Understanding geographic variations in psychiatric inpatient admission rates: width of the variations and associations with the supply of health and social care in France

Association of mental disorders with costs of somatic admissions in France

OBJECTIVES

Mentally ill patients have worse health outcomes when they suffer from somatic conditions compared to other patients. The objective of this study was to assess the association of mental illness with hospital inpatient costs for somatic reasons.

METHODS

All adult inpatient stays for somatic reasons in acute care hospitals between 2009 and 2013 were included using French exhaustive hospital discharge databases. Total inpatient costs were calculated from the all-payer perspective and compared in patients with and without a mental disorder. Only patients who had been admitted at least once for a mental disorder (either full-time or part-time) were considered to be mentally ill in this study. Generalized linear models with and without interaction terms studied the factors associated with hospital inpatient costs.

RESULTS

17,728,424 patients corresponding to 37,458,810 admissions were included. 1,163,972 patients (6.57%) were identified as having a mental illness. A previous full-time or part-time admission for a mental disorder significantly increased hospital inpatient costs (+32.64%, 95%CI=1.3243-1.3284). Interaction terms found an increased impact of mental disorders on costs in patients with low socio-economic status, as well as in men, patients aged between 45 and 60, and patients with a cardiovascular disease or diabetes.

CONCLUSION

Mentally ill patients have higher hospital costs than non-mentally ill patients. Improving curative and preventive treatments in those patients could improve their health and decrease the burden on healthcare systems.

Geographic variation in the utilisation of specialist healthcare for patients with severe mental illness in Norway: a population-based registry study

PURPOSE

The aim of this study is to measure geographic variations in mental healthcare service utilisation among patients with severe mental illness in Norway.

METHOD

We analysed data from the Norwegian patient registry for 2014-2018 for patients with severe mental illness. The outcomes measured in this study were: outpatient contact, admission, bed days and total contact rates. Total contacts were calculated as the sum of observed outpatient contacts plus four times the hospital bed days for each hospital catchment area based on the Norwegian health director's report on clinical activity and patient treatment cost. Geographic variations were measured using extreme quotient (EQ), coefficient of variation (CV) and systematic component of variation (SCV). Maps, figures, and tables were used to visualise geographic variation.

RESULTS

The geographic variations saw a six-fold increase in the outpatient contact rate and a three-fold increase in the admission rate between the areas with lowest rate and areas with the highest rate. However, there was low geographic variation in calculated total contact rates (Eqs. 5 - 95 =1.77). The low-level geographic variation in the total calculated contact rate was also confirmed with an SCV of less than three.

CONCLUSION

The levels of geographic variations in the utilisation of outpatient and inpatient mental healthcare services among patients with severe mental illness are high. However, the geographic variation in total services provided by hospital catchment areas calculating the two service modalities together using their treatment cost ratio, is low. This may reflect the relatively equal performance of hospital catchment areas in terms of resource utilisation regardless which service modality they prioritise. Factors contributing to high geographic variation in individual service modalities need further investigation.

Psychiatric advance directives facilitated by peer workers among people with mental illness: economic evaluation of a randomized controlled trial (DAiP study)

AIMS

We aimed to assess the cost-effectiveness of psychiatric advance directives (PAD) facilitated by peer workers (PW-PAD) in the management of patients with mental disorders in France.

METHODS

In a prospective multicentre randomized controlled trial, we randomly assigned adults with a Diagnostic and Statistical Manual of Mental Disorders, fifth edition diagnosis of schizophrenia, bipolar I disorder or schizoaffective disorders, who were compulsorily hospitalized in the past 12 months, to either fill out a PAD form and meet a peer worker for facilitation or receive usual care. We assessed differences in societal costs in euros (€) and quality-adjusted life-years (QALYs) over a year-long follow-up to estimate the incremental cost-effectiveness ratio of the PW-PAD strategy. We conducted multiple sensitivity analyses to assess the robustness of our results.

RESULTS

Among the 394 randomized participants, 196 were assigned to the PW-PAD group and 198 to the control group. Psychiatric inpatient costs were lower in the PW-PAD group than the control group (relative risk, -0.22; 95% confidence interval, [-0.33 to -0.11]; P < 0.001), and 1-year cumulative savings were obtained for the PW-PAD group (mean difference, -€4,286 [-4,711 to -4,020]). Twelve months after PW-PAD implementation, we observed improved health utilities (difference, 0.040 [0.003-0.077]; P = 0.032). Three deaths occurred. QALYs were higher in the PW-PAD group (difference, 0.045 [0.040-0.046]). In all sensitivity analyses, taking into account sampling uncertainty and unit variable variation, PW-PAD was likely to remain a cost-effective use of resources.

CONCLUSION

PW-PAD was strictly dominant, that is, less expensive and more effective compared with usual care for people living with mental illness.

Investigating geographical variation in the use of mental health services by area of England: a cross-sectional ecological study

BACKGROUND

There is evidence of geographical variation in the use of mental health services in the UK and in international settings. It is important to understand whether this variation reflects differences in the prevalence of mental disorders, or if there is evidence of variation related to other factors, such as population socioeconomic status and access to primary care services.

METHODS

This is a cross-sectional ecological study using Public Health England data. The unit of analysis was the population served by clinical commissioning groups (CCGs), National Health Service (NHS) catchment areas. The analysis explored associations between area characteristics and the number of people in contact with mental health services using regression modelling. Explanatory variables included age, gender, prevalence of severe mental illness (SMI), prevalence of common mental disorder (CMD), index of multiple deprivation (IMD), unemployment, proportion of the population who are Black and Minority Ethnic (BAME), population density, access to and recovery in primary care psychological therapies. Unadjusted results are reported, as well as estimates adjusted for age, prevalence of CMD and prevalence of SMI.

RESULTS

The populations of 194 CCGs were included, clustered within 62 trusts (NHS providers of mental health services). The number of people in contact with mental health services showed wide variation by area (range from 1131 to 5205 per 100,000 population). Unemployment (adjusted IRR 1.11; 95% CI 1.05 to 1.17; p < 0.001) and deprivation (adjusted IRR 1.02 95% CI 1.01 to 1.04; p < 0.001) were associated with more people being in contact with mental health services. Areas with a higher proportion of the population who are BAME (IRR 0.95 95% CI 0.92 to 0.99 p = 0.007) had lower service use per 100,000 population. There was no evidence for association with access to primary care psychological therapies.

CONCLUSIONS

There is substantial variation in the use of mental health services by area of England. Social factors including deprivation, unemployment and population ethnicity continued to be associated with the outcome after controlling for the prevalence of mental illness. This suggests that there are factors that influence the local population use of mental health services in addition to the prevalence of mental disorder.

Diet, Exercise, Lifestyle, and Mental Distress among Young and Mature Men and Women: A Repeated Cross-Sectional Study

Customization of mental health therapies needs to consider the differences in degree of brain maturity between young (18–29 years) and mature (30 years or older) adults as well as brain morphology among men and women. The aim of this study was to identify the significant dietary and lifestyle contributors to mental distress in these sub-populations. Independent repeated cross-sectional sampling was performed for over a 5-year period (2014–2019) to collect data from different populations at different time-points and seasons. A backward stepwise regression analysis was used on 2628 records. Mental distress in young women was associated with high consumption of caffeine and fast-food, and it was negatively correlated with moderate-high levels of exercise as well as frequent breakfast consumption. Mature women shared several common factors with young women; however, high fruit consumption was negatively associated with mental distress. For young men, high exercise, moderate consumption of dairy, and moderate-high intake of meat were negatively associated with mental distress. In addition, high fast-food and caffeine consumption were positively associated with mental distress in young men. For mature men, strong negative associations between higher education, moderate intake of nuts and mental distress surfaced. Our results support the need to customize dietary and lifestyle recommendations to improve mental wellbeing.

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.