature search of articles published between 1997 and 2018 was conducted in PubMed/MEDLINE, Google Scholar, and PsycINFO for original peer-reviewed articles investigating predictors of psychiatric hospital readmission among youths (<18 years old). Effect sizes were extracted and combined by using random-effects meta-analysis. Covariates were investigated with meta-regression and subgroup analyses.

RESULTS

Thirty-three studies met inclusion criteria, containing information on 83,361 children and adolescents, of which raw counts of readmitted vs. non-readmitted youths were available for 76,219. Of these youths, 13.2% (N=10,076) were readmitted. The mean±SD study follow-up was 15.9±15.0 months, and time to readmission was 13.1±12.8 months. Readmission was associated with, but not limited to, suicidal ideation at index hospitalization (pooled odds ratio [OR_pooled]=2.35, 95% confidence interval [CI]=1.64-3.37), psychotic disorders (OR_pooled=1.87, 95% CI=1.53-2.28), prior hospitalization (OR_pooled=2.51, 95% CI=1.76-3.57), and discharge to residential treatment (OR_pooled=1.84, 95% CI=1.07-3.16). There was evidence of moderate study bias. Prior investigations were methodologically and substantively heterogeneous, particularly for measurement of family-level factors.

CONCLUSIONS

Interventions to reduce child psychiatric readmissions should place priority on youths with indicators of high clinical severity, particularly with a history of suicidality, psychiatric comorbidity, prior hospitalization, and discharge to residential treatment. Standardization of methods to determine prevalence rates of readmissions and their predictors is needed to mitigate potential biases and inform a national strategy to reduce repeated child psychiatric hospital readmissions.

Cross-sectional study of readmissions to the psychiatric ward of Hospital Estadual Mário Covas in Santo André, state of São Paulo, between 2008 and 2015

OBJECTIVES

To assess the sociodemographic and diagnostic profile of data related to psychiatric readmissions to the psychiatric ward at Hospital Estadual Mário Covas between January 2008 and September 2015, in order to investigate the possible correlation between the rate of admission and readmission and the presence or absence of a discharged patient unit or other outpatient treatment unit.

METHODS

This was a cross-sectional, descriptive study. Data on patients readmitted during the study period were sourced from a statistical analysis of the Hospital Estadual Mário Covas database using STATA 11.0.

RESULTS

During the study period, hospitalization rates decreased, while the readmission rates increased over the years, at a total of 662 readmissions. This rise in readmissions had no correlation with the presence of a discharged patient unit or other outpatient unit. Women comprised the majority of the sample, with a mean age of 42; the most prevalent disorder among women was bipolar affective disorder, while among men it was schizophrenia. The length of hospitalization increased over time, with a maximum mean time of 23 days in 2015. Most of the patients were referred from Santo André as well as from hospitals in São Paulo.

CONCLUSION

The increase in the rate of readmissions over the years suggests that the mental healthcare model may have shortcomings along the chain. It is important to understand the epidemiological profile and chain of events that led to repeated hospitalizations in order to design new strategies and approaches to care so as to keep the patients stabilized.

The association between comorbid psychiatric diagnoses and hospitalization-related factors among individuals with schizophrenia

BACKGROUND

Though schizophrenia is associated with substantial psychiatric comorbidity, data pertaining to multiple comorbid psychiatric disorders among individuals with schizophrenia is missing. Furthermore, despite abundant research indicating that the course of schizophrenia is characterized by relapses, often leading to psychiatric emergency room visits and consequent hospitalizations, data regarding the association between different comorbid psychiatric diagnoses among schizophrenia patients, and these hospitalization-related factors is lacking. The aim of this study was to describe the number and types of comorbid psychiatric diagnoses of inpatients diagnosed with schizophrenia, and to explore whether these are associated with hospitalization-related factors.

METHODS

Registry data from the years 1997-2017 was analyzed from a large psychiatric hospital database. We compared the annual mean number of psychiatric emergency room visits and hospitalizations, as well as mean length of hospitalizations, among individuals with schizophrenia and no additional psychiatric diagnosis, to those with one or more comorbid psychiatric diagnoses. Furthermore, we compared these hospitalization-related based on the different types of the comorbid diagnoses.

RESULTS

Among inpatient individuals with schizophrenia, the greater the number of comorbid psychiatric diagnoses, the higher the increase in number of emergency room visits and hospitalizations, as well as in the mean length of hospitalizations. Furthermore, all comorbid psychiatric disorders explored were found to be associated with an increase in the mentioned hospital-related factors. Such diagnoses include substance use disorders, bipolar, personality and depressive disorders, which were the most common disorders associated with schizophrenia.

CONCLUSIONS

Comorbid psychiatric disorders among inpatients with schizophrenia are associated with greater utilization of hospital-related services. These comorbid disorders should be addressed in the assessment and treatment of patients suffering from schizophrenia.

Rehospitalization to a child and adolescent psychiatry unit: Role of trauma and bullying

OBJECTIVE

Psychiatric rehospitalizations results in a significant burden to patients, families, and health care systems. Understanding psychiatric rehospitalizations offers an opportunity to identify weaknesses in current systems of care. The objective of this study was to test the hypothesis that a history of trauma or ongoing bullying increases the risk of psychiatric rehospitalization.

METHOD

Retrospective cohort study of 366 individual patients (71% female) admitted to a pediatric psychiatry unit between 1/1/2015 and 12/31/2015. The primary outcome measure was rehospitalization to the same psychiatric hospital unit within one year of first discharge. Trauma was defined as having a history of Post-Traumatic Stress Disorder, Reactive Attachment Disorder, or a filed Suspected Abuse and Neglect of a Child report by the end of first hospitalization. Ongoing bullying was identified by medical record review.

RESULTS

History of trauma (Odds Ratio (OR) = 3.2, 95% Confidence Interval (CI) = 1.8-5.6, p < 0.0001) and ongoing bullying (OR = 2.2, CI = 1.2-3.9, p = 0.009) were significantly associated with increased rates of rehospitalizations. We controlled for the following covariates: Patient Health Questionnaire-9 Modified (PHQ-9M) score, gender, age, relative age, initial length of stay, disrupted family system, and sexual orientation/identity.

CONCLUSION

History of trauma or ongoing bullying are important risk factors for pediatric psychiatric rehospitalization.

A Novel Model for Enhanced Prediction and Understanding of Unplanned 30-Day Pediatric Readmission

OBJECTIVES

To develop a model to assist clinicians in reducing 30-day unplanned pediatric readmissions and to enhance understanding of risk factors leading to such readmissions.

METHODS

Data consisting of 38 143 inpatient clinical encounters at a tertiary pediatric hospital were retrieved, and 50% were used for training on a multivariate logistic regression model. The pediatric Rothman Index (pRI) was 1 of the novel candidate predictors considered. Multivariate model selection was conducted by minimization of Akaike Information Criteria. The area under the receiver operator characteristic curve (AUC) and values for sensitivity, specificity, positive predictive value, relative risk, and accuracy were computed on the remaining 50% of the data.

RESULTS

The multivariate logistic regression model of readmission consists of 7 disease diagnosis groups, 4 measures of hospital resource use, 3 measures of disease severity and/or medical complexities, and 2 variables derived from the pRI. Four of the predictors are novel, including history of previous 30-day readmissions within last 6 months (P < .001), planned admissions (P < .001), the discharge pRI score (P < .001), and indicator of whether the maximum pRI occurred during the last 24 hours of hospitalization (P = .005). An AUC of 0.79 (0.77-0.80) was obtained on the independent test data set.

CONCLUSIONS

Our model provides significant performance improvements in the prediction of unplanned 30-day pediatric readmissions with AUC higher than the LACE readmission model and other general unplanned 30-day pediatric readmission models. The model is expected to provide an opportunity to capture 39% of readmissions (at a selected operating point) and may therefore assist clinicians in reducing avoidable readmissions.

Undiagnosed depression: A community diagnosis

Many large provider networks are investing heavily in preventing disease within the communities that they serve. We explore the potential benefits and challenges associated with tackling depression at the community level using a unique dataset designed for one such provider network. The economic costs of having depression (increased medical care use, lower quality of life, and decreased workplace productivity) are among the highest of any disease. Depression often goes undiagnosed, yet many believe that depression can be treated or prevented altogether. We explore the prevalence, distribution, economic burden, and the psychosocial and economic factors associated with undiagnosed depression in a lower-income neighborhood in northern Manhattan. Even using state-of-the art data to "diagnose" the risk factors within a community, it can be challenging for provider networks to act against such risk factors.

Risk Factors for Readmission on an Adult Inpatient Psychiatric Unit

OBJECTIVE

Readmission rates have been proposed as a possible quality metric for inpatient psychiatry. Little is known about predicting readmissions and identifying modifiable factors that may reduce early readmissions in these settings.

METHODS

We reviewed 693 medical records from our adult inpatient psychiatric unit to identify factors associated with patients' readmission within 90 days of discharge.

RESULTS

After adjusting for all variables, and including interactions between identified factors, we found several demographic features predicting readmission, including male gender with suicidal ideation on admission (odds ratio [OR] = 13.2; 95% confidence interval [CI], 3.4-51.9), a diagnosis of a psychotic disorder with a prior medical admission (OR = 5.7; 95% CI, 1.7-20.6), and suicidal ideation with comorbid personality disorder (OR = 5.3; 95% CI, 1.4-20.6). Demographic features decreasing the odds of readmission included being non-white with homeless living situation (OR = 0.18; 95% CI, 0.04-0.82), medication changes made within 48 hours of discharge (OR = 0.44; 95% CI, 0.23-0.84), and the number of medications dispensed without documented follow-up plan or appointment (OR = 0.88; 95% CI, 0.81-0.96).

CONCLUSION

Future prospective studies utilizing qualitative and quantitative methods are required to more precisely define a wider array of metrics. Improved identification of demographic features associated with early readmissions may suggest areas to target as we seek to the quality of inpatient psychiatric care.

Effectiveness of a Brief Care Management Intervention for Reducing Psychiatric Hospitalization Readmissions

This study examines a recovery-focused care management bridging strategy implemented during time of inpatient stay with the goal to increase engagement in aftercare and reduce early psychiatric readmissions. The sample included 195 individuals who received care from a large psychiatric specialty hospital. Eighty-seven individuals were assigned to receive the intervention, while 108 individuals were assigned to the control group. Individuals in the intervention group received a brief interview prior to inpatient discharge plus usual care, and individuals in the control group received usual care. After controlling for age, living situation, and utilization, individuals in the control group were more likely to be readmitted within 30 days of an index readmission than individuals in the intervention group (OR = 2.44, p = .02). Bridging strategies utilized prior to discharge for individuals at higher risk of early mental health inpatient readmission may be used as an effective alternative to more costly interventions.

Pre-discharge factors predicting readmissions of psychiatric patients: a systematic review of the literature

BACKGROUND

Readmission rate is considered an indicator of the mental health care quality. Previous studies have examined a number of factors that are likely to influence readmission. The main objective of this systematic review is to identify the studied pre-discharge variables and describe their relevance to readmission among psychiatric patients.

METHODS

Studies on the association between pre-discharge variables and readmission after discharge with a main psychiatric diagnosis were searched in the bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management and OpenGrey. Relevant publications published between January 1990 and June 2014 were included. For each variable, the number of papers that considered it as a predictor of readmission and that found a significant association was recorded, together with the association direction and whether it was found respectively in bivariate and in multivariate analyses.

RESULTS

Of the 734 articles identified in the search, 58 papers were included in this review, mainly from the USA and concerning patients with severe mental disorders. Analysed variables were classified according to the following categories: patients' demographic, social and economic characteristics; patients' clinical characteristics; patients' clinical history; patients' attitude and perception; environmental, social and hospital characteristics; and admission and discharge characteristics. The most consistently significant predictor of readmission was previous hospitalisations. Many socio-demographic variables resulted as influencing readmission, but the results were not always homogeneous. Among other patients' clinical characteristics, diagnosis and measures of functional status were the most often used variables. Among admission characteristics, length of stay was the main factor studied; however, the results were not very consistent. Other relevant aspects resulted associated with readmission, including the presence of social support, but they have been considered only in few papers. Results of quality assessment are also reported in the review. The majority of papers were not representative of the general psychiatric population discharged from an inpatient service. Almost all studies used multivariate analytical methods, i.e., confounders were controlled for, but only around 60% adjusted for previous hospitalisation, the variable most consistently considered associated to readmission in the literature.

CONCLUSIONS

The results contribute to increase knowledge on pre-discharge factors that could be considered by researchers as well as by clinicians to predict and prevent readmissions of psychiatric patients. Associations are not always straightforward and interactions between factors have to be considered.

Readmissions - can they be predicted on admission?

This paper looks at the development of logistic regression models to predict readmissions for medical patients on their initial admission to hospital. The design of our study was a retrospective analysis of a large dataset drawn from a range of secondary sources - medical, nursing, therapy and social care records. Three northern hospitals and related community health districts and social care organizations in the UK participated. Records of 1,192 patients discharged from medical wards during the period April 1992-March 1995 were analysed. Readmission within six weeks of discharge was the main outcome measure.Four logistic regression equations were produced. Three individual site equations were calculated and classification levels for readmission of 17-22 per cent were achieved. Component factors that differed in importance were age, GP contact, social services contact, marital status and living status. The weakest equation was the equation that encompassed patients from all three sites, which classified 7 per cent of readmissions. It is possible to develop equations that will explain readmission for a fifth of medical patients on admission to individual hospitals. Further exploratory work needs to be undertaken to explore reasons for differences between districts and develop more generalizable predictive equations.

Validity of clinically significant change classifications yielded by Jacobson-Truax and Hageman-Arrindell methods

BACKGROUND

Reporting of the clinical significance of observed changes is recommended when publishing mental health treatment outcome studies and is increasingly used in routine outcomes monitoring systems. Since recovery rates vary with the method chosen, we investigated the validity of classifications of clinically significant change when the Jacobson-Truax method and the Hageman-Arrindell method were used.

METHODS

Of 718 inpatients who completed the Depression Anxiety Stress Scales (DASS-21) and Quality of Life Enjoyment and Satisfaction Questionnaire at admission and discharge to a psychiatric clinic, 355 were invited (and 119 agreed) to complete the questionnaires and the Recovery Assessment Scale six weeks post discharge.

RESULTS

Both the JT and HA methods showed comparably good validity when referenced against the other indices. Clinically significant change on the DASS-21 was related to a greater consumer-based sense of recovery, greater perceived quality of life, and fewer readmissions to hospital within 28 days of discharge.

CONCLUSIONS

Since there was found to be no advantage to using one method over another when recovery is of interest, the simpler JT method is recommended for routine usage.

Association between in-hospital supportive visits by primary care physicians and patient outcomes: A population-based cohort study

BACKGROUND

One long-standing method for continuity of care as patients transition between the hospital and community are supportive visits by primary care physicians during hospitalization.

METHODS

This retrospective cohort study used administrative data of adults hospitalized from 2008 to 2009 and primary care physicians who conduct supportive visits. Patients who received a visit from their primary care physician while hospitalized were compared to those who did not. Composite outcomes of death, emergency department visit, or emergent readmission within 30 and 90 days were assessed. Postdischarge home-care utilization and primary care physician visits were also examined. Multivariate logistic regression models adjusted for age, sex, low income, rurality, and readmission risk.

RESULTS

Of the 164,059 patients linked to 3236 primary care physicians, 12.0% received visits while hospitalized. Visited patients had more readmissions, more deaths, and fewer emergency department visits than patients who did not. However, after adjusting, visited patients had a lower risk for the composite outcome at 30 days (adjusted OR [aOR]: 0.92; 95% confidence interval [CI]: 0.89-0.96) and 90 days (aOR: 0.90; 95% CI: 0.87-0.92). Visited patients were also more likely to access community primary care-provider visits and more home-care services. The in-hospital visit resulted in an increased likelihood of health services utilization at 30 days (aOR: 1.16; 95% CI: 1.11-1.22) and 90 days (aOR: 1.20; 95% CI: 1.12-1.27).

CONCLUSION

A hospital supportive-care visit from a primary care physician resulted in lower risks of adverse patient outcomes and increased access to community health services. Journal of Hospital Medicine 2016;11:418-424. © 2016 Society of Hospital Medicine.

Patient outcomes following discharge from secure psychiatric hospitals: systematic review and meta-analysis

BACKGROUND

Secure hospitals are a high-cost, low-volume service consuming around a fifth of the overall mental health budget in England and Wales.

AIMS

A systematic review and meta-analysis of adverse outcomes after discharge along with a comparison with rates in other clinical and forensic groups in order to inform public health and policy.

METHOD

We searched for primary studies that followed patients discharged from a secure hospital, and reported mortality, readmissions or reconvictions. We determined crude rates for all adverse outcomes.

RESULTS

In total, 35 studies from 10 countries were included, involving 12 056 patients out of which 53% were violent offenders. The crude death rate for all-cause mortality was 1538 per 100 000 person-years (95% CI 1175-1901). For suicide, the crude death rate was 325 per 100 000 person-years (95% CI 235-415). The readmission rate was 7208 per 100 000 person-years (95% CI 5916-8500). Crude reoffending rates were 4484 per 100 000 person-years (95% CI 3679-5287), with lower rates in more recent studies.

CONCLUSIONS

There is some evidence that patients discharged from forensic psychiatric services have lower offending outcomes than many comparative groups. Services could consider improving interventions aimed at reducing premature mortality, particularly suicide, in discharged patients.

Outpatient Follow-Up Visit after Hospital Discharge Lowers Risk of Rehospitalization in Patients with Schizophrenia: A Nationwide Population-Based Study

OBJECTIVE

Non-adherence to medication is a recognized problem in psychiatric patients and may be one of the most challenging aspects of treatment for patients with schizophrenia. Failure of follow-up care after discharge greatly increases non-adherence to prescribed medications, relapse and rehospitalization. However, it is still unknown whether and how much outpatient follow-up visits can mitigate the risk of rehospitalization. Therefore we sought to investigate the continuity and effectiveness of outpatient care after inpatient discharge and its effect on rehospitalization of patients with schizophrenia.

METHODS

Data were extracted from National Health Insurance Claim Database covering the period from 2007 through 2010. We identified 10,246 patients aged 18 years or older who were admitted in psychiatric facilities with the diagnosis of schizophrenia between January 1 and December 31 in 2007. The number of outpatient visits within 60 days after discharge from index admission was defined as the indicator for the continuous care and rehospitalization was inspected during the following 36-month period. Cox's proportional hazard model was used to examine the factors affecting the risk of rehospitalization including the number of outpatient visits, age, sex, comorbidities, antipsychotics, and characteristics of medical institution.

RESULTS

We found that 12.7% (n=1,327) of the patients visited psychiatric outpatient department once within 60 days after hospital discharge, 34.8% (n=3,626) twice, and 27.8% (n=2,900) more than three times. Patients taking atypical antipsychotics showed higher proportion in 2 or more outpatient visits, whereas patients taking typical antipsychotics showed higher proportion in one or no outpatient visits. Cox hazard ratios of rehospitalization for the factor of 3 or more outpatient visits referenced to that of no follow-up visit were 0.567 (0.428-0.750, 95% confidence interval) within 90 days, 0.673 (0.574-0.789) within 180 days, 0.800 (0.713-0.898) within a year, 0.906 (0.824-0.997) within 2 years, and 0.993 (0.910-1.084) within 3 years.

CONCLUSION

Although continuous outpatient treatment is important for relapse prevention, patients with schizophrenia showed a low rate of outpatient visit as 62.6% of total patients in 2 or more visits within 60 days after discharge. Lack of follow-up treatment might lead to increase psychotic symptoms and raised risk of relapse and rehospitalization. Our data suggest that the number of outpatient visits within 60 days after discharge in patients with schizophrenia is an important indicator of rehospitalization within a year. Therefore, further efforts to examine factors affecting failure of outpatient follow-up after discharge are warranted.

The Affordable Care Act, Accountable Care Organizations, and Mental Health Care for Older Adults: Implications and Opportunities

The Patient Protection and Affordable Care Act (ACA) represents the most significant legislative change in the United States health care system in nearly half a century. Key elements of the ACA include reforms aimed at addressing high-cost, complex, vulnerable patient populations. Older adults with mental health disorders are a rapidly growing segment of the population and are among the most challenging subgroups within health care, and they account for a disproportionate amount of costs. What does the ACA mean for geriatric mental health? We address this question by highlighting opportunities for reaching older adults with mental health disorders by leveraging the diverse elements of the ACA. We describe nine relevant initiatives: (1) accountable care organizations, (2) patient-centered medical homes, (3) Medicaid-financed specialty health homes, (4) hospital readmission and health care transitions initiatives, (5) Medicare annual wellness visit, (6) quality standards and associated incentives, (7) support for health information technology and telehealth, (8) Independence at Home and 1915(i) State Plan Home and Community-Based Services program, and (9) Medicare-Medicaid Coordination Office, Center for Medicare and Medicaid Innovation, and the Patient-Centered Outcomes Research Institute. We also consider potential challenges to full implementation of the ACA and discuss novel solutions for advancing geriatric mental health in the context of projected workforce shortages and the opportunities afforded by the ACA.

Factors differentially associated with early readmission at a university teaching psychiatric hospital

RATIONALE, AIMS AND OBJECTIVES

The rate of psychiatric readmissions within 30 days of discharge is a well-established behavioural health system performance measure linked to the quality of inpatient hospital care as well as to access to community-based aftercare services. The purpose of this study was to examine the factors differentially associated with earlier readmission among a sample of patients (n = 588) readmitted within 30 days of discharge to a university teaching psychiatric hospital from 2001 to 2010.

METHODS

Quality assurance interviews were conducted with patients readmitted within 30 days of discharge. The interview data were merged with clinical symptom and electronic medical record data. Multinomial logistic regression analysis was used to examine readmission within 7 days and from 8 to 14 days compared with 15-30 days after discharge while controlling for socio-demographic and treatment variables previously associated with psychiatric readmission.

RESULTS

Multiple clinical, treatment and patient-reported factors were differentially associated with earlier readmission. In particular, lack of engagement in post-discharge aftercare services was a strong predictor of earlier readmission.

CONCLUSIONS

Strategies are needed to improve patients' transition from inpatient psychiatric hospitalization to aftercare services. Psychiatric hospitals attempting to reduce very early readmissions should seek to implement innovative transitional care initiatives targeting both patient and treatment factors.

Risk factors associated with psychiatric readmission

The present study focused on identifying risk factors for early readmission of patients discharged from an urban community hospital. Retrospective chart reviews were conducted on 207 consecutive inpatient psychiatric admissions that included patients who were readmitted within 15 days, within 3 to 6 months, and not admitted for at least 12 months post-discharge. Findings indicated that a diagnosis of schizophrenia/schizoaffective disorder (OR = 18; 95% CI 2.70-117.7; p < 0.05), history of alcohol abuse (OR = 9; 95% CI 1.80-40.60; p < 0.05), number of previous psychiatric hospitalizations (OR = 2; 95% CI 1.28-3.73; p < 0.05), and type of residence at initial admission (e.g., homeless, OR = 29; 95% CI 3.99-217; p < 0.05) were significant risk factors for early readmission, where OR compares readmission group 1 versus group 3 in the multinomial logistic regression. Initial positive urine drug screen, history of drug abuse or incarceration, and legal status at initial admission did not predict early readmission. Reducing the risk factors associated with psychiatric readmissions has the potential to lead to the identification and development of preventative intervention strategies that can significantly improve patient safety, quality of care, well-being, and contain health care expenditures.

The effects of state psychiatric hospital waitlist policies on length of stay and time to readmission

This study examined the effects of a waitlist policy for state psychiatric hospitals on length of stay and time to readmission using data from North Carolina for 2004-2010. Cox proportional hazards models tested the hypothesis that patients were discharged "quicker-but-sicker" post-waitlist, as hospitals struggled to manage admission delays and quickly admit waitlisted patients. Results refute this hypothesis, indicating that waitlists were associated with increased length of stay and time to readmission. Further research is needed to evaluate patients' clinical outcomes directly and to examine the impact of state hospital waitlists in other areas, such as state hospital case mix, local emergency departments, and outpatient mental health agencies.

Predictors of readmission to a psychiatry inpatient unit

OBJECTIVE

To determine predictors of time to readmission to a general psychiatry inpatient unit.

METHOD

Data from the Minimum Data Set-Mental Health (MDS-MH), a standardized assessment used to collect demographic and clinical information, were retrospectively reviewed from April 2006 through October 2008. A total of 758 patients were eligible for the study. A set of clinically relevant predictors was generated based on a literature review. A Cox regression model was applied to determine which variables were most predictive of shorter time to readmission, and their respective hazard ratios (HR).

RESULTS

Covariates that were significantly associated with readmission (HR [95% CI]) included receiving a pass (3.48 [2.33, 5.17], p ≤ 0.0005), 1-2 psychiatric admissions in the past two years (15.63 [7.50, 32.55], p ≤ 0.0005), and more than 3 psychiatric admissions in the past two years (24.15 [11.58, 50.36], p ≤ 0.0005). Post hoc analysis indicated that those issued passes were more commonly male (57.1% vs. 43.9%, p=0.03), with a longer length of stay (25.4 ± 21.2 days vs. 18.7 ± 21.1 days, p=0.008), and higher GAF score (62.8 ± 11.1 vs. 57.8 ± 13.9, p=0.003), but were otherwise similar.

CONCLUSIONS

The factors that were associated with reduced time to readmission were a history of previous admissions and receipt of a pass prior to discharge. These results suggest that while physicians may be able to identify patients at high risk of early readmission, issuing a pass may not fully mitigate this risk. There is a need for critical research evaluating the potential benefits of passes.

Hospital readmission among medicaid patients with an index hospitalization for mental and/or substance use disorder

Hospital readmission rates are increasingly used as a performance indicator. Whether they are a valid, reliable, and actionable measure for behavioral health is unknown. Using the MarketScan Multistate Medicaid Claims Database, this study examined hospital- and patient-level predictors of behavioral health readmission rates. Among hospitals with at least 25 annual admissions, the median behavioral health readmission rate was 11% (10th percentile, 3%; 90th percentile, 18%). Increased follow-up at community mental health centers was associated with lower probabilities of readmission, although follow-up with other types of providers was not significantly associated with hospital readmissions. Hospital average length of stay was positively associated with lower readmission rates; however, the effect size was small. Patients with a prior inpatient stay, a substance use disorder, psychotic illness, and medical comorbidities were more likely to be readmitted. Additional research is needed to further understand how the provision of inpatient services and post-discharge follow-up influence readmissions.

Efficacy of continuous follow-up for preventing the involuntary readmission of psychiatric patients in Japan: a retrospective cohort study

BACKGROUND

Providing aftercare to psychiatric inpatients is important for preventing frequent readmissions; however, the lack of social resources is a problem in Japan. The prefectural Tama-Fuchu Public Health Centre has attempted to establish a new continuous follow-up system for all discharged psychiatric patients in order to reduce the frequency of readmissions.

AIMS

This study aims to evaluate the efficacy of this system.

METHODS

The subjects of the present study were 200 psychiatric inpatients from the Tokyo catchment area. The continuous follow-up system was applied to 130 subjects for one year in addition to conventional standard care (the intervention group). Seventy subjects received conventional care alone (the comparison group). The incident rate ratios (IRR) of total and involuntary readmission to hospital were compared by survival analysis.

RESULTS

During the observation period, there were 41 readmissions and 29 involuntary readmissions in 49,731 person-days. The patients subjected to continuous follow-up showed a trend towards a lower overall risk of readmission (IRR = 0.56, 95% CI: 0.29-1.10, p = .057) and a significantly reduced risk of involuntary admission (IRR = 0.48, 95% CI: 0.22-0.96, p = .047).

CONCLUSION

This study provides empirical evidence that providing continuous follow-up examinations as aftercare for discharged psychiatric patients significantly reduces the incidence of involuntary readmission.

Performance indicators for public mental healthcare: a systematic international inventory

Background

The development and use of performance indicators (PI) in the field of public mental health care (PMHC) has increased rapidly in the last decade. To gain insight in the current state of PI for PMHC in nations and regions around the world, we conducted a structured review of publications in scientific peer-reviewed journals supplemented by a systematic inventory of PI published in policy documents by (non-) governmental organizations.

Methods

Publications on PI for PMHC were identified through database- and internet searches. Final selection was based on review of the full content of the publications. Publications were ordered by nation or region and chronologically. Individual PI were classified by development method, assessment level, care domain, performance dimension, diagnostic focus, and data source. Finally, the evidence on feasibility, data reliability, and content-, criterion-, and construct validity of the PI was evaluated.

Results

A total of 106 publications were included in the sample. The majority of the publications (n = 65) were peer-reviewed journal articles and 66 publications specifically dealt with performance of PMHC in the United States. The objectives of performance measurement vary widely from internal quality improvement to increasing transparency and accountability. The characteristics of 1480 unique PI were assessed. The majority of PI is based on stakeholder opinion, assesses care processes, is not specific to any diagnostic group, and utilizes administrative data sources. The targeted quality dimensions varied widely across and within nations depending on local professional or political definitions and interests. For all PI some evidence for the content validity and feasibility has been established. Data reliability, criterion- and construct validity have rarely been assessed. Only 18 publications on criterion validity were included. These show significant associations in the expected direction on the majority of PI, but mixed results on a noteworthy number of others.

Conclusions

PI have been developed for a broad range of care levels, domains, and quality dimensions of PMHC. To ensure their usefulness for the measurement of PMHC performance and advancement of transparency, accountability and quality improvement in PMHC, future research should focus on assessment of the psychometric properties of PI.

Effectiveness and costs of flupentixol compared to other first- and second-generation antipsychotics in the treatment of schizophrenia

RATIONALE

The purpose of this study is to analyse the effectiveness of flupentixol compared to other first- and second-generation antipsychotics for the treatment of schizophrenia in routine care.

METHOD

A retrospective cohort study was conducted using administrative data from four sickness funds covering 12.6 million insured. Patients discharged from hospital in 2003 with an ICD-10 diagnosis of schizophrenia were followed for 12 months. Rehospitalisation during follow-up was analysed using a hurdle regression model. Treatment costs were defined as cost of pharmaceutical and cost of inpatient care. Two thousand eight hundred ninety insured were included, of which 177 were treated with flupentixol during follow-up, while 429 and 2,284 were treated with other first-and second-generation antipsychotics, respectively.

RESULTS

Compared to patients treated with flupentixol (21.0 days), predicted hospitalisation did not differ significantly for patients treated with other first- (21.3 days, p = 0.8313) or second-generation antipsychotics (25.6 days, p = 0.4035). Predicted treatment costs for the average patient were 4,193 Euro if treated with flupentixol, 4,846 Euro if treated with other first-generation antipsychotic, and 6,523 Euro if treated with a second-generation antipsychotic. Second-generation antipsychotics showed a clear advantage over flupentixol concerning extrapyramidal symptoms co-medication.

CONCLUSION

The effectiveness of flupentixol preventing relapse in patients with schizophrenia appears to be similar to that of other first- and second-generation antipsychotics. However, the low treatment costs for patients treated with flupentixol could be explained by the small number of patients with readmissions (70 insured) and the larger share of patients treated with its depot formulation.

Factors associated with length of stay and the risk of readmission in an acute psychiatric inpatient facility: a retrospective study

OBJECTIVE

This study was to investigate factors influencing the length of stay and predictors for the risk of readmission at an acute psychiatric inpatient unit.

METHOD

Two comparative studies were embedded in a retrospective cross-sectional clinical file audit. A randomly selected 226 episodes of admissions including 178 patients during a twelve-month period were reviewed. A total of 286 variables were collected and analysed. A case control study was employed in the study of length of stay. A retrospective cohort study was used to investigate the predictors for the risk of readmission.

RESULTS

Logistic regression analyses showed that 10 variables were associated with length of stay. Seclusion during the index admission, accommodation problems and living in an area lacking community services predicted longer stay. During the follow-up period 82 patients (46%) were readmitted. Cox regression analyses showed 9 variables were related to the risk of readmission. Six of these variables increased the risk of readmission, including history of previous frequent admission, risk to others at the time of the index admission and alcohol intoxication. More active and assertive treatment in the community post-discharge decreased the risk of readmission.

CONCLUSIONS

Length of stay is multifactorially determined. Behavioural manifestations of illness and lack of social support structures predicted prolonged length of stay. Good clinical practice did not necessarily translate to a shorter length of stay. Therefore, length of stay is predictable, but not readily modifiable within the clinical domain. Good clinical practice within the community following discharge likely reduces the risk of readmission. Quality of inpatient care does not influence the risk of readmission, which therefore raises a question about the validity of using the rate of readmission as an outcome measure of psychiatric inpatient care.

An examination of risk factors for readmission to acute adult mental health services within 28 days of discharge in the Australian setting

OBJECTIVE

The aim of this paper was to identify risk factors associated with readmission within 28 days of discharge from eight Australian adult acute mental health inpatient services.

METHOD

A detailed file audit was conducted comparing 222 patients readmitted within 28 days of discharge with 253 patients not readmitted during the same period.

RESULTS

There was an association between early readmission and having had contact with the service in the previous 12 months (51% vs 21%), having been admitted in the previous 12 months (65% vs 36%), and having been diagnosed with an emotionally unstable personality disorder (14% vs 4%). Those who were not readmitted had a significantly higher score in the Health of the Nation Outcome Scales on index admission than those who were readmitted. Those who had community team contact on the day of discharge and those who received follow up by the mental health team within 7 days of discharge were more likely to be readmitted (55% vs 45% and 29% vs 19% respectively).

CONCLUSIONS

Significant determinants of early readmission identified were a history of recent previous admissions and a diagnosis of unstable personality disorder. The usefulness of this performance measure to Area Mental Health Services and clinicians is discussed.

Sleep and school problems among children and adolescents in state custody

Population-level research into the association between sleep problems and school problems among high-risk youth is limited. This study uses cross-sectional administrative and standardized assessment information for youth entering Tennessee state custody in fiscal year 2009 (n = 4280) to examine whether sleep problems are independently associated with school problems. Sleep problems were identified in 9.8% of the sample. There was no association between sleep and school problems for youth adjudicated delinquent. Among youth adjudicated dependent-neglect/unruly, multivariate logistic regression analysis indicates that youth at risk for sleep problems are 1.78 (95% confidence interval = 1.24-2.55) and youth with actionable sleep problems are 3.30 (95% confidence interval = 1.78-6.14) times more likely than youth without sleep problems to have school problems. Results suggest that the school performance of youth entering state custody adjudicated dependent-neglect/unruly may benefit from systematic screening and intervention for sleep problems.

Socio-economic correlates of relapsed patients admitted in a Nigerian mental health institution

BACKGROUND

Relapse in psychiatric disorders is highly distressing, costly and engenders burn-out syndrome among mental-health workers.

AIMS

To study the socio-economic factors associated with relapse in individual admitted with psychiatric disorders and the pattern of socio-economic impact of relapse in those groups.

METHODS

A cross-sectional survey of all relapsed patients without cognitive deficit admitted into the federal Neuro-Psychiatric Hospital, Lagos, Nigeria between June and October 2007 was conducted using a self-validated Structured Interview Schedule (Relapse Socio-economic Impact Interview Schedule) and Key Informant Interview Guide. Secondary data were elicited from the patient folders, case notes, ward admission registers and nominal rolls. Data were summarised using mean, standard deviation, frequency and percentiles. Pearson's moment correlation coefficient was used to test the association among variables. The Mann-Whitney U-test was used to compare the pre-morbid and the post-morbid states.

RESULTS

This study involved 102 respondents. Their mean age was 36.5 ± 9.8 years, mainly of male gender (72.5%) suffering from schizophrenic disorder (37.8%). Relapse and re-admission ranged between 2 and 12. Unemployment rate, marital separation and divorce increased more than 5-fold from pre-morbid to morbid states. Few (4.9%) could still settle their hospital/drug bills on their own, while most (95.1%) depended on family, philanthropist and government/waivers to pay for their bills. Their social relationships were negatively influenced with most of them expressing social isolation and low quality of life. There were significant relationships (P<0.05) between age, sex, number of relapses, number of admissions, pre-morbid marital status, morbid state marital status, pre-morbid state occupational status and morbid state occupational status. There was significant change (P= 0.00) in the quality of life, societal integration/acceptability, economic status, employment status and marital status of the respondents between the pre-morbid and post-morbid periods. The illness significantly affected the emotional status of the participants.

CONCLUSION

Relapse and readmission in psychiatric patients have a negative impact on socio-economic well-being of patients, family and the society. Efforts should be taken to provide early interventions.

Discharge management for patients in Flemish psychiatric hospitals

RATIONALE AND AIMS

At the end of the 1990 s, a case management service called 'discharge management' was implemented in Belgian psychiatric hospitals. This study aimed to describe the profile of patients receiving discharge management in Flemish psychiatric hospitals as well as to analyse the discharge management indicators of these hospitals on micro and meso level.

METHODS

Ten Flemish psychiatric hospitals participated. A descriptive analysis of the profile of patients receiving discharge management (gender, age, length of stay, family situation, assistance at home, living environment and Global Assessment of Functioning) and of the indicators of discharge management (screening, interdisciplinary patient file, interdisciplinary meeting, timely announcement of discharge date, transfer of discharge documents, readmission and institutionalization) were carried out.

RESULTS

Of the 1306 patients included in the database, one-fourth received discharge management. In general, patients (54% were male) were about 45 years old, stayed for 55 days in hospital, were single and had no aid at home. Most of them came from and returned to their own home. On the micro level of discharge management, nearly all patients were screened and half of them were positively screened. Half of these patients received discharge management. Of the discharged patients who received discharge management (meso level), 13.5% were institutionalized after discharge, 37.6% had been previously admitted and 27.2% received discharge management during that previous admission. Differences between diagnostic groups occurred.

CONCLUSION

Hospitals have made efforts to support and prepare patients for discharge, although a number of improvements are suggested for different indicators.

Reducing 30-day inpatient psychiatric recidivism and associated costs through intensive case management

PURPOSE OF THE STUDY

Intensive case management (ICM) holds promise in reducing 30-day inpatient psychiatric recidivism and associated costs. The purpose of this study is to determine the impact of ICM on 30-day inpatient psychiatric recidivism and associated costs among adult health plan members at elevated risk of psychiatric hospitalization.

PRIMARY PRACTICE SETTING

Psychiatric settings.

METHODOLOGY AND SAMPLE

An intent-to-treat, historical control design was used to examine utilization differences between 305 intervention group members eligible to receive ICM services and a cohort of 347 baseline group members identified retrospectively using identical criteria during a similar 1-year time period before implementation of the ICM program.

RESULTS

The 30-day recidivism rate for baseline group members was 29.11% as compared with 8.52% among intervention group members. Logistic regression results indicated a significant main effect for the ICM intervention. Inpatient psychiatric costs for the 30-day outcome period were on $1,528.91 lower per member in the intervention group. Regression results indicated a main effect for the ICM intervention. Program costs were estimated at $41.39 per member.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The ICM intervention was associated with significant reductions in inpatient, psychiatric 30-day readmission rates, and associated costs among adult members who are at elevated risk of inpatient, psychiatric recidivism. The intervention, enrollment process, and measurement strategies can be adapted for use by case managers in a variety of different settings.

Readmission to an acute psychiatric unit within 28 days of discharge: identifying those at risk

Objective.To examine factors that could help identify those most at risk of readmission to an acute psychiatric in-patient unit within 28 days of a discharge. Method.A detailed file audit was conducted comparing 54 consecutive patients who had been readmitted within 28 days of discharge with 61 patients, chosen at random, who had not been readmitted during the same period. Results.Readmission within 28-days of discharge was associated with having been admitted in the previous year (P = 0.004), receiving the Disability Support Pension (P = 0.015), not having a discharge plan sent to the patient’s GP on discharge from the index admission (P = 0.05), receiving follow-up by the mental health team within 7 days of discharge (P = 0.007) and being unemployed (P = 0.015). Conclusions.Targeting those with previous admissions for focussed discharge planning may help organisations reduce the numbers of unnecessary early readmissions. What is known about the topic?Readmission within 28-days of discharge is being increasingly used by service funders and organisations as an indicator of the effectiveness of community care and of the organisation’s ability to provide continuous care across programs. Previous studies, mainly conducted in the US in the mid-90s, often reach contradictory conclusions and their relevance to the Australian setting is limited. What does this paper add?This paper uses data from an Australia mental health service. It identifies patient and service characteristics associated with rapid re-admission and provides a baseline to evaluate strategies to reduce the readmission rate. What are the implications for practitioners?This paper highlights the importance of careful discharge planning and communication with general practitioners particularly in relation to patients who have had previous admissions.

Quality assurance in psychiatry: quality indicators and guideline implementation

In many occasions, routine mental health care does not correspond to the standards that the medical profession itself puts forward. Hope exists to improve the outcome of severe mental illness by improving the quality of mental health care and by implementing evidence-based consensus guidelines. Adherence to guideline recommendations should reduce costly complications and unnecessary procedures. To measure the quality of mental health care and disease outcome reliably and validly, quality indicators have to be available. These indicators of process and outcome quality should be easily measurable with routine data, should have a strong evidence base, and should be able to describe quality aspects across all sectors over the whole disease course. Measurement-based quality improvement will not be successful when it results in overwhelming documentation reducing the time for clinicians for active treatment interventions. To overcome difficulties in the implementation guidelines and to reduce guideline non-adherence, guideline implementation and quality assurance should be embedded in a complex programme consisting of multifaceted interventions using specific psychological methods for implementation, consultation by experts, and reimbursement of documentation efforts. There are a number of challenges to select appropriate quality indicators in order to allow a fair comparison across different approaches of care. Carefully used, the use of quality indicators and improved guideline adherence can address suboptimal clinical outcomes, reduce practice variations, and narrow the gap between optimal and routine care.

Duration of first admission and its relation to the readmission rate in a psychiatry hospital

BACKGROUND

Most psychiatric illnesses have a chronic relapsing course. It is estimated that the readmission rate for discharged patients is approximately 40-50% within one year of their discharge from the hospital. The current emphasis in mental health service is on brief hospitalization and providing community-based services.

AIM

To understand the relationship between the duration of first hospital admission and the rates of readmission in a psychiatry hospital.

MATERIALS AND METHODS

All the patients admitted at Asha hospital, Hyderabad for the first time between16 September, 2003 to 15 March, 2004, were included in the study. The hospital records of these patients were examined and the data was collected on various variables, which included demographic variables, duration of hospital stay, diagnosis, and the number of readmissions for a period of approximately three-and-a-half years. The duration of the first hospital stay was divided into four categories, Group 1:1-7 days, Group 2:8 to 14 days, Group 3:15 to 30 days, and Group 4: More than 30 days.

RESULTS

The sample consisted of 516 patients, out of whom 17 were excluded because of insufficient data. Two hundred and fifty patients belonged to Group 1 (1 to 7 days), 206 patients in Group 2 (8 to 14 days), Group 3 (15 to 30 days) constituted 35 patients, and eight patients were in Group 4 ( > 30 days).

CONCLUSION

The length of the initial hospital stay is important to prevent future hospitalization. There are no definite predictors for readmission that could be detected, except for the length of the initial admission in the study.