Predictors of mental health-related acute service utilisation and treatment costs in the 12 months following an acute psychiatric admission

The effectiveness of the mental health social worker-led multiprofessional program in preventing long-term hospitalization and readmission in acute psychiatric inpatients in Japan: A retrospective analysis

Aim

The large number of new long-stay (NLS) patients and high readmission rates in psychiatric hospitals are longstanding concerns in Japan despite reforms to encourage multidisciplinary support of such patients. Staffing shortages of specialists, especially mental health social workers (MHSWs), may be one of the reasons for these problems to remain unsolved.

Methods

The authors examined the effectiveness of the MHSW-centered multidisciplinary care model in preventing NLSs and rehospitalization in terms of both patient dynamics and cost by retrospective comparison of before and after program implementation.

Results

After our program was introduced, NLS was almost completely prevented. In addition, a significant decrease in readmissions of involuntarily admitted patients was also observed. On the other hand, the resulting decrease in treatment costs and hospital revenues was mismatched by an increase in personnel costs.

Conclusion

While MHSW-centered multidisciplinary care is effective for the community integration of patients, there are cost challenges. State policy changes are needed to resolve staffing problems, along with the introduction of appropriate indicators of community integration.

Is there a prospective association between psychological distress as measured by the CORE-OM and treatment attendance and treatment duration? A follow-up study at a Norwegian Community Mental Health Centre

BACKGROUND

Feasible and reliable methods for identifying factors associated with treatment duration and treatment attendance in mental health services are needed. This study examined to what degree the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at the start of treatment is associated with treatment attendance and treatment duration.

METHODS

Outpatients (N = 124) at a community mental health centre in Norway completed the 34-item CORE-OM questionnaire addressing the domains of subjective well-being, problems and symptoms, functioning and risk at the start of treatment. The CORE-OM subscales and the 'all' items total scale were used as predictor variables in regression models, with treatment duration, number of consultations attended, treatment attendance (number of therapy sessions attended divided by number of sessions offered) and termination of treatment (planned versus unplanned) as outcome variables.

RESULTS

Higher CORE-OM subscale scores and the 'all' scale were associated with longer treatment duration. No association was found between CORE-OM scales and number of therapy sessions, treatment attendance (sessions attended/offered) or whether the patients unexpectedly ended treatment.

CONCLUSION

Higher patient-reported psychological distress as measured by the CORE-OM at the start of treatment was prospectively associated with treatment duration but not with treatment attendance or drop-out of treatment. The findings imply that patients with higher initial psychological distress need longer treatment but that treatment attendance may be related to factors other than the severity of distress.

Interaction of mental comorbidity and physical multimorbidity predicts length-of-stay in medical inpatients

BACKGROUND

Mental comorbidities of physically ill patients lead to higher morbidity, mortality, health-care utilization and costs.

OBJECTIVE

The aim of the study was to investigate the impact of mental comorbidity and physical multimorbidity on the length-of-stay in medical inpatients at a maximum-care university hospital.

DESIGN

The study follows a retrospective, quantitative cross-sectional analysis approach to investigate mental comorbidity and physical multimorbidity in internal medicine patients.

PATIENTS

The study comprised a total of n = 28.553 inpatients treated in 2017, 2018 and 2019 at a German Medical University Hospital.

MAIN MEASURES

Inpatients with a mental comorbidity showed a median length-of-stay of eight days that was two days longer compared to inpatients without a mental comorbidity. Neurotic and somatoform disorders (ICD-10 F4), behavioral syndromes (F5) and organic disorders (F0) were leading with respect to length-of-stay, followed by affective disorders (F3), schizophrenia and delusional disorders (F2), and substance use (F1), all above the sample mean length-of-stay. The impact of mental comorbidity on length-of-stay was greatest for middle-aged patients. Mental comorbidity and Elixhauser score as a measure for physical multimorbidity showed a significant interaction effect indicating that the impact of mental comorbidity on length-of-stay was greater in patients with higher Elixhauser scores.

CONCLUSIONS

The findings provide new insights in medical inpatients how mental comorbidity and physical multimorbidity interact with respect to length-of-stay. Mental comorbidity had a large effect on length-of-stay, especially in patients with high levels of physical multimorbidity. Thus, there is an urgent need for new service models to especially care for multimorbid inpatients with mental comorbidity.

Application of mixture distributions for identifying thresholds of frequent and high inpatient mental health service use in longitudinal data

BACKGROUND

There is a need for greater understanding about frequent and high use of inpatient mental health services, and those with ongoing increased needs. Most studies employ a threshold of frequent use (e.g. numbers of admissions) and high use (e.g. lengthy stays) without justification.

AIMS

To identify model-driven thresholds for frequent/high inpatient mental health service use and contrast characteristics of patients identified using various models and thresholds.

METHOD

Retrospective population-based study using 12 years of longitudinal data for 5631 patients admitted with a mental health diagnosis. Two-component negative binomial and poisson mixture (truncated/untruncated) models identified thresholds for frequent/high use in a 12-month period.

RESULTS

The two-component negative binomial mixture model resulted in the best model fit. Using negative binomial-derived thresholds, 5.3% of patients had a period of frequent use (admitted six or more times), 15.8% of high use (hospitalised for 45 or more days) and 3.5% of heavy use (both frequent and high use). The prevalence of specific mental health disorders (e.g. mood disorder and schizophrenia) among frequent and high use cohorts varied across thresholds.

CONCLUSIONS

This model-driven approach can be applied to identify thresholds in other cohorts. Threshold choice may depend on the magnitude and focus of potential interventions.

Improving Patient Flow and Access to Care at an Academically Affiliated Urban Safety-Net Hospital

Access to inpatient psychiatric beds remains a significant barrier to care for patients having a mental health crisis. A quality improvement initiative described here was designed to increase access to care by increasing efficiency of health care delivery on an adult and adolescent inpatient psychiatric unit. Design and implementation centered on collaborative relationships among hospital administration, physician leadership, frontline physicians, and members of the multidisciplinary treatment team. Initial 5 months of data indicated significant improvements in care access as measured by number of encounters on both units. Reductions in length of stay were made possible by optimizing internal work flows and standardizing goals of hospitalization.

The Impact of Smoking Cessation on Hospitalization and Psychiatric Medication Utilization among People with Serious Mental Illness

Background: Despite the high prevalence of smoking amongst people with serious mental illness (SMI), referral rates to smoking cessation programs (SCPs) are low. Mental health workers reticence to refer to SCPs has been attributed, in part, to their belief that quitting will have a deleterious effect on their patients' mental health status. Objectives: This study's objective was to determine if participating in a smoking cessation program had an adverse effect on mental health status among people with SMI, measured here by a change in hospitalization occurrence or psychiatric medication utilization. People with SMI who had participated in at least one SCP session in a large health maintenance organization (n = 403) were compared to an age-gender-diagnosis matched sample of SMI smokers (1,209) who had never participated. Results: No change in psychiatric hospitalization occurrence pre- versus post-SCP participation was found among participants (Pre:7.2% vs. Post:5.2, p = 0.2) or nonparticipants (Pre:7.0% vs. Post:6.0%, p = 0.2). Mean defined daily dose (DDD) for anti-psychotic, mood stabilizer, anti-depressant and anxiolytic medications also did not change over time for participants and nonparticipants. However, participants who did not complete the SCP and didn't quit had a 0.35 higher mean DDD for anti-psychotic medications compared with participants who had completed the SCP or quit, and with nonparticipants (p = 0.006), and were the only group to exhibit an increase in mean antipsychotic DDD over time (Pre:1.42, Post:1.63). SCP participation was not associated with hospitalization occurrence or psychiatric medication utilization. Conclusions/Importance: Smoking cessation should be encouraged, with close monitoring during the quit process.

Factors associated with length of stay and readmission in acute psychiatric inpatient services in Portugal

Assessing the factors that influence duration and number of hospitalizations may support mental health services planning and delivery. This study examines the factors associated with length of stay and readmission in Portuguese psychiatric inpatient services during 2002, 2007 and 2012. Data from all admissions were extracted from clinical files. Logistic regression models estimated the association between length of stay (<17 vs ≥17 days) and number of admissions per year (1 vs >1 admission) with sociodemographic, clinical, and contextual factors. Older age, a diagnosis of psychosis, and compulsory admission were associated with higher odds of longer length of stay. Being married, secondary education, suicide attempt, a diagnosis of substance use and "other mental disorders", being admitted in 2012, and two of the psychiatric inpatient services associated with lower odds of longer length of stay. Being retired (or others), a diagnosis of psychosis, compulsory admission, and psychiatric service were associated with increased odds of readmission. Older age, and secondary and higher education were associated with lower odds of readmission. The findings indicate that multiple factors influence length of stay and readmission. Identifying these factors provides useful evidence for clinicians and policy makers to design more targeted and cost-effective interventions.

Costs and outcomes for individuals with psychosis prior to hospital admission and following discharge in Bulgaria

PURPOSE

To examine the cost of psychotic disorders in Bulgaria prior to hospital admission and following discharge from two perspectives: healthcare and societal; and to evaluate the association between the costs and the patient's characteristics.

METHODS

96 individuals with psychosis experiencing psychotic exacerbation and their primary caregivers were evaluated upon the patients' hospital admission. The participants were followed up after 12 months. The costs were evaluated from healthcare and societal perspective using the Client's Sociodemographic and Service Receipt Inventory (CSSRI-EU). The psychopathology, functioning, quality of life and caregiver's burden were measured using standardized instruments. The mean differences in the costs and the associations with the clinical and socio-demographic characteristics of the patients were evaluated.

RESULTS

The healthcare costs increase from EUR 120.66 (SD = 163.85) at baseline to EUR 177.54 (SD = 136.98) at follow-up. The total cost from societal perspective are up to sixfold higher than the healthcare costs at both assessments [EUR 717.41 (SD = 402.33) and 880.40 (SD = 1592.00), respectively] and do not change significantly. A major shift in the subtypes of costs, and significant associations of the costs with the socio-demographic and clinical characteristics, were found.

CONCLUSIONS

Psychotic disorders and psychotic exacerbations have high societal costs. The underfunding of mental healthcare in Bulgaria is at the expense of high caregivers' and societal cost. The treatment of psychotic exacerbation is effective and investment in mental healthcare for the improvement of the psychopathology, social functioning, quality of life and the burden of informal care should be viewed as a sustainable investment.

Hospital length of stay variation and comorbidity of mental illness: a retrospective study of five common chronic medical conditions

BACKGROUND

With the increasing burden of mental illness globally, it is becoming common for hospitalised patients with chronic medical conditions to have a comorbidity of mental illness. This combination could prolong length of stay (LOS) of this patient cohort. We conducted an investigation in Tasmania, Australian hospitals to characterise this cohort and assess if co-morbidity of mental illness is a distinguishing factor that generates LOS variation across different chronic medical conditions.

METHODS

The retrospective study analysed 16,898 admissions of patients with a primary diagnosis of one of five chronic medical conditions: lung or colorectal cancer, chronic obstructive pulmonary disease (COPD), type II diabetes, ischaemic heart disease (IHD) and stroke. Data were from July 2010 to June 2015, across four hospitals that collectively cover 95% of public hospital admissions in Tasmania, Australia. Descriptive statistics were used to compare characteristics of patients between the scenarios of with and without co-morbidity of mental illness. We used negative binomial regression models to assess whether co-morbidity of mental illness, along with its sub-types, after adjustment for potential confounding variables, associated with LOS variation in patients of each medical condition. Based on the adjusted LOS variation, we estimated differences in bed days' use between patients with and without comorbidity of mental illness.

RESULTS

Patients with co-morbidity of mental illness were significantly younger in comparison to patients without mental illness. With each medical condition, patients with comorbidity of mental illness had incurred higher bed days' use than for those without mental illness. In cancer and stroke cohorts, co-morbidity of mental illness unfavourably affected the LOS variation by as high as 97% (CI: 49.9%-159%) and 109% (78%-146%), respectively. Though mental and behavioural disorders due to psychoactive substances was a dominant sub-type of mental illness across the medical conditions, it contributed significant unfavourable LOS variation only in the stroke patients i.e. 36.3% (CI: 16.2%-59.9%).

CONCLUSIONS

Mental illness consistently produced unfavourable LOS variation. Upskilling of healthcare teams and greater reporting and analysis of LOS variation for this patient cohort, and the sub-cohorts within it, are necessary to provide improved medical care and achieve system efficiencies.

Unplanned admissions to inpatient psychiatric treatment and services received prior to admission

BACKGROUND

Inpatient bed numbers are continually being reduced but are not being replaced with adequate alternatives in primary health care. There is a considerable risk that eventually all inpatient treatment will be unplanned, because planned or elective treatments are superseded by urgent needs when capacity is reduced.

AIMS OF THE STUDY

To estimate the rate of unplanned admissions to inpatient psychiatric treatment facilities in Norway and analyse the difference between patients with unplanned and planned admissions regarding services received during the three months prior to admission as well as clinical, demographical and socioeconomic characteristics of patients.

METHOD

Unplanned admissions were defined as all urgent and involuntary admissions including unplanned readmissions. National mapping of inpatients was conducted in all inpatient treatment psychiatric wards in Norway on a specific date in 2012. Binary logit regressions were performed to compare patients who had unplanned admissions with patients who had planned admissions (i.e., the analyses were conditioned on admission to inpatient psychiatric treatment).

RESULTS

Patients with high risk of unplanned admission are suffering from severe mental illness, have low functional level indicated by the need for housing services, high risk for suicide attempt and of being violent, low education and born outside Norway.

CONCLUSION

Specialist mental health services should support the local services in their efforts to prevent unplanned admissions by providing counselling, short inpatient stays, outpatient treatment and ambulatory outpatient psychiatry services.

IMPLICATIONS FOR HEALTH POLICIES

This paper suggests the rate of unplanned admissions as a quality indicator and considers the introduction of economic incentives in the income models at both service levels.

In-patient costs of agitation and containment in a mental health catchment area

BACKGROUND

There is a scarce number of studies on the cost of agitation and containment interventions and their results are still inconclusive. We aimed to calculate the economic consequences of agitation events in an in-patient psychiatric facility providing care for an urban catchment area.

METHODS

A mixed approach combining secondary analysis of clinical databases, surveys and expert knowledge was used to model the 2013 direct costs of agitation and containment events for adult inpatients with mental disorders in an area of 640,572 adult inhabitants in South Barcelona (Spain). To calculate costs, a seven-step methodology with novel definition of agitation was used along with a staff survey, a database of containment events, and data on aggressive incidents. A micro-costing analysis of specific containment interventions was used to estimate both prevalence and direct costs from the healthcare provider perspective, by means of a mixed approach with a probabilistic model evaluated on real data. Due to the complex interaction of the multivariate covariances, a sensitivity analysis was conducted to have empirical bounds of variability.

RESULTS

During 2013, 918 patients were admitted to the Acute Inpatient Unit. Of these, 52.8% were men, with a mean age of 44.6 years (SD = 15.5), 74.4% were compulsory admissions, 40.1% were diagnosed with schizophrenia or non-affective psychosis, with a mean length of stay of 24.6 days (SD = 16.9). The annual estimate of total agitation events was 508. The cost of containment interventions ranges from 282€ at the lowest level of agitation to 822€ when verbal containment plus seclusion and restraint have to be used. The annual total cost of agitation was 280,535€, representing 6.87% of the total costs of acute hospitalisation in the local area.

CONCLUSIONS

Agitation events are frequent and costly. Strategies to reduce their number and severity should be implemented to reduce costs to the Health System and alleviate patient suffering.

Managing preconceived expectations: mental health service users experiences of going home from hospital: a grounded theory study

ACCESSIBLE SUMMARY

What is known on the subject? The time of discharge from a mental health hospital can be challenging for mental health service users, with high rates of readmission in the immediate months following discharge. Although some research exists that explores service users' perspectives of being discharged, little evidence exists that explores the processes influencing or used by service users' to adapt to the transition from in-patient acute mental health service. What this papers adds to existing knowledge? The findings of this grounded theory study demonstrates the strategies service users used to managed their own, as well as their social audiences, preconceived expectations arising from their new identity as 'psychiatric patients' following their discharge from hospital. While there is a move to develop recovery-orientated mental health services, key indicators of recovery-oriented practices were often absent from service users' experiences of service provision. What are the implications for practice? Nurses and other mental health professionals need to recognize their contribution to the architecture of stigma that transcends the physical structures of hospital or ward and are entrenched within attitudes, interactions and practices. The findings of this study can provide guidance to those working with service users and help them to understand the complexities of their experiences when using mental health services, which go far beyond the management of their symptoms.

INTRODUCTION

Following a period of hospitalization, the transition to home can result in increased vulnerability and a source of stress for mental health service users. Readmission rates have been suggested as one indicator of the success of the transition from hospital to community care. Despite knowledge of some of the factors that impact on service users following discharge, no coherent model or theoretical framework could be located in the literature, which explains or aides an in-depth understanding of the transition from hospital to community for service users.

AIM

The aim of this study was to develop a grounded theory that explored service users' experiences of going home from hospital.

METHOD

This qualitative study used grounded theory, and a total of 35 interviews were conducted with 31 service users.

RESULTS

The core category was 'Managing Preconceived Expectations', which had seven subcategories, describes how the participants were negatively perceived by themselves and others following their admission and discharge from hospital.

IMPLICATIONS FOR PRACTICE

This theory presents the strategies that the participants used to manage this new identity. This theory demonstrates that although there has been a move to adopt recovery-orientated services, key indicators of recovery were often absent for service users being admitted and subsequently discharged.