Overview of post-discharge predictors for psychiatric re-hospitalisations: a systematic review of the literature

A predictive model for readmission within 1-year post-discharge in patients with schizophrenia

BACKGROUND

Schizophrenia is a pervasive and severe mental disorder characterized by significant disability and high rates of recurrence. The persistently high rates of readmission after discharge present a serious challenge and source of stress in treating this population. Early identification of this risk is critical for implementing targeted interventions. The present study aimed to develop an easy-to-use predictive instrument for identifying the risk of readmission within 1-year post-discharge among schizophrenia patients in China.

METHODS

A prediction model, based on static factors, was developed using data from 247 schizophrenia inpatients admitted to the Mental Health Center in Wuxi, China, from July 1 to December 31, 2020. For internal validation, an additional 106 patients were included. Multivariate Cox regression was applied to identify independent predictors and to create a nomogram for predicting the likelihood of readmission within 1-year post-discharge. The model's performance in terms of discrimination and calibration was evaluated using bootstrapping with 1000 resamples.

RESULTS

Multivariate cox regression demonstrated that involuntary admission (adjusted hazard ratio [aHR] 4.35, 95% confidence interval [CI] 2.13-8.86), repeat admissions (aHR 3.49, 95% CI 2.08-5.85), the prescription of antipsychotic polypharmacy (aHR 2.16, 95% CI 1.34-3.48), and a course of disease ≥ 20 years (aHR 1.80, 95% CI 1.04-3.12) were independent predictors for the readmission of schizophrenia patients within 1-year post-discharge. The area under the curve (AUC) and concordance index (C-index) of the nomogram constructed from these four factors were 0.820 and 0.780 in the training set, and 0.846 and 0.796 for the validation set, respectively. Furthermore, the calibration curves of the nomogram for both the training and validation sets closely approximated the ideal diagonal line. Additionally, decision curve analyses (DCAs) demonstrated a significantly better net benefit with this model.

CONCLUSIONS

A nomogram, developed using pre-discharge static factors, was designed to predict the likelihood of readmission within 1-year post-discharge for patients with schizophrenia. This tool may offer clinicians an accurate and effective way for the timely prediction and early management of psychiatric readmissions.

Associations between readmission and patient-reported measures in acute psychiatric inpatients: a multicenter prospective longitudinal study

PURPOSE

This study examined whether patient-reported measures (PRMs) addressing quality of life, personal agency, functional impairment, and treatment satisfaction at hospital discharge were associated with future readmission during a 12-month follow-up period. The study also examined whether readmission influenced changes in the same measures.

METHODS

A multicenter prospective cohort study was conducted at 21 psychiatric hospitals in Japan. Participants completed the EuroQol-five-dimensions-five-level (EQ-5D), the Five-item Subjective Personal Agency Scale, and the Sheehan Disability Scale (SDS) at the time of index admission (T1), discharge from index admission (T2), and 6 months (T3) and 12 months (T4) after discharge. Inpatient treatment satisfaction was assessed at T2. Readmission and variables potentially associated with hospitalization and PRMs were evaluated using mixed-effects logistic regression models and mixed models for repeated measures.

RESULTS

A total of 491 participants were followed for 12 months (attrition rate: 19.4%), and 480 were included in the EQ-5D analysis. The most common diagnoses were schizophrenia (59%), depression (14%), and bipolar disorder (13%). No patient-reported measures were significantly associated with readmission over the follow-up period. Interaction of readmission and time did not significantly affect changes in EQ-5D. Readmission did significantly influence SDS score changes between T2 and T3 (B = 1.78, 95% CI = 0.30-3.25, p = 0.018) and between T3 and T4 (B = 1.43, 95% CI = 0.14-2.72, p = 0.029). The same influence of readmission on SDS score changes was not observed in the model which adjusted for all potential covariates.

CONCLUSION

Readmission was potentially associated with changes in self-reported functional impairment. Findings highlight the potential role of intensive post-discharge services in preventing readmission, rather than relying on time-of-discharge PRMs in order to predict readmission risk.

TRIAL REGISTRATION

This study was registered in UMIN Clinical Trials Registry (UMIN000034220).

Risks for re-hospitalization of persons with severe mental illness living in rehabilitation care settings

BACKGROUND

The high rates of psychiatric re-hospitalizations (also termed "revolving door") presents a "wicked problem" which requires a systematic and holistic approach to its resolution. Israel's mental-health rehabilitation law provides a comprehensive set of services intended to support the ability of persons with severe mental illness to rely on community rather than in-patient facilities for their ongoing care needs. Guided by the Health Behavior Model, we examined the relationship between psychiatric re-hospitalizations and the three Health Behavior Model factors (predisposing factor: socio-demographic characteristics and health beliefs; enabling factor: personal and social/vocational relationships facilitated by rehabilitation interventions and services; and need factor: outcomes including symptoms, and mental health and functional status) among persons with severe mental illness receiving rehabilitation services.

METHODS

Logistic regression models were used to measure the association between re-hospitalization within a year and variables comprising the three Health Behavior Model factors on the sample of consumers utilizing psychiatric services (n = 7,165). The area under the curve for the model was calculated for each factor separately and for all three factors combined.

RESULTS

A total of 846 (11.8%) consumers were hospitalized within a year after the study began. Although multivariable analyses showed significant associations between re-hospitalization and all three Health Behavior Model factors, the magnitude of the model's area under the curve differed: 0.61 (CI = 0.59-0.64), 0.56 (CI = 0.54-0.58), 0.78 (CI = 0.77-0.80) and 0.78 (CI = 0.76-0.80) for predisposing, enabling, need and the full three-factor Health Behavior Model, respectively.

CONCLUSION

Findings revealed that among the three Health Behavior Model factors, the need factor best predicted re-hospitalization. The enabling factor, comprised of personal relationships and social/vocational activities facilitated by interventions and services representing many of psychiatric rehabilitation's key goals, had the weakest association with reduced rates of re-hospitalization. Possible explanations may be inaccurate assessments of consumers' personal relationships and social/vocational activities by the mental healthcare professionals, problematic provider-consumer communication on the consumers' involvement in social/vocational activities, or ineffective methods of facilitating consumer participation in these activities. Clearly to reduce the wicked "revolving-door" phenomenon, there is a need for targeted interventions and a review of current psychiatric rehabilitation policies to promote the comprehensive integration of community rehabilitation services by decreasing the fragmentation of care, facilitating continuity of care with other healthcare services, and utilizing effective personal reported outcomes and experiences of consumers with severe mental illness.

The effect of neuroendocrine abnormalities on the risk of psychiatric readmission after hospitalization for bipolar disorder: A retrospective study

BACKGROUND

The correlation between the endocrine system and bipolar disorder(BD) has been well recognized, yet the influence of neuroendocrine hormones on readmission risk post-hospitalization for BD remains largely unexplored. This retrospective cohort study was to scrutinize the impact of neuroendocrine functionality on the readmission of patients with BD post-hospitalization for mental disorders.

METHODS

The dataset was derived from the electronic medical records of the First Affiliated Hospital of Jinan University in Guangzhou, China. Both univariate and multivariate logistic regression analysis were conducted on all patients hospitalized for BD, and from 1 January 2017 to October 2022.

RESULTS

Of the 1110 eligible patients, 83 and 141 patients experienced psychiatric readmissions within 90 and 180 days post-discharge, respectively. Multivariate analysis revealed that high serum TSH levels (aOR = 1.079; 95%CI = 1.003-1.160) and thyroid disease comorbidities (aOR = 2.899; 95%CI = 1.303-6.452) were independently correlated with the risk of 90-day readmission; while increased serum TSH levels (aOR = 1.179; 95%CI = 1.081-1.287) represented a risk factor for 180-day readmission. These results indicate that high serum TSH levels and thyroid disease comorbidities may contribute to an elevated readmission risk in patients with BD following hospitalization.

CONCLUSION

Routinely evaluating and intervening in thyroid function is crucial in the treatment of BD, as it may aid in preventing re-hospitalization.

Ensuring Continuity of Care: Effective Strategies for the Post-hospitalization Transition of Psychiatric Patients in a Family Medicine Outpatient Clinic

In healthcare, continuity of care is a crucial element, especially for patients in the field of psychiatry who have recently been discharged from a hospital. The shift from inpatient to outpatient care poses challenges for patients and healthcare providers, including openness to treatment, competing priorities, financial insecurity, concerns and dilemmas faced by patients regarding their post-hospitalization life after improvements in symptoms, lack of social support, poor patient-doctor relationships, lack of insight, and stigma associated with mental illness. Therefore, it is vital to employ effective strategies to ensure patients receive the required care and support during this transition. This review delves into the significance of continuity of care for psychiatric patients post-hospitalization, effective strategies for the transition, and the challenges and barriers to implementation from the perspective of a family medicine practice. To analyze physicians' role in managing psychiatric patients post-hospitalization, we developed a comprehensive search strategy. This involved extracting relevant data, updates, guidelines, and recommendations. Our search spanned various online repositories, such as PubMed and Google Scholar, specifically focusing on US-based guidelines aligned with our objectives. The search was conducted using medical subject headings (MeSH) and combinations of "OR," "AND," and "WITH." We crafted keywords to optimize our search strategy, including psychiatric illness, post-hospitalization, follow-up, follow-up care, primary care follow-up, and guidelines. Exploring online repositories yielded 132 articles, and we identified some guidelines that addressed our objectives. We established inclusion and exclusion criteria for our review and reviewed 21 papers. Post-hospitalization follow-up is a critical facet of psychiatric care, aligning with guidelines from the American Psychiatric Association and other relevant sources. Emphasizing continuity of care ensures a smooth transition from inpatient to outpatient settings, sustaining therapeutic momentum and minimizing the risk of relapse. This comprehensive approach involves careful medication management, regular mental health assessments, education on condition-specific coping strategies, and coordinated care between healthcare providers. It includes conducting risk assessments, safety planning, building social support and community integration, prompt post-hospitalization follow-up, and tailored treatment plans. Together, these measures enhance overall wellness for recently discharged patients. This holistic strategy tackles pressing short-term needs while facilitating long-term stability, promoting resilience and successful community reintegration, reducing readmission likelihood, and ultimately supporting sustained recovery.

Predictors for early and long-term readmission in involuntarily admitted patients

BACKGROUND

It is a common aim to reduce psychiatric readmissions. Although risk factors for readmissions were described, specific data in the group of patients with potentially aversively experienced involuntary admissions are lacking. To better understand underlying mechanisms, it is important to identify factors that are linked to readmissions in this specific patient group, which is the purpose of the current paper.

METHODS

A four-year cohort of N = 3575 involuntary admissions (IA) was followed-up for subsequent re-hospitalization. Demographic, administrative and clinical factors associated with short- (within 30 days) or long-term (> 30 days) readmissions were examined using logistic regression modelling.

RESULTS

Almost half of all IA cases were readmitted within the observation period, whereof every fifth readmission was within the first month after discharge from the involuntary index hospitalization. Adjusted regression modelling revealed problematic substance use at admission and assisted living or homelessness as risk factors for readmission, while high functioning at discharge, anxiety disorders, no subsequent treatment after discharge or IA due to danger to others were negatively associated with readmission. Factors specifically linked to short-term readmission were substance use and personality disorders, abscondence or discharge by initiation of the clinic, as well as being discharged to any place except the patient's home. There were no specific risk-factors for long-term readmission.

CONCLUSIONS

To prevent readmissions after IA, especially for patients at risk, the aim of treatment strategies should be to focus on intensive discharge planning, enable continuous treatment in the outpatient setting, and provide social support.

Patient-centered inpatient psychiatry is associated with outcomes, ownership, and national quality measures

Following discharge from inpatient psychiatry, patients experience elevated suicide risk, unplanned readmission, and lack of outpatient follow-up visits. These negative outcomes might relate to patient-centered care (PCC) experiences while hospitalized. We surveyed 739 former patients of inpatient psychiatric settings to understand the relationship between PCC and changes in patients' trust, willingness to engage in care, and self-reported 30-day follow-up visits. We also linked PCC measures to facility-level quality measures in the Inpatient Psychiatric Facility Quality Reporting program. Relative to patients discharged from facilities in the top quartile of PCC, those discharged from facilities in the bottom quartile were more likely to experience reduced trust (predicted probability [PP] = 0.77 vs 0.46; P < .001), reduced willingness to go to the hospital voluntarily (PP = 0.99 vs 0.01; P < .001), and a lower likelihood of a 30-day follow-up (PP = 0.71 vs 0.92; P < .001). PCC was lower among patients discharged from for-profits, was positively associated with facility-level quality measures of 7- and 30-day follow-up and medication continuation, and was inversely associated with restraint use. Findings underscore the need to introduce systematic measurement and improvement of PCC in this setting.

YouBelong Home: A Ugandan Community Mental Health Intervention

In Uganda, low resources for mental health provision combine with disadvantage and inadequate supports for family and community-based care. Catalysed by the need to reduce overcrowded psychiatric hospital wards and frequent readmissions at Butabika National Referral Mental Hospital (BNRMH) in Kampala, the nongovernment organisation YouBelong Uganda (YBU) developed the YouBelong Home (YBH) intervention. YBH is a theoretically eclectic pre and post hospital discharge intervention. This paper reports on qualitative findings of the project Curtailing Hospital Readmissions for Patients with Severe Mental Illness in Africa (CHaRISMA), which explored how to refine the YBH intervention. The project was funded by a UK Joint Global Health Trials (JGHT) Development Grant. Data was collected through structured interviews with service users and caregivers, reflective practice by the YBH implementing team and a stakeholder focus group. A summary of refinements to the YBH intervention follows the TIDieR format (Template for Intervention Description and Replication).

Exploring risk factors for re-hospitalization in a psychiatric inpatient setting: a retrospective naturalistic study

BACKGROUND

The reduction of multiple psychiatric hospitalizations is an important clinical challenge in mental health care. In fact, psychiatric re-hospitalization negatively affects the quality of life and the life expectancy of patients with psychiatric disorders. For these reasons, identifying predictors of re-hospitalization is important for better managing psychiatric patients. The first purpose of the present study was to examine the readmission rate in a large sample of inpatients with a psychiatric disorder. Second, we investigated the role of several demographical and clinical features impacting re-hospitalization.  METHOD: This retrospective study enrolled 1001 adult inpatients (510 men and 491 women) consecutively admitted to the University Psychiatric Clinic, Sant'Andrea Hospital, Sapienza University of Rome between January 2018 and January 2022. To identify risk factors for psychiatric re-hospitalization, we divided the sample into 3 subgroups: the Zero-Re group which had no readmission after the index hospitalization, the One-Re group with patients re-admitted only once, and the Two-Re with at least two re-admissions.  RESULTS: The groups differed according to previous hospitalizations, a history of suicide attempts, age at onset, and length of stay. Furthermore, the results of the regression model demonstrated that the Two-Re group was more likely to have a history of suicide attempts and previous hospitalizations.

DISCUSSION

These results indicate the importance of assessing risk factors in psychiatric hospitalized patients and implementing ad hoc prevention strategies for reducing subsequent re-hospitalizations.

Machine Learning in Cardiac Surgery: Predicting Mortality and Readmission

Predicting outcomes in open-heart surgery can be challenging. Unexpected readmissions, long hospital stays, and mortality have economic implications. In this study, we investigated machine learning (ML) performance in data visualization and predicting patient outcomes associated with open-heart surgery. We evaluated 8,947 patients who underwent cardiac surgery from April 2006 to January 2018. Data visualization and classification were performed at cohort-level and patient-level using clustering, correlation matrix, and seven different predictive models for predicting three outcomes ("Discharged," "Died," and "Readmitted") at binary level. Cross-validation was used to train and test each dataset with the application of hyperparameter optimization and data imputation techniques. Machine learning showed promising performance for predicting mortality (AUC 0.83 ± 0.03) and readmission (AUC 0.75 ± 0.035). The cohort-level analysis revealed that ML performance is comparable to the Society of Thoracic Surgeons (STS) risk model even with limited number of samples ( e.g. , less than 3,000 samples for ML versus more than 100,000 samples for the STS risk models). With all cases (8,947 samples, referred as patient-level analysis), ML showed comparable performance to what has been reported for the STS models. However, we acknowledge that it remains unknown at this stage as to how the model might perform outside the institution and does not in any way constitute a comparison of the performance of the internal model with the STS model. Our study demonstrates a systematic application of ML in analyzing and predicting outcomes after open-heart surgery. The predictive utility of ML in cardiac surgery and clinical implications of the results are highlighted.

Sociodemographic, clinical and pharmacological factors influencing early readmission in mental health settings

Early readmissions (between 24 hours and 30 days after discharge) can be disruptive for psychiatric patients and their families.

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.

A mirror-image analysis of psychiatric hospitalisations among people with severe mental illness using Independent Supported Housing

BACKGROUND

Evidence on the effectiveness of Independent Supported Housing (ISH) for non-homeless people with severe mental illness primarily comes from observational cohort studies, which have high risk of bias due to confounding by time-invariant sample characteristics. The present study proposes an alternative study design known from pharmacology to overcome this bias and strengthen evidence.

METHODS

We conducted a retrospective mirror-image analysis with medical records of 144 ISH service users to assess the effectiveness of ISH in reducing the number and duration of hospitalisations. Outcomes occurring in equal periods before and during ISH utilisation were compared for every ISH user. Differences between the periods were tested with incidence rate ratios (IRR).

RESULTS

Included service users were on average 38.2 years old, female (54%) and predominately had an affective (28.5%) or a schizophrenic or psychotic (22.9%) disorder with ISH utilisation days ranging from 36-960. Fewer admissions (IRR = 0.41, 95%-CI 0.27-0.64) and fewer person-days hospitalised (IRR = 0.38, 95%-CI 0.35-0.41) were observed during ISH utilisation compared to prior to their ISH utilisation. While the reduction in psychiatric admissions may be somewhat confounded by time-variant characteristics, the substantial reduction in hospitalised bed-bays represents at least partially an intervention effect.

CONCLUSIONS

The mirror-image study design allowed for a cost-effective investigation of ISH effectiveness in reducing hospitalisation without confounding by time-invariant sample characteristics. We provide recommendations for the design's application and suggest further research with larger samples.

Waiting for Care: Length of Stay for ED Mental Health Patients by Disposition, Diagnosis, and Region (2009–2015)

Objective

Emergency departments (EDs) face increasing mental health visits on a backdrop of insufficient mental health resources. We study ED length of stay (LOS) and disposition by 1) mental health vs. medical visits; 2) psychiatric vs. substance use visits; and 3) the four regions of the United States. 

Methods

We used weighted data from the National Hospital Ambulatory Medical Care Survey (2009-2015). Visits by patients ages 18-64 were categorized into mental health and medical groups. The mental health group was then subdivided into psychiatric, substance use, and co-occurring disorders. The LOS was compared by disposition. Mental health vs. medical LOS and disposition were examined across four regions of the US.

Results

An estimated 28 million mental health and 526 million medical visits were included in the study. Mental health visits had a median (interquartile range [IQR]) of 3.7 (4.7) hours while medical visits had a median (IQR) of 2.6 (2.7) hours. Mental health compared to medical visits were more likely to result in admission or transfer and to last >6 and >12 hours. Mental health visits resulting in transfer had the longest LOS with a median (IQR) of 6.23 (7.7) hours. Of mental health visit types, co-occurring disorders visits were more likely to be >6 and >12 hours regardless of disposition. Across US regions, there was significant variation in disposition patterns for mental health vs. medical visits. The odds of mental health visits lasting >6 and >12 hours were greatest in the Northeast and the least in the South with a median (IQR) of 4.6 (5.8) hours and 3.3 (4.0) hours, respectively.

Conclusions

Metal health compared to medical visits had longer LOS, especially when the patient had co-occurring disorders or required transfer. Regionally, there is a large variation in disposition for mental health vs. medical visits. This study makes it clear that there are no standards for managing psychiatric emergencies.

Personality predictors of 6-month readmission in adult psychiatric inpatients

Readmission of psychiatric inpatients is highly prevalent and places a significant financial burden on the healthcare system. Rehospitalisation is often used as a metric of quality of care in psychiatric settings, but little is known about how specific personality traits impact readmission in adult psychiatric inpatients. A convenience sample of 94 adults (mean age = 36.8 years; female = 54.3%; European American = 76.6%) at an inpatient psychiatric hospital completed the Personality Inventory for DSM-5-Brief Form (PID-5-BF; American Psychiatric Association, 2013); demographic and medical information and readmission data were extracted via chart review. Poisson regression was used to predict number of readmissions at 6 months after discharge from PID-5-BF domain scores of Negative Affectivity, Detachment, Antagonism, Disinhibition and Psychoticism. Twenty-three patients (24.5%) were readmitted at least once by 6-month follow-up. Higher PID-5-BF Negative Affectivity domain scores predicted greater number of readmissions at 6 months (incidence rate ratio (IRR) = 1.14, robust standard error (RSE) = 0.05, p < .01, 95% confidence interval [1.04, 1.25]). The other PID-5-BF domain scores were not significantly related to number of readmissions. Thus, greater negative affect, indicative of higher trait neuroticism, heightened experience of negative emotions and poor self-concept, was a significant personality predictor of readmission in the study. These results suggest that assessing this trait domain might help to identify psychiatric inpatients at greater risk for readmission and determine those most in need of enhanced services to reduce rehospitalisation.

Peer support for discharge from inpatient mental health care versus care as usual in England (ENRICH): a parallel, two-group, individually randomised controlled trial

BACKGROUND

High numbers of patients discharged from psychiatric hospital care are readmitted within a year. Peer support for discharge has been suggested as an approach to reducing readmission post-discharge. Implementation has been called for in policy, however, evidence of effectiveness from large rigorous trials is missing. We aimed to establish whether peer support for discharge reduces readmissions in the year post-discharge.

METHODS

We report a parallel, two-group, individually randomised, controlled superiority trial, with trial personnel masked to allocation. Patients were adult psychiatric inpatients (age ≥18 years) with at least one previous admission in the preceding 2 years, excluding those who had a diagnosis of any organic mental disorder, or a primary diagnosis of learning disability, an eating disorder, or drug or alcohol dependency, recruited from seven state-funded mental health services in England. Patients were randomly assigned (1:1) to the intervention (peer support plus care as usual) or control (care as usual) groups by an in-house, online randomisation service, stratified by site and diagnostic group (psychotic disorders, personality disorders, and other eligible non-psychotic disorders) with randomly permuted blocks of randomly varying length to conceal the allocation sequence and achieve the allocation ratio. The peer support group received manual-based, one-to-one peer support, focused on building individual strengths and engaging with activities in the community, beginning during the index admission and continuing for 4 months after discharge, plus care as usual. Care as usual consisted of follow-up by community mental health services within 7 days of discharge. The primary outcome was psychiatric readmission 12 months after discharge (number of patients readmitted at least once), analysed on an intention-to-treat basis. All patients were included in a safety analysis, excluding those who withdrew consent for use of their data. The trial is registered with the ISRCTN registry, ISRCTN10043328. The trial was complete at the time of reporting.

FINDINGS

Between Dec 1, 2016, and Feb 8, 2019, 590 patients were recruited and randomly assigned, with 294 allocated to peer support (287 included in the analysis after withdrawals and loss to follow-up), and 296 to care as usual (291 in the analysis). Mean age was 39·7 years (SD 13·7; range 18-75). 306 patients were women, 267 were men, three were transgender, and two preferred not to say. 353 patients were White, 94 were Black, African, Caribbean, or Black British, 68 were Asian or Asian British, 48 were of mixed or multiple ethnic groups, and 13 were of other ethnic groups. In the peer support group, 136 (47%) of 287 patients were readmitted at least once within 12 months of discharge. 146 (50%) of 291 were readmitted in the care as usual group. The adjusted risk ratio of readmission was 0·97 (95% CI 0·82-1·14; p=0·68), and the adjusted odds ratio for readmission was 0·93 (95% CI 0·66-1·30; p=0·68). The unadjusted risk difference was 0·03 (95% CI -0·11 to 0·05; p=0·51) in favour of the peer support group. Serious adverse events were infrequent (67 events) and similar between groups (34 in the peer support group, 33 in the care as usual group). Threat to life (self-harm) was the most common serious adverse event (35 [52%] of 67 serious adverse events). 391 other adverse events were reported, with self-harm (not life threatening) the most common (189 [48%] of 391).

INTERPRETATION

One-to-one peer support for discharge from inpatient psychiatric care, plus care as usual, was not superior to care as usual alone in the 12 months after discharge. This definitive, high-quality trial addresses uncertainty in the evidence base and suggests that peer support should not be implemented to reduce readmission post-discharge for patients at risk of readmission. Further research needs to be done to improve engagement with peer support in high-need groups, and to explore differential effects of peer support for people from different ethnic communities.

FUNDING

UK National Institute for Health Research.

Predictors of community mental health nursing services use in Switzerland: Results from a representative national survey

Community mental health services are the service of choice in the mental health field. In recent years, demand for these services has increased significantly. Nurses play a central role in community mental health services. Nevertheless, predictive factors of the use of such services are unclear, especially in Switzerland. This study aimed to examine relevant predictors of persons with mental health problems' use of community mental health nursing services in Switzerland. Swiss Health Survey 2017 data were used to compare those who use community mental health nursing services with those who do not. We found that age, number of doctor visits, problems with instrumental activities of daily life, use of informal help, use of emergency services, taking psychotropic medication, being female, and living without a partner were positive predictors, while experiencing severe physical symptoms was a negative predictor. Several of our findings confirm the similarity between the utilization of community mental health nursing services and the use of community mental health services in general. Our results suggest that community mental health nursing services deserve the same prominent place in the mental health system and its corresponding policies. This should be taken as an argument for policy development and better reimbursement. In research, health surveys should focus on nursing and need-related questions. Additionally, it is necessary to develop community mental health nursing services from an add-on service into independent nursing services and evaluate these services.

Inpatient Mental Healthcare before and during the COVID-19 Pandemic

Prior studies have demonstrated disruption to outpatient mental health services after the onset of the COVID-19 pandemic. Inpatient mental health services have received less attention. The current study utilized an existing cohort of 33 Veterans Health Affairs (VHA) acute inpatient mental health units to examine disruptions to inpatient services. It further explored the association between patient demographic, clinical, and services variables on relapse rates. Inpatient admissions and therapeutic services (group and individual therapy and peer support) were lower amongst the COVID-19 sample than prior to the onset of COVID-19 while lengths of stay were longer. Relapse rates did not differ between cohorts. Patients with prior emergent services use as well as substance abuse or personality disorder diagnoses were at higher risk for relapse. Receiving group therapy while admitted was associated with lower risk of relapse. Inpatient mental health services saw substantial disruptions across the cohort. Inpatient mental health services, including group therapy, may be an important tool to prevent subsequent relapse.

The effect of thyroid function on the risk of psychiatric readmission after hospitalization for major depressive disorder

The relationship between thyroid function and depression has long been recognized, but little is known about the effect of thyroid function on the risk of readmission after hospitalization for major depressive disorder (MDD). This retrospective cohort study was aimed to explore the effect of thyroid function on psychiatric readmission after hospitalization for MDD. Data was derived from electronic medical records (EMR) of the Shanghai Mental Health Center (SMHC), Shanghai, China. Univariate and multivariate logistic regression analyses were conducted in subjects aged ≥ 18 years who had been hospitalized for MDD between January 1, 2007, and May 31, 2019. Of the 1803 eligible patients, 85 and 132 patients experienced psychiatric readmission within 90 days and 180 days after discharge respectively. Multivariate analyses showed that serum FT3 level (aOR=1.271; 95%CI=1.051-1.537) and comorbidity of thyroid disease (aOR=2,179; 95%CI=1.136-4.179) was independently associated with the risk of 90-day and 180-day readmission respectively. These findings indicated that high serum FT3 levels and comorbidity of thyroid disease could increase the risk of readmission after hospitalization for MDD. It is warranted to provide routine assessment and intervention of the thyroid function during the treatment of depression so as to prevent re-hospitalization.

Predicting 30-Day Readmissions: Evidence From a Small Rural Psychiatric Hospital

To improve quality of care and patient outcomes, and to reduce costs, hospitals in the United States are trying to mitigate readmissions that are potentially avoidable. By identifying high-risk patients, hospitals may be able to proactively adapt treatment and discharge planning to reduce the likelihood of readmission. Our objective in this study was to derive and validate a predictive model of 30-day readmissions for a small rural psychiatric hospital in the northeast. However, this model can be adapted by other rural psychiatric hospitals-a context that has been understudied in the literature. Our sample consisted of 1912 adult inpatients (1281 in the derivation cohort and 631 in the validation cohort), who were admitted between August 1, 2014, and July 31, 2016. We used deidentified data from the hospital's electronic medical record, including physician orders and discharge summaries. These data were merged with community-level variables that reflected the availability of care in the patients' zip codes. We first considered the correlates of 30-day readmission in a regression framework. We found that the probability of readmission increased with the number of previous admissions (vs. no readmissions). Moreover, the probability of readmission was much higher for patients with a depressive disorder (vs. no depressive disorder), with another mood disorder (vs. no other mood disorder), and/or with a psychotic disorder (vs. no psychotic disorder). We used these associations to derive a predictive model, in which we used the regression coefficients to construct a score for each patient. We then estimated the predicted probability of 30-day readmission on the basis of that score. After validating the model, we discuss the implications for clinical practice and the limitations of our approach.

Searching for factors associated with the "Revolving Door phenomenon" in the psychiatric inpatient unit: A 5-year retrospective cohort study

The revolving door (RD) phenomenon refers to subjects who undergo frequent rehospitalizations in psychiatric units. The main aim of this study was to analyze clinical factors associated with RD in acute inpatient psychiatric ward. In a 5-year cohort study, subjects hospitalized three or more times in 12 months (revolving door subjects-RDS) were identified. A total of 1,324 subjects were hospitalized. RDS represented 6.3% (n = 84) of the entire sample with a total of 337 RD hospitalizations (revolving door hospitalizations-RDH) (16.7% of all admissions). RDS were younger, unmarried, with comorbid substance related disorders, with mood or psychotic disorders and affected by comorbid medical conditions. After controlling for age, sex and marital status, the most strongly associated variable with RDH was the comorbidity between mood and substance use disorders. Other associated factors were the presence of a comorbid medical condition and a longer length of stay. The commitment to community residential facilities and the treatment with a first generation long-acting antipsychotic were also associated with RDH. On the contrary, admissions to the psychiatric unit for manic/hypomanic episode or for self-directed harmful behavior were inversely associated with RDH. Attention should be given to these clinical variables in order to reduce RD.

Video consultations from an Indian academic hospital: First 3 years of experience from telepsychiatric after-care clinic

Background Continuity of care for psychiatric disorders by conventional in-person consultation by psychiatrists is associated with several challenges. There is a need to develop alternative models of specialist care. We studied our 3 years' experience of live video consultations (VCs) from the tele after-care clinic to patients with psychiatric disorders at an Indian academic hospital. Methods We did a file review of 669 VCs provided to 213 patients in the first 3 years (2017-2019) from the telemedicine centre of a tertiary care academic hospital. We analysed details of sociodemography, clinical profile, tele after-care consultations and outcome. Results Two hundred and thirteen patients (55% men) were enrolled for the tele after-care clinic. The mean (SD) age of the patients was 42.2 (17.29) years and a majority were educated till high school and beyond. Patients with severe and common mental disorders constituted 60.1% and 40%, respectively. Among the total 669 appointments, 542 (81%) VCs were successfully provided; of the remaining, 125 were cancelled and 2 were aborted due to a medical emergency. Medication prescriptions were unchanged in 499 and modified/totally changed in 47 VCs. Conclusion Our large study shows that telepsychiatric after-care is a useful alternative method which can supplement in-person follow-up. Barriers such as distance, cost and medical illness can be overcome using tele after-care clinics for regular follow-ups in stabilized psychiatric patients. There is a need for prospective studies, preferably, randomized controlled trials comparing effectiveness of tele after-care with in-person consultations to assess treatment outcomes.

Recovering the Capacity to Live outside of a Psychiatric Hospital: Impact of a Specialized Inpatient Program

Deinstitutionalization in psychiatry led to a decrease in hospital beds, short hospital admissions focussed on symptoms reduction, and the development of ambulatory care. However, the needs of patients who despite symptoms reduction do not display the minimal competencies to live alone or in a sheltered accommodation, are not met in such a context. They usually go through long admissions and fail to improve. In 2016, we implemented a new inpatient program focused on fostering the development of the competencies needed to adapt to living outside the hospital; the aim of this study was to evaluate if it lead to the resolution of these situations or in contrary if it turned into a long stay unit. 116 patients admitted to the program between 2016 and 2018 were included in the study. They were psychiatric inpatients who had no home, did not find a place in a sheltered accommodation and couldn't be discharged. In the majority of cases, the situation was resolved within 180 days and the majority of patients was referred to a sheltered accommodation. Functional and symptom levels improved significantly over time. A specific focus on restoring competencies to live outside of hospital allows complex patients to improve their functional level and to find a place to live in the community within a relatively short time. While deinstitutionalization has been beneficial to the vast majority of patients, denying the specific needs of a minority of patients leads to unnecessary long and inefficient hospital admissions.

[Individual and contextual factors associated with violent behaviours during psychiatric hospitalizations]

BACKGROUND

The prevention of Physical Violent Behavior (VB) toward others during psychiatric hospitalization is a major concern of clinicians. These VBs can have a deleterious impact on the victims, inpatients or caregivers, as well as on the therapeutic milieu. Such violence can also have negative consequences for the assailant patients, such as repeatedly being hospitalized under restraint, stigmatization, and difficulties reintegrating into the community.

OBJECTIVES

This study explored individual (age, gender, marital status, living status, diagnostic) and institutional (type of admission, length of stay, number of previous hospitalizations) risk factors, and how their interactions could increase the risk of VB during psychiatric hospitalizations.

METHOD

The study was carried out over a period of four years in the psychiatry department of the Lausanne University Hospital, on the 15 wards (219 beds) specialized in acute psychiatric care for adults. All the patients admitted to one of these wards during this period (n=4518), aged between 18 and 65 years, were included in the study. The sample was divided in two groups: non-violent patients (NVPs) and violent patients (VPs). VBs, defined as physical aggressions against another person, were assessed by the Staff Observation Aggression Scale - Revised (SOAS - R). Only physical assaults, associated or not with other types of violence, involving hospitalized patients were analyzed. Personal and institutional factors were extracted from the hospital database. Chi² independence tests were used to assess differences between groups. Logistic regression models were used to identify the links between each factor and the VB. Classification and regression trees were used to study the hierarchical effect of factors, and combinations of factors, on VBs.

RESULTS

During the study period, 414 VBs were reported involving 199 patients (4.40 % of all patients). VPs were significantly younger, male, more likely to be unmarried and living in sheltered housing before hospitalization. In this group, the proportion of patients with diagnoses of schizophrenia, and/or schizophrenia with comorbid substance abuse and cognitive impairment, were higher compared to NVPs. VPs were more frequently admitted involuntarily, had a longer average length of stay and a greater number of previous hospitalizations. The logistic regression model performed on individual factors have shown a significant link between age (OR=0.99; CI: 0.97-1.00; P-value=0.024), living in sheltered housing before admission (OR=2.46; CI: 1.61-3.75; P-value<0.000), schizophrenic disorders (OR=2.18; CI: 1.35-3.57; P-value=0.001), schizophrenic disorders with substance abuse comorbidity (OR=2.00; CI: 1.16-3.37; P-value=0.016), cognitive impairment (OR=3.41; CI: 1,21-8.25; P-value=0.010), and VBs. The logistic regression model on institutional factors have shown a significant link between involuntary hospitalization (OR=4.38; CI: 3.20-6.08; P-value<0.000), length of previous stay (OR=1.01; CI: 1.00-1.01; P-value<0.000), number of previous hospitalizations (OR=1.06; CI: 1.00-1.12; P-value=0.031), and VBs. The logistic regression model on individual and institutional factors have shown a significant link between age (OR=0.99; CI: 0.97-1.00; P-value=0.008), living in sheltered housing before admission (OR=2.46: CI: 1.61-3.75; P-value=0.034), cognitive impairment (OR=3.41; CI: 1.21-8.25; P-value=0.074), involuntary hospitalization (OR=3.46; CI: 2.48-4.87; P-value<0.000), length of previous stay (OR=1.01; CI: 1.00-1.01; P-value<0.000), and VBs. The classification and regression trees have shown that the relationship between long length of stay and repeated hospitalizations mainly potentiate the risk of violence.

CONCLUSION

The results of this study have shown the existence of a small group of vulnerable patients who accumulate constrained hospital stays during which violence occurs. Exploring the clinical profiles and institutional pathways of patients could help to better identify these patients and promote a more appropriate mode of support, such as intensive clinical case management. This model could facilitate the development of a clinical network and the links between the structures and partners caring for a patient. This would create a continuous support, avoiding or limiting the lack of continuity of care and care disruption.

Family care for persons with severe mental illness: experiences and perspectives of caregivers in Uganda

BACKGROUND

In low-income settings with limited social protection supports, by necessity, families are a key resource for care and support. Paradoxically, the quality of family care for people living with Severe Mental Illness (PLSMI) has been linked to support for recovery, hospital overstay and preventable hospital readmissions. This study explored the care experiences of family members of PLSMI with patients at the national mental hospital in Kampala, Uganda, a low income country. This study was undertaken to inform the development of YouBelongHome (YBH), a community mental health intervention implemented by YouBelong Uganda (YBU), a registered NGO in Uganda.

METHODS

Qualitative data was analysed from 10 focus groups with carers of ready to discharge patients on convalescent wards in Butabika National Referral Mental Hospital (BNRMH), Kampala. This is a subset of data from a mixed methods baseline study for YouBelong Uganda, undertaken in 2017 to explore hospital readmissions and community supports for PLSMI from the Wakiso and Kampala districts, Uganda.

RESULTS

Three interrelated themes emerge in the qualitative analysis: a range of direct, practical care provided by the caregiver of the PLSMI, emotional family dynamics, and the social and cultural context of care. The family care giving role is multidimensional, challenging, and changing. It includes protection of the PLSMI from harm and abuse, in the context of stigma and discrimination, and challenging behaviours that may result from poor access to and use of evidence-based medicines. There is reliance on traditional healers and faith healers reflecting alternative belief systems and health seeking behaviour rather than medicalised care. Transport to attend health facilities impedes access to help outside the family care system. Underpinning these experiences is the impact of low economic resources.

CONCLUSIONS

Family support can be a key resource and an active agent in mental health recovery for PLSMI in Uganda. Implementing practical family-oriented mental health interventions necessitates a culturally aware practice. This should be based in understandings of dynamic family relationships, cultural understanding of severe mental illness that places it in a spiritual context, different family forms, caregiving practices and challenges as well as community attitudes. In the Ugandan context, limited (mental) health system infrastructure and access to medications and service access impediments, such as economic and transport barriers, accentuate these complexities.

A sequence analysis of hospitalization patterns and service utilization in patients with major psychiatric disorders in China

BACKGROUND

Understanding the long-term inpatient service cost and utilization of psychiatric patients may provide insight into service demand for these patients and guide the design of targeted mental health programs. This study assesses 3-year hospitalization patterns and quantifies service utilization intensity of psychiatric patients in Beijing, China.

METHODS

We identified patients admitted for one of three major psychiatric disorders (schizophrenia, bipolar and depressive disorders) between January 1 and December 31, 2013 in Beijing, China. Inpatient admissions during the following 3 years were extracted and analyzed using sequence analysis. Clinical characteristics, psychiatric and non-psychiatric service use of included patients were analyzed.

RESULTS

The study included 3443 patients (7657 hospitalizations). The patient hospitalization sequences were grouped into 4 clusters: short stay (N = 2741 (79.61% of patients), who had 126,911 or 26.82% of the hospital days within the sample), repeated long stay (N = 404 (11.73%), 76,915 (16.26%) days), long-term stay (N = 101 (2.93%), 59,909 (12.66%) days) and permanent stay (N = 197 (5.72%), 209,402 (44.26%) days). Length and frequency of hospitalization, as well as readmission rates were significantly different across the 4 clusters. Over the 3-year period, hospitalization days per year decreased for patients in the short stay and repeated long stay clusters. Patients with schizophrenia (1705 (49.52%)) had 78.4% of cumulative psychiatric stays, with 11.14% of them in the permanent stay cluster. Among patients with depression, 23.11% had non-psychiatric hospitalizations, and on average 46.65% of their total inpatient expenses were for non-psychiatric care, the highest among three diagnostic groups.

CONCLUSION

Hospitalization patterns varied significantly among psychiatric patients and across diagnostic categories. The high psychiatric care service use of the long-term and permanent stay patients underlines the need for evidence-based interventions to reduce cost and improve care quality.

Structure and predictors of in-hospital nursing care leading to reduction in early readmission among patients with schizophrenia in Japan: A cross-sectional study

Schizophrenia is a disorder characterized by psychotic relapses. Globally, about 15%-30% of patients with schizophrenia discharged from inpatient psychiatric admissions are readmitted within 90 days due to exacerbation of symptoms that leads to self-harm, harm to others, or self-neglect. The purpose of this study was to investigate the structure and predictors of in-hospital nursing care leading to reduction in early readmission among patients with schizophrenia. A new questionnaire was developed to assess the extent to which respondents delivered in-hospital nursing care leading to reduction in early readmission among patients with schizophrenia. This study adopted a cross-sectional research design. The survey was conducted with the new questionnaires. The participants were registered nurses working in psychiatric wards. Item analyses and exploratory factor analyses were performed using the new questionnaires to investigate the structure of in-hospital nursing care leading to reduction in early readmission. Stepwise regression analyses were conducted to examine the factors predicting in-hospital nursing care leading to reduction in early readmission. Data were collected from 724 registered nurses in Japan. In-hospital nursing care leading to reduction in early readmission was found to consist of five factors: promoting cognitive functioning and self-care, identifying reasons for readmission, establishing cooperative systems within the community, sharing goals about community life, and creating restful spaces. In-hospital nursing care leading to reduction in early readmission was predicted by the following variables: the score on the nursing excellence scale in clinical practice, the score on therapeutic hold, and the participation of community care providers in pre-discharge conferences. Japanese psychiatric nurses provide nursing care based on these five factors leading to reduction in early readmission. Such nursing care would be facilitated by not only nurses' excellence but also nurses' environmental factors, especially the therapeutic climate of the ward and the participation of community care providers in pre-discharge conferences.

Psychiatric readmission rates in a multi-level mental health care system - a descriptive population cohort study

BACKGROUND

Readmission rates are frequently used as a quality indicator for health care, yet their validity for evaluating quality is unclear. Published research on variables affecting readmission to psychiatric hospitals have been inconsistent. The Norwegian specialist mental health care system is characterized by a multi-level structure; hospitals providing specialized -largely unplanned care and district psychiatric centers (DPCs) providing generalized -more often planned care. In certain service systems, readmission may be an integral part of individual patients' treatment plan. The aim of the present study was to describe and examine the task division in a multi-level health care system. This we did through describing differences in patient population (age, sex, diagnosis, substance abuse comorbidity and length of stay) and admissions types (unplanned vs. planned) treated at different levels (hospital, DPC or both), and by examining whether readmission risk differ according to type and place of treatment of index-admission and travel-time to nearest hospital and DPC.

METHODS

In this population-based cohort study using administrative data we included all individuals aged 18 and older who were discharged from psychiatric inpatient care with an ICD-10 diagnosis F2-F6 ("functional mental disorders") in 2012. Selecting each individual's first discharge during 2012 as index gave N = 16,185 for analyses following exclusions. Analysis of readmission risk were done using Kaplan-Maier failure curves.

RESULTS

Overall, 15.1 and 47.7% of patients were readmitted within 30 and 365 days, respectively. Unplanned admission patients were more likely to be readmitted within 30 days than planned patients. Those transferred between hospital and DPC during index admission were more likely to be readmitted within 365 days, and to experience planned readmission. Patients with short travel time were more likely to have unplanned readmission, while patients with long travel time were more likely to have planned readmission.

CONCLUSIONS

DPCs and hospitals fill different purposes in the Norwegian health care system, which is reflected in different patient populations. Differences in short term readmission rates between hospitals and DPCs disappeared when type of admission (unplanned/planned) was considered. The results stress the importance of addressing differences in organisation and task distribution when comparing readmission rates between mental health systems.

Exploration of recovery of people living with severe mental illness (SMI) in low/middle-income countries (LMICs): a scoping review

OBJECTIVE

To examine the literature on how recovery of people with severe mental illness (SMI) is conceptualised in low/middle-income countries (LMICs), and in particular what factors are thought to facilitate recovery.

DESIGN

Scoping review.

DATA SOURCES AND ELIGIBILITY

We searched 14 electronic databases, hand searched citations and consulted with experts during the period May-December 2019. Eligible studies were independently screened for inclusion and exclusion by two reviewers. Unresolved discrepancies were referred to a third reviewer.

DATA EXTRACTION AND SYNTHESIS

All bibliographical data and study characteristics were extracted using a data charting form. Selected studies were analysed through a thematic analysis emerging from extracted data.

RESULTS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram offers a summary of the results: 4201 titles, 1530 abstracts and 109 full-text articles were screened. Ten articles were selected for inclusion: two from Turkey, two from India, and one each from China, Swaziland, Indonesia, Egypt, South Africa and Vietnam. Although most studies used qualitative methods, data collection and sampling methods were heterogeneous. One study reported on service provider perspectives while the rest provided perspectives from a combination of service users and caregivers. Three themes emerged from the data analysis. First, studies frame recovery as a personal journey occurring along a continuum. Second, there was an emphasis on social relationships as a facilitator of recovery. Third, spirituality emerged as both a facilitator and an indicator of recovery. These themes were not mutually exclusive and some overlap exists.

CONCLUSION

Although there were commonalities with how high-income countries describe recovery, we also found differences in conceptualisation. These differences in how recovery was understood reflect the importance of framing the personal recovery concept in relation to local needs and contextual issues found in LMICs. This review highlighted the current sparse evidence base and the need to better understand recovery from SMI in LMICs.

Mobile device use among inpatients on a psychiatric unit: A preliminary study

Few studies have investigated barriers to mobile phone use for health purposes among patients with serious mental illness. In an inpatient psychiatric adult sample, we examined: (a) patterns and perceptions of mobile phone use and (b) the role of psychiatric diagnoses on mobile phone use for mental health purposes. Participants completed questionnaires after using a psychometrically validated scale to determine capacity for consent. Descriptive analyses revealed that most participants owned a smartphone (94%), data plan (94%), and frequently accessed the internet (75%). Only 27% used their mobile phones daily for health purposes and 47% had used their mobile phone to access their electronic medical record (EMR). Participants with psychotic disorders were significantly less likely to have mobile access to their EMR and expressed difficulty in using a mobile app for mental health purposes; whereas participants with depressive disorders expressed low interest in using their mobile devices to monitor their mental health. Adult psychiatric inpatients may have access to and be willing to use mobile phones for purposes related to mental health. However, key barriers may include frequency of mobile phone use for health purposes and lack of mobile access to the EMR, particularly among those with psychotic disorders.

Identifying profiles of need among psychiatric inpatients approaching discharge in New York City: a latent class analysis

PURPOSE

Understanding the needs of individuals transitioning to the community following a psychiatric hospitalization can inform community service planning. This study is among the first to examine the needs of a sample of psychiatric inpatients approaching discharge in a large urban area in the USA.

METHODS

Representative data were drawn from 1129 acutely hospitalized psychiatric inpatients from eight New York City hospitals. Descriptive statistics were used to estimate patient needs at discharge across nine domains: housing, employment, income, transportation, education, time use, social support, and help accessing medical and mental health care. Latent class analysis (LCA) was applied to identify subgroups of patients based on needs profiles. Multinomial logistic regression was used to investigate socio-demographic associations with class membership.

RESULTS

Respondents were most likely to have needs related to income (50.7%), housing (49.2%), and employment (48.7%). Results from the LCA suggested a five class solution of patient needs: three domain-specific classes whose members endorsed needs for 'housing and employment' (22.5%), 'social support and time use' (15.0%) and 'access to care' (6.4%) and two classes where overall member needs were high ('high needs,'18.4%) or low ('low needs,' 37.7%) across all needs. Compared to the 'low needs' class, members of the 'high needs' class had significantly greater odds of being black or Latino, male, uninsured, and parents of a child under 18 years.

CONCLUSION

Patients have unique profiles of need that are significantly associated with the socio-demographic characteristics. These findings may help practitioners and policymakers improve mental health services.

Sociodemographic and clinical characteristics of patients with recurrent psychiatric readmissions in Qatar

OBJECTIVE

To examine the sociodemographic and clinical characteristics of psychiatric patients with recurrent psychiatric readmissions (RPR).

METHODS

A retrospective study was conducted at Hamad General Hospital in Qatar on psychiatric patients with recurrent readmissions from August 2018 to January 2019.

RESULTS

Of 380 psychiatric patients admitted during the study period, 40 (10.5%) were readmitted within 30 days of discharge. Most of the patients who were readmitted were single, male and unemployed. Psychotic spectrum disorder was the most frequent psychiatric condition and was diagnosed in 18 (45%) patients. A total of 30% of the patients were receiving treatment with anti-psychotics, and a similar number received more than one medication. Most patients showed poor or no compliance. Only 12.5% of patients stayed in the hospital for more than 5 weeks in their last admission during the study period.

CONCLUSIONS

Poor compliance, male sex and single status were the most common demographic and clinical features of patients with RPR. Post-discharge psychiatric care should be tailored to meet the requirements of patients prone to RPR.

Predictors of civil and forensic inpatient psychiatric readmissions at a Public Mental Health Hospital

Inpatient psychiatric readmissions are increasingly prevalent and associated with worse prognostic outcomes and high economic costs, regardless of the medicolegal ramifications that necessitate them. Unlike most general medical readmissions, psychiatric readmissions are commonly warranted for both medical and legal purposes. However, studies focusing on analyzing the predictors of inpatient psychiatric readmission and their relationship to civil versus forensic readmission are limited. The purpose of this study was to examine the predictors of psychiatric readmission among civil and forensic patients admitted to a psychiatric hospital. In this retrospective chart review, we extrapolated data from medical records of 741 patients admitted from 2012 to 2017 with follow up until 2019. Analyses involved chi-square tests for comparing the distribution of demographic and clinical variables between forensic and civil readmission, and Cox regression to determine predictors of time to first readmission. Our results show that race, diagnosis, restraint/seclusion, type of admission, and disposition are significantly associated with an increased risk of psychiatric readmission. This study has important implications for healthcare providers and policy makers in revising mental health policies and improving systems-based practices for the mental health system. Future efforts in improving community psychiatric services and enhancing inpatient therapeutic environment may reduce psychiatric readmissions.

Factors associated with 30-days and 180-days psychiatric readmissions: A snapshot of a metropolitan area

Psychiatric re-hospitalization rate is a widely used quality indicator within mental health care. This study aims to investigate which variables are implied in determining readmissions over two intervals after the index event, 30 days and 6 months. The study sample included 798 inpatients, it was divided into two groups: not readmitted patients (NRP) and readmitted patients (RP), which has been further split into: Readmitted within 30 days (RP30dd) and Readmitted during the 150-day period (between 31 and 180 days) after the index discharge (RP150). A multivariate logistic regression with backward selection method was performed in order to find variables independently associated with readmission. The overall incidence of readmissions was 16.04%. Discharge to a Psychiatric Nursing Home was found to be a protective factor for all the groups. In adds, for the overall readmission, compulsory index admission and higher education (this lasts as in RP30dd group) were protective factors; whereas higher length of stay (as for readmission within 31-180 days) and a diagnosis of Personality Disorder were risk factors. The patient-specific factors significantly associated with likelihood of rehospitalization in the final model do identify some high-risk groups toward to whom possibly address prevention strategies.

Measures of Care Coordination at Inpatient Psychiatric Facilities and the Medicare 30-Day All-Cause Readmission Rate

OBJECTIVE

Since late 2012, the Medicare Inpatient Psychiatric Facility Quality Reporting (IPFQR) program of the Centers for Medicare and Medicaid Services (CMS) has required inpatient psychiatric facilities to collect and publicly report a suite of quality measures. This study explored the association between facility-level 30-day risk-adjusted all-cause readmission (medical or psychiatric) after psychiatric hospitalization (READM-30-IPF) and care coordination process measures in the IPFQR program.

METHODS

The study used publicly reported IPFQR facility-level performance data of the Hospital Compare Web site for 1,343 inpatient psychiatric facilities, reflecting performance from July 2015 to June 2017. The authors used a cross-sectional design and linear regression models controlling for hospital and community characteristics and using state as fixed effect.

RESULTS

The mean±SD facility-level READM-30-IPF was 20%±3%, with substantial variation by facility type, ownership status, rurality, and percentage of racial-ethnic minority residents in the county. Regression results showed that facilities with performance in the top tercile on the measure of 7-day mental health follow-up after discharge had readmission rates significantly lower than facilities in the bottom tercile (coefficient=-0.58, p<0.01), although the magnitude of this difference was small. READM-30-IPF, however, did not vary by facilities' performance on measures of discharge plan creation and transmission.

CONCLUSIONS

Results suggest that facilities have substantial opportunities to reduce readmissions after psychiatric hospitalization. The association between hospital performance on care coordination process measures and the all-cause readmission measure currently included in the IPFQR program was minimal. The CMS should evaluate whether the IPFQR measures adequately capture compliance with evidence-based processes and desired outcomes.

'If we would change things outside we wouldn't even need to go in…' supporting recovery via community-based actions: A focus group study on psychiatric rehospitalization

BACKGROUND

Psychiatric rehospitalization is a complex phenomenon in need of more person-centred approaches. The current paper aimed to explore how community-based actions and daily life influence mental health and rehospitalization.

DESIGN, SETTING AND PARTICIPANTS

The qualitative study included focus group data from six European countries including 59 participants. Data were thematically analysed following an inductive approach deriving themes and subthemes in relation to facilitators and barriers to mental health.

RESULTS

Barriers consisted of subthemes (financial difficulty, challenging family circumstances and stigma), and facilitators consisted of three subthemes (complementing services, signposting and recovery). The recovery subtheme consisted of a further five categories (family and friends, work and recreation, hope, using mental health experience and meaning).

DISCUSSION

Barriers to mental health largely related to social determinants of mental health, which may also have implications for psychiatric rehospitalization. Facilitators included community-based actions and aspects of daily life with ties to personal recovery. By articulating the value of these facilitators, we highlight benefits of a person-centred and recovery-focused approach also within the context of psychiatric rehospitalization.

CONCLUSIONS

This paper portrays how person-centred approaches and day-to-day community actions may impact psychiatric rehospitalization via barriers and facilitators, acknowledging the social determinants of mental health and personal recovery.

PATIENT OR PUBLIC CONTRIBUTION

The current study included participants with experience of psychiatric rehospitalization from six different European countries. Furthermore, transcripts were read by several of the focus group participants, and a service user representative participated in the entire research process in the original study.

Risk factors of hospitalization for any medical condition among patients with prior emergency department visits for mental health conditions

BACKGROUND

This longitudinal study identified risk factors for frequency of hospitalization among patients with any medical condition who had previously visited one of six Quebec (Canada) emergency departments (ED) at least once for mental health (MH) conditions as the primary diagnosis.

METHODS

Records of n = 11,367 patients were investigated using administrative databanks (2012-13/2014-15). Hospitalization rates in the 12 months after a first ED visit in 2014-15 were categorized as no hospitalizations (0 times), moderate hospitalizations (1-2 times), and frequent hospitalizations (3+ times). Based on the Andersen Behavioral Model, data on risk factors were gathered for the 2 years prior to the first visit in 2014-15, and were identified as predisposing, enabling or needs factors. They were tested using a hierarchical multinomial logistic regression according to the three groups of hospitalization rate.

RESULTS

Enabling factors accounted for the largest percentage of total variance explained in the study model, followed by needs and predisposing factors. Co-occurring mental disorders (MD)/substance-related disorders (SRD), alcohol-related disorders, depressive disorders, frequency of consultations with outpatient psychiatrists, prior ED visits for any medical condition and number of physicians consulted in specialized care, were risk factors for both moderate and frequent hospitalizations. Schizophrenia spectrum and other psychotic disorders, bipolar disorders, and age (except 12-17 years) were risk factors for moderate hospitalizations, while higher numbers (4+) of overall interventions in local community health service centers were a risk factor for frequent hospitalizations only. Patients with personality disorders, drug-related disorders, suicidal behaviors, and those who visited a psychiatric ED integrated with a general ED in a separate site, or who visited a general ED without psychiatric services were also less likely to be hospitalized. Less urgent and non-urgent illness acuity prevented moderate hospitalizations only.

CONCLUSIONS

Patients with severe and complex health conditions, and higher numbers of both prior outpatient psychiatrist consultations and ED visits for medical conditions had more moderate and frequent hospitalizations as compared with non-hospitalized patients. Patients at risk for frequent hospitalizations were more vulnerable overall and had important biopsychosocial problems. Improved primary care and integrated outpatient services may prevent post-ED hospitalization.

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.

Community Treatment Order Outcomes in Quebec: A Unique Jurisdiction

OBJECTIVE

We study compulsory community treatment orders (CTOs) for patients with severe and persistent mental illness (SPMI). Focusing on a unique jurisdiction in Canada that allows for long duration CTOs with strict enforcement procedures, our objectives are to determine whether extended duration CTOs are effective and to determine whether associated hospitalization costs are reduced.

METHOD

A mirror image, naturalistic design was employed using patients as their own controls to enhance external validity. No inclusive or exclusive criteria were employed for the 367 SPMI clinic patients who were studied over a 5-year period. Detailed documentation of the dates of all CTOs, long-acting antipsychotic injections (LAIs), emergency visits, hospitalizations, duration of hospitalizations, crimes and/or police involvement were collected. To study the relation between CTO and injection adherence, we use a mixed-effect linear regression model. To study the effect of injection adherence and hospitalization, we use survival analysis via Kaplan-Meier and Cox survival models.

RESULTS

CTO and non-CTO patients did not differ with respect to demographics, but CTO patients were significantly more severely ill. Following a CTO, adherence to LAIs increased over time (P < 0.001). The average time the patients spent in the community, that is, outside the hospital, was significantly longer under a CTO, and the duration of hospitalizations was decreased.

CONCLUSIONS

LAI adherence and outpatient office visits were enhanced by extended duration CTOs, as was time out of the hospital. The shorter duration of hospital stays implies cost savings. These must be weighed against their undesirable coercive nature.

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.

Discharge planning, self-management, and community support: Strategies to avoid psychiatric rehospitalisation from a service user perspective

OBJECTIVE

Psychiatric rehospitalisation is often seen as a negative outcome in terms of healthcare quality and cost, as well as potentially hindering the process of recovery. The purpose of our study was to explore psychiatric rehospitalisation from a service-user perspective, paying attention to how rehospitalisation can be avoided.

METHOD

Eight focus groups, including a total of 55 mental health service users, were conducted in six European countries (Austria, Finland, Italy, Norway, Romania, and Slovenia). The results were analysed using systematic text condensation.

RESULTS

All participants had been in touch with mental health services for at least one year, and had experienced more than one psychiatric hospitalisation. Participants emphasised the importance of discharge planning and psychoeducation both during and after the hospital stay, as well as the benefits of structured plans, coping strategies, self-monitoring techniques, and close contact with local community services.Social contacts and meaningful activities were also considered to be critical, as was support from peers and family members.

CONCLUSION

Efforts to avoid psychiatric rehospitalisation should include actions that support a functional day-to-day life, improve coping strategies, and build on cross-sectoral collaboration.

PRACTICE IMPLICATIONS

The study emphasises the need for psychoeducational and psychosocial interventions, starting already during the inpatient stay.

Short stay unit for patients in acute mental health crisis: A case-control study of readmission rates

INTRODUCTION

Past evaluations of psychiatric short stay units have shown positive outcomes for patients, yet very little is known about the factors related to readmissions.

METHODS

A Short Stay Pathway (SSP) has been introduced on the Gold Coast, Australia, for patients in acute mental health crisis with admissions of up to 3 days. Rates of readmissions within 28 days were compared for SSP patients (N = 678), and a diagnosis-matched control group of patients from acute mental health beds (N = 1356). Demographic and clinical factors were considered as predictors of subsequent readmissions.

RESULTS

Average length of stay for SSP patients was 3.4 days, compared to 7.6 days in the control group. 10.6% of SSP patients and 18.4% of the control group were readmitted within 28 days (P < .001). For both groups, a 7-day follow up significantly reduced readmissions (P < .05). Indigenous patients on SSP had higher odds of readmissions than non-Indigenous patients (P < .05), and a diagnosis of a personality disorder increased readmission in the control group but not the SSP group (P < .001).

DISCUSSION

SSP reduced repeated hospitalizations for patients in acute crisis by 42%. An identification of factors related to future admissions can inform future tailoring of this model of care to subgroups of patients.

Exploration of recovery of people living with severe mental illness (SMI) in low-income and middle-income countries (LMIC): a scoping review protocol

INTRODUCTION

The construct of recovery was conceptualised in high-income countries and its applicability in low-income and middle- income countries is underexplored. A scoping review is proposed to synthesise knowledge, review conceptual overlap and map key elements of recovery from severe mental illness in low-income and middle-income countries. We aim to appraise the literature so as to inform future recovery-oriented services that consider the cultural and contextual influences on recovery from severe mental illness.

METHODS AND ANALYSIS

The following electronic databases: MEDLINE via PubMed, SCOPUS (which included contents of Embase), PsycINFO, CINAHL, Africa-Wide Information, PsycARTICLES, Health source: Nursing/Academic Edition, Academic Search Premier and SocINDEX all via the EBSCOHOST platform, the Latin American and Caribbean Health Sciences Literature, the Cochrane Centre Register of Controlled Trials) and grey literature sources will be searched between May and December 2019. Eligible studies will be independently screened for inclusion and exclusion by two reviewers using a checklist developed for this purpose. Studies published between January 1993 and November 2019 that focus on recovery from severe mental illness in a low-income and middle-income country will be included. Findings will be compared and discrepancies will be discussed. Unresolved discrepancies will be referred to a third reviewer. All bibliographic data and study characteristics will be extracted and thematically analysed using a tool developed through an iterative process by the research team. Indicators will be classified according to a predefined conceptual framework and categorised and described using qualitative content analysis.

ETHICS AND DISSEMINATION

The review aims to synthesise information from available publications, hence it does not require ethical approval. The results will be disseminated through publications, conference presentations and future workshops with stakeholders involved within the recovery paradigm of mental health policy and practice. The scoping review title is registered with the Joanna Briggs Institute.

Clinical and organizational factors predicting readmission for mental health patients across Italy

PURPOSE

The aims of our study are: to explore rehospitalization in mental health services across Italian regions, Local Health Districts (LHDs), and hospitals; to examine the predictive power of different clinical and organizational factors.

METHODS

The data set included adult patients resident in Italy discharged from a general hospital episode with a main psychiatric diagnosis in 2012. Independent variables at the individual, hospital, LHD, and region levels were used. Outcome variables were individual-level readmission and LHD-level readmission rate to any hospital at 1-year follow-up. The association with readmission of each variable was assessed through both single- and multi-level logistic regression; descriptive statistics were provided to assess geographical variation. Relevance of contextual effects was investigated through a series of random-effects regressions without covariates.

RESULTS

The national 1-year readmission rate was 43.0%, with a cross-regional coefficient of variation of 6.28%. Predictors of readmission were: admission in the same LHD as residence, psychotic disorder, higher length of stay (LoS), higher rate of public beds in the LHD; protective factors were: young age, involuntary admission, and intermediate number of public healthcare staff at the LHD level. Contextual factors turned out to affect readmission only to a limited degree.

CONCLUSIONS

Homogeneity of readmission rates across regions, LHDs, hospitals, and groups of patients may be considered as a positive feature in terms of equity of the mental healthcare system. Our results highlight that readmission is mainly determined by individual-level factors. Future research is needed to better explore the relationship between readmission and LoS, discharge decision, and resource availability.

Clinical risk model to predict 28-day unplanned readmission via the accident and emergency department after discharge from acute psychiatric units for patients with psychotic spectrum disorders

BACKGROUND

Unplanned readmissions rates are an important indicator of the quality of care provided in a psychiatric unit. However, there is no validated risk model to predict this outcome in patients with psychotic spectrum disorders.

AIMS

This paper aims to establish a clinical risk prediction model to predict 28-day unplanned readmission via the accident and emergency department after discharge from acute psychiatric units for patients with psychotic spectrum disorders.

METHOD

Adult patients with psychotic spectrum disorders discharged within a 5-year period from all psychiatric units in Hong Kong were included in this study. Information on the socioeconomic background, past medical and psychiatric history, current discharge episode and Health of the Nation Outcome Scales (HoNOS) scores were used in a logistic regression to derive the risk model and the predictive variables. The sample was randomly split into two to derive (n = 10 219) and validate (n = 10 643) the model.

RESULTS

The rate of unplanned readmission was 7.09%. The risk factors for unplanned readmission include higher number of previous admissions, comorbid substance misuse, history of violence and a score of one or more in the discharge HoNOS overactivity or aggression item. Protective factors include older age, prescribing clozapine, living with family and relatives after discharge and imposition of conditional discharge. The model had moderate discriminative power with a c-statistic of 0.705 and 0.684 on the derivation and validation data-set.

CONCLUSIONS

The risk of readmission for each patient can be identified and adjustments in the treatment for those with a high risk may be implemented to prevent this undesirable outcome.

Core services of intensive case management for people with mental illness: A network analysis

BACKGROUND

In intensive case management (ICM), users receive a wide variety of services of varying content, which makes it difficult to understand the global features of ICM programs.

AIMS

The aim of this study was to examine the features of ICM programs using network analysis.

METHODS

A total of 233 ICM users in two Japanese medical institutions were recruited to participate. All received services were recorded for 2 months. In the network analysis, nodes represented types of ICM services and edges between two nodes depicted when over 5% of participants received both types of services.

RESULTS

We found high centrality values for 'H5. Hospital-based counseling', 'O13. Outreach support for mental health medications', 'H13. Hospital-based support for mental health medication', 'T5. Counseling via telecommunication', 'H3. Hospital-based coordination of services in the medical institution' and 'T2. Coordination of services with other institutions via telecommunication'. These results indicated that these services were associated with various other types of services. Social functioning was related to 'O13. Outreach support for mental health medication', whereas need for ICM was related to 'H13. Hospital-based support for mental health medications', 'T5. Counseling via telecommunication' and 'T2. Coordination of services with other institutions via telecommunication'.

CONCLUSION

Based on these findings, we speculated that there are at least five types of core services in ICM: regular face-to-face contact, outreach services, hospital-based services, easy contacts and coordination. These findings clarified the features of ICM programs, which may help improve the understanding of case managers' practice.

Using national electronic health care registries for comparing the risk of psychiatric re-hospitalisation in six European countries: Opportunities and limitations

Psychiatric re-hospitalisation rates have been of longstanding interest as health care quality metric for planners and policy makers, but are criticized for not being comparable across hospitals and countries due to measurement unclarities. The objectives of the present study were to explore the interoperability of national electronic routine health care registries of six European countries (Austria, Finland, Italy, Norway, Romania, Slovenia) and, by using variables found to be comparable, to calculate and compare re-hospitalisation rates and the associated risk factors. A "Methods Toolkit" was developed for exploring the interoperability of registry data and protocol led pilot studies were carried out. Problems encountered in this process are described. Using restricted but comparable data sets, up to twofold differences in psychiatric re-hospitalisation rates were found between countries for both a 30- and 365-day follow-up period. Cumulative incidence curves revealed noteworthy additional differences. Health system characteristics are discussed as potential causes for the differences. Multi-level logistic regression analyses showed that younger age and a diagnosis of schizophrenia/mania/bipolar disorder consistently increased the probability of psychiatric re-hospitalisation across countries. It is concluded that the advantage of having large unselected study populations of national electronic health care registries needs to be balanced against the considerable efforts to examine the interoperability of databases in cross-country comparisons.

Factors Associated with Rapid Readmission Among Nevada State Psychiatric Hospital Patients

Rapid readmission (RR) of psychiatric patients within 30 days of discharge places a costly burden on state psychiatric facilities and may indicate suboptimal service provisions. Information regarding variables associated with RR of psychiatric patients is limited, particularly in Nevada. This study attempts to identify factors associated with RR at a Nevada state psychiatric hospital. Participants included 7177 patients admitted between May 2012 and April 2014. Using logistic regression, all admissions were reviewed and rapid readmits compared to counterparts who were not readmitted within 30 days. Nevada suffers from budget cuts in mental health care spending because of recent economic crisis and severe lack of bed space. This study demonstrates that it may be possible to reduce rates of costly RR by focusing on those with a history of RR and modifiable factors including social and financial support, as well as reliable and stable housing.