Effects of health care cost-containment programs on patterns of care and readmissions among children and adolescents

Perspectives of Parents and Providers on Reasons for Mental Health Readmissions: A Content Analysis Study

Pediatric hospitalizations for mental health conditions are rapidly increasing, with readmission rates for mental health conditions surpassing those for non-mental health conditions. The objective of this study was to identify reasons for pediatric mental health readmissions from the perspectives of parents and providers. We performed a retrospective content analysis of surveys administered to parents and providers of patients with a 14-day readmission to an inpatient pediatric psychiatry unit between 5/2017 and 8/2018. Open-ended survey items assessed parent and provider perceptions of readmission reasons. We used deductive coding to categorize survey responses into an a priori coding scheme based on prior research. We used inductive coding to identify and categorize responses that did not fit into the a priori coding scheme. All data were recoded using the revised schema and reliability of the coding process was assessed using kappa statistics and consensus building. We had completed survey responses from 89 (64%) of 138 readmission encounters (56 parent surveys; 61 provider surveys). The top three readmission reasons that we identified from parent responses were: discordant inpatient stay expectations with providers (41%), discharge hesitancy (34%), and treatment plan failure (13%). Among providers, the top readmission reasons that we identified were: access to outpatient care (30%), treatment adherence (13%), and a challenging home (11%) and social environment (11%). We identified inpatient stay expectations, discharge hesitancy, and suboptimal access to outpatient care as the most prominent reasons for mental health readmissions, which provide targets for future quality improvement efforts.

Longitudinal examination of youth readmission to mental health inpatient units

OBJECTIVE

Significant barriers exist for youth in obtaining mental health services. These barriers are exacerbated by growing demand, attributed partially to children and adolescents who have repeat hospital admissions. The purpose of this study was to identify demographic, socioeconomic and clinical predictors of readmission to inpatient psychiatric services in New Brunswick, Canada.

METHOD

Key demographic, support and clinical predictors of readmission were identified. The New Brunswick Discharge Abstract Database (DAD) was used to compile a cohort of all children and adolescents ages 3-19 years with psychiatric hospital admissions between 1 April 2003 and 31 March 2014 (N = 3825). Primary analyses consisted of Kaplan-Meier survival methods with log-rank tests to assess time-to-readmission variability, and Cox regression to identify significant predictors of readmission.

RESULTS

In total, 27.8% of admitted children and adolescents experienced at least one readmission within the 10-year period, with 57.3% readmitted to hospital within 90 days following discharge. Bivariate results indicated that male, upper-middle socioeconomic status (SES) youths aged 11-15 years from nonrural communities were most likely to be readmitted. Notable predictors of increased readmission likelihood were older age, being male, higher SES, referral to care by medical practitioner, discharge to another health facility, psychosis, and previous psychiatric admission.

CONCLUSION

A significant portion of the variance in readmission was accounted for by youth demographic characteristics (i.e. age, SES, geographic location) and various support structures, including referrals to inpatient care and aftercare support services.

KEY PRACTITIONER MESSAGE

Readmission to inpatient psychiatric care among youth is affected by a number of multifaceted risk factors across individual, environmental and clinical domains. This study used provincial population-scale longitudinal administrative data to demonstrate the influence of various individual and demographic factors on likelihood of readmission, which is notably absent from the majority of studies that make use of smaller, short-term data samples. Ensuring that multiple factors outside of the clinical context are considered when examining readmission among youth may contribute to a more thorough understanding of youth hospitalization patterns.

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.

Acute psychiatric care for pediatric patients

Higher level or acute psychiatric care for youth is intended to be active but short-term treatment focussing on crisis stabilisation, assessment, safety monitoring, and longer-term treatment planning. The focus of this article is on describing common challenges and the effort to address these challenges through new approaches to acute psychiatric care for children and adolescents. The review finds that (1) inpatient paediatric psychiatry beds are in high demand and often difficult to access, (2) there are a number of common challenges these units face including managing length of stays, readmissions, and adverse events, and (3) there are encouraging therapeutic approaches adapted for this setting. There is still much work to be done to advance the evidence-base for acute psychiatric care for youth particularly in defining and assessing an effective admission. Paediatric psychiatry patients are a vulnerable population and call for our best tools to be put to use to improve the quality and safety of care.

Factors Associated With Multiple Psychiatric Readmissions for Youth With Mood Disorders

OBJECTIVE

Inpatient psychiatric readmission rates are increasingly considered indicators of quality of care. This study builds upon prior research by examining patient-, hospital-, and community-level factors associated with single and multiple readmissions for youth.

METHOD

A retrospective cohort study was conducted using Medicaid claims data from four states supplemented with the American Hospital Association survey, the Area Resource File, and the National Survey of Mental Health Treatment Services. Multinomial logistic regression examined patient-, hospital-, and community-level factors that were associated with inpatient psychiatric readmission for 6,797 Medicaid-eligible youth with a primary diagnosis of mood disorder using a three-level nominal dependent variable coded as no readmission, one readmission, and two or more readmissions within 6 months after discharge.

RESULTS

Six months after initial discharge, 941 youth (13.8%) were readmitted once and 471 (6.9%) were readmitted two or more times. The odds of single or multiple readmissions were significantly higher (p < .05) for youth classified as disabled or in foster care, those with multiple psychiatric comorbidities, medical comorbidity, and prior psychiatric hospitalization. Treatment in hospitals with high percentage of Medicaid discharges and a high number of beds was associated with lower odds of readmission. There was a significant interaction between length of stay and outpatient mental health follow-up within 7 days of discharge.

CONCLUSION

Patient- and hospital-level factors are associated with likelihood of both single and multiple youth inpatient psychiatric readmissions, suggesting potential risk markers for psychiatric readmission.

Health Care Reform, Length of Stay, and Readmissions for Child Mental Health Hospitalizations

BACKGROUND

Health care reform may impact inpatient mental health services by increasing access and changing insurer incentives. We examined whether implementation of the 2014 Affordable Care Act (ACA) was associated with changes in psychiatric length of stay (LOS) and 30-day readmissions for pediatric patients.

METHODS

We conducted an interrupted time-series analysis to evaluate LOS and 30-day readmissions during the 30 months before and 24 months after ACA implementation, with a 6-month wash-out period, on patients aged 4 to 17 years who were discharged from the psychiatry unit of a children's hospital. Differences by payer (Medicaid versus non-Medicaid) were examined in moderated interrupted time series. Logistic regression was used to examine the association between psychiatric LOS and 30-day readmissions.

RESULTS

There were 1874 encounters in the pre-ACA period and 2186 encounters in the post-ACA period. Compared with pre-ACA implementation, post-ACA implementation was associated with LOS that was significantly decreasing over time (pre-ACA versus post-ACA slope difference: -0.10 days per encounter per month [95% confidence interval -0.17 to -0.02]; P = .01), especially for Medicaid-insured patients (pre-ACA versus post-ACA slope difference: -0.14 days per encounter per month [95% confidence interval -0.26 to -0.01]; P = .03). The overall proportion of 30-day readmissions increased significantly (pre-ACA 6%, post-ACA 10%; P < .05 for the difference). We found no association between LOS and 30-day readmissions.

CONCLUSIONS

ACA implementation was associated with a decline in psychiatric inpatient LOS over time, especially for those on Medicaid, and an increase in 30-day readmissions. LOS was not associated with 30-day inpatient readmissions. Further investigation to understand the drivers of these patterns is warranted.

Inpatient Psychiatric Care Outcomes for Adolescents: A Test of Clinical and Psychosocial Moderators

Financial pressures have led to a reduced length of stay (LOS) in inpatient psychiatric facilities for adolescents, yet research on the outcomes of short-term programs remains scant. The present study evaluated the outcomes of an adolescent inpatient program by: (1) probing depression, anxiety, and suicidal ideation at admission and discharge and (2) testing whether clinical or psychosocial factors moderate treatment response. Participants included adolescents (n = 777) aged 13-19 years admitted to an inpatient treatment program for acute psychiatric concerns. Clinical interviews were administered to probe mental disorders and past suicidal thoughts and behaviors (STBs), and self-report measures assessed symptom severity, child abuse, and peer victimization (i.e., bullying). Results showed a significant decrease in depression, anxiety, and suicidal ideation from admission to discharge. Comorbidity, past month NSSI, and lifetime suicide attempts emerged as moderators of treatment response, and peer victimization predicted symptom severity at discharge. Although findings suggest an overall improvement, participants with more severe clinical presentations (e.g., comorbidity, past month NSSI, lifetime suicide attempts, and more severe bullying) reported greater symptom severity at admission and discharge, suggesting that these patients may benefit from longer inpatient stays to achieve further symptom reduction. Although this may incur greater costs in the short-term, it also may prevent unintended economic and psychosocial consequences in the long-term.

Therapeutic Assessment With Child Inpatients

Growing evidence supports Therapeutic Assessment (TA), a collaborative and therapeutic approach to psychological assessment, as an effective method for enhancing motivation for and engagement with psychotherapy across a variety of clinical populations and treatment settings. However, to date there are no known studies assessing the use of TA in child psychiatric inpatient settings. This article briefly reviews the structure of child and family TA, enumerates the challenges and risks associated with short-term inpatient stays, and proposes a path for integrating TA into these units as a way to enhance the quality of care and reduce the risk of rapid rehospitalization. The authors provide three case examples from a child psychiatric inpatient unit, each using a modified version of TA and each integrating assessments into brief family interventions. The authors conclude with suggestions for best practice for child psychiatric inpatient TAs.

The Effect of Utilization Review on Emergency Department Operations

STUDY OBJECTIVE

Increasingly, hospitals are using utilization review software to reduce hospital admissions in an effort to contain costs. Such practices have the potential to increase the number of unsafe discharges, particularly in public safety-net hospitals. Utilization review software tools are not well studied with regard to their effect on emergency department (ED) operations. We study the effect of prospectively used admission decision support on ED operations.

METHODS

In 2012, Los Angeles County + University of Southern California Medical Center implemented prospective use of computerized admission criteria. After implementation, only ED patients meeting primary review (diagnosis-based criteria) or secondary review (medical necessity as determined by an on-site emergency physician) were assigned inpatient beds. Data were extracted from electronic medical records from September 2011 through December 2013. Outcomes included operational metrics, 30-day ED revisits, and 30-day admission rates. Excluding a 6-month implementation period, monthly summary metrics were compared pre- and postimplementation with nonparametric and negative binomial regression methods. All adult ED visits, excluding incarcerated and purely behavioral health visits, were analyzed. The primary outcomes were disposition rates. Secondary outcomes were 30-day ED revisits, 30-day admission rate among return visitors to the ED, and estimated cost.

RESULTS

Analysis of 245,662 ED encounters was performed. The inpatient admission rate decreased from 14.2% to 12.8%. Increases in discharge rate (82.4% to 83.4%) and ED observation unit utilization (2.5% to 3.4%) were found. Thirty-day revisits increased (20.4% to 24.4%), although the 30-day admission rate decreased (3.2% to 2.8%). Estimated cost savings totaled $193.17 per ED visit.

CONCLUSION

The prospective application of utilization review software in the ED led to a decrease in the admission rate. This was tempered by a concomitant increase in ED observation unit utilization and 30-day ED revisits. Cost savings suggest that resources should be redirected to the more highly affected ED and ED observation unit, although more work is needed to confirm the generalizability of these findings.

Does the Hospital Predict Readmission? A Multi-level Survival Analysis Approach

Time to psychiatric rehospitalization was predicted for a sample of 1473 Medicaid-insured youth in Illinois in 2005 and 2006. A multi-level model statistical strategy was employed to account for the fact that youth days to rehospitalization were nested within hospital and to test the hypothesis that hospitals would vary significantly in return rates, controlling for individual-level (e.g., symptom, demographic) variables. Hospitals did not vary significantly in days to rehospitalization. At the individual-level, level of externalizing behavior and residential treatment placement predicted a faster return to the hospital. These results support the perspective that hospital outcomes are best operationalized using variables tied more directly to the inpatient episode (e.g., LOS, reductions in acuity).

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

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

Predictors for readmission into children's inpatient mental health treatment

The goal of this study was to examine factors associated with time to first and subsequent readmissions of youth (N = 1,432) to one of Florida's residential mental health treatment programs, known as State Inpatient Psychiatric Program (SIPP). Results of multivariate Cox regression analysis indicated that greater maltreatment severity, shorter length of time spent in SIPP during the initial episode, and longer time to provision of targeted case management services were associated with earlier readmission. When time to subsequent readmission was examined, results of multivariate Cox regression analysis indicated that shorter length of stay during the second hospitalization and having more than one mental health diagnosis increased the odds of experiencing subsequent readmission. One consistent finding across initial and subsequent readmissions was that the timing of service provision but not the amount of services was crucial for preventing readmissions to inpatient residential programs.

Antipsychotic adherence patterns and health care utilization and costs among patients discharged after a schizophrenia-related hospitalization

BACKGROUND

This study aimed to assess antipsychotic adherence patterns and all-cause and schizophrenia-related health care utilization and costs sequentially during critical clinical periods (i.e., before and after schizophrenia-related hospitalization) among Medicaid-enrolled patients experiencing a schizophrenia-related hospitalization.

METHODS

All patients aged ≥ 18 years with a schizophrenia-related inpatient admission were identified from the MarketScan Medicaid database (2004-2008). Adherence (proportion of days covered [PDC]) to antipsychotics and schizophrenia-related and all-cause health care utilization and costs were assessed during preadmission (182- to 121-day, 120- to 61-day, and 60- to 0-day periods; overall, 6 months) and postdischarge periods (0- to 60-day, 61- to 120-day, 121- to 180-day, 181- to 240-day, 241- to 300-day, and 301- to 365-day periods; overall, 12 months). Health care utilization and costs (2010 US dollars) were compared between each adjacent 60-day follow-up period after discharge using univariate and multivariable regression analyses. No adjustment was made for multiplicity.

RESULTS

Of the 2,541 patients with schizophrenia (mean age: 41.2 years; 57% male; 59% black) who were identified, approximately 89% were "discharged to home self-care." Compared with the 60- to 0-day period before the index inpatient admission, greater mean adherence as measured by PDC was observed during the 0- to 60-day period immediately following discharge (0.46 vs. 0.78, respectively). The mean PDC during the overall 6-month preadmission period was lower than during the 6-month postdischarge period (0.53 vs. 0.69; P < 0.001). Compared with the 0- to 60-day postdischarge period, schizophrenia-related health care costs were significantly lower during the 61- to 120-day postdischarge period (mean: $2,708 vs. $2,102; P < 0.001); the primary cost drivers were rehospitalization (mean: $978 vs. $660; P < 0.001) and pharmacy (mean: $959 vs. $743; P < 0.001). Following the initial 60-day period, both all-cause and schizophrenia-related costs declined and remained stable for the remaining postdischarge periods (days 121-365).

CONCLUSIONS

Although long-term (e.g., 365-day) adherence measures are important, estimating adherence over shorter intervals may clarify the course of vulnerability to risk and enable clinicians to better design adherence/risk-related interventions. The greatest risk of rehospitalization and thus greater resource utilization were observed during the initial 60-day postdischarge period. Physicians should consider tailoring management and treatment strategies to help mitigate the economic and humanistic burden for patients with schizophrenia during this period.

Impact of length of stay after coronary bypass surgery on short-term readmission rate: an instrumental variable analysis

OBJECTIVE

: To determine the effect of postoperative length of stay (LOS) on 30-day readmission after coronary artery bypass surgery.

DATA SOURCES/STUDY SETTING

: We analyzed a final database consisting of Medicare claims of a cohort (N=157,070) of all fee-for-service beneficiaries undergoing bypass surgery during 2007-2008, the American Hospital Association annual survey file, and the rural urban commuting area file.

STUDY DESIGN

: We regressed the probability of 30-day readmission on postoperative LOS using (1) a (naive) logit model that controlled for observed patient and hospital covariates only; and (2) a residual inclusion instrumental variable (IV) logit model that further controlled for unobserved confounding. The IV was defined using a measure of the hospital's risk-adjusted LOS for patients admitted for gastrointestinal hemorrhage.

PRINCIPAL FINDINGS

: The naive logit model predicted that a 1-day reduction in median postoperative LOS (ie, from a median of 6-5 d) lowered the 30-day readmission rate by 2 percentage points. The IV model predicted that a 1-day reduction in median postoperative LOS increased 30-day readmission rate by 3 percentage points.

CONCLUSIONS

: The findings indicate that a reduction in postoperative LOS is associated with an increased risk for 30-day readmission among Medicare patients undergoing bypass surgery, after both observed and unobserved confounding effects are corrected.

Residential Care for Youth in the Child Welfare System: Stop-Gap Option or Not?

This study provides national estimates for length of stay in residential care and examines within-group variability along salient predictors. Using data from the National Study on Child and Adolescent Well-Being, the sample included 254 youth with episodes in residential care. Descriptive analyses provided estimates for length of stay over the three-year study period. Negative binomial regression was used to examine the effect of predictor variables on length of stay. Results indicate that a minority of youth experienced short stays in residential care. Chronic health problems and a greater number of placements were associated with longer stays. Implications for practice and research are discussed.

Examining Outcomes of Acute Psychiatric Hospitalization among Children

Within the past two decades, few studies have examined outcomes of acute psychiatric hospitalization among children, demonstrating change in emotional and behavioral functioning. A secondary analysis of pre-test/post-test data collected on 36 children was conducted, using the Target Symptom Rating (TSR). The TSR is a 13-item measure with two subscales - Emotional Problems and Behavioral Problems and was designed for evaluation of outcome among children and adolescents in acute inpatient psychiatric settings. Results of this study, its limitations, and the barriers encountered in the implementation of the TSR scale as part of routine clinical practice are discussed.

Post-discharge services and psychiatric rehospitalization among children and youth

This study examined risk and determinants of rehospitalization of children and adolescents (n = 186) following a first psychiatric hospitalization. It specifically examined the role of post-discharge services. Data were collected for a 30-month follow-up period through structured telephone interviews with caregivers and case record abstractions. 43% of youth experienced readmissions during the follow-up period. Risk of rehospitalization was highest during the first 30 days following discharge and remained elevated for 3 months. 72% of youth received 284 post-discharge services during the follow-up period, which significantly reduced the risk of rehospitalization. Longer first hospitalizations and a higher risk score at admission increased risk.

State-level child health system performance and the likelihood of readmission to children's hospitals

OBJECTIVES

To assess the relationship between children's hospital readmission and the performance of child health systems in the states in which hospitals are located.

STUDY DESIGN

We conducted a retrospective cohort study of 197,744 patients 2 to 18 years old from 39 children's hospitals located in 24 states in the United States in 2005. Subjects were observed for a year after discharge for readmission to the same hospital. The odds of readmission were modeled on the basis of patient-level characteristics and state child health system performance as ranked by the Commonwealth Fund.

RESULTS

A total of 1.8% of patients were readmitted within a week, 4.8% within a month, and 16.3% within 365 days. After adjustment for patient-level characteristics, the probability of readmission varied significantly between states (P=.001), and the likelihood of readmission during the ensuing year increased as the states' health system performance ranking improved. States in the best ranking quartile had a 2.03% higher readmission rate than states in the lowest quartile (P=.02); the same directional relationship was observed for readmission intervals from 1 to 365 days after discharge.

CONCLUSIONS

Hospital readmission rates are significantly related to the performance of the surrounding health care system.

Crisis discharges and readmission risk in acute psychiatric male inpatients

BACKGROUND

Severe pressures on beds in psychiatric services have led to the implementation of an early ("crisis") discharge policy in the Western Cape, South Africa. The study examined the effect of this policy and length of hospital stay (LOS) on readmission rates in one psychiatric hospital in South Africa.

METHODS

Discharge summaries of adult male patients (n = 438) admitted to Stikland Psychiatric Hospital during 2004 were retrospectively examined. Each patient's clinical course was then analysed for the period between January 1st, 2004, and August 31st, 2006.

RESULTS

Although shorter LOS was associated with decreased readmission rates, the effect of crisis discharges was far more powerful. Patients discharged as usual had a far lower risk of readmission than those discharged due to bed pressures (i.e. crisis discharge).

CONCLUSION

Increased risks associated with the early discharge policy necessitate the urgent review of the current management of bed shortages in this inpatient facility. The strengthening of community initiatives, particularly assertive outreach could be a way forward.

Evaluation of standardized teaching plans for hospitalized pediatric patients: a performance improvement project

Discharge teaching in a pediatric hospital setting is difficult because the situation involves multiple learners, time constraints, and differing skill levels of nurse teachers. Shortened length of stay forces nurses to complete patient education efficiently. Unstructured education can lead to failed learning, as evidenced by readmissions and postdischarge feedback. A performance improvement project was conducted to evaluate the effectiveness of standardized teaching plans for diabetes mellitus and infant cardiopulmonary resuscitation. Preliminary data indicated a passing score of at least 90% on posttests by all learners, suggesting that standardized teaching plans may help nurses complete prescribed discharge teaching.

Provider-level effects on psychiatric inpatient length of stay for youth with mental health and substance abuse disorders

OBJECTIVE

Previous research on inpatient care for children and adolescents with emotional or behavioral problems indicates that patient-level factors predict length of stay (LOS) poorly. This analysis examines whether patient-level factors are poor predictors of LOS, because LOS is primarily determined by facilities rather patients.

STUDY DESIGN

This study uses Tennessee Medicaid claims data from 1996 to 2001. The data include information on 14,162 observations related to 8400 patients (age 12-21) from 163 hospitals. We estimate log LOS using a cross-classified model. Covariates include admission-level characteristics (age, diagnosis, qualification for Medicaid, year), patient-level characteristics (gender, race), and facility characteristics (facility type).

PRINCIPLE FINDINGS

Our results suggest that variation in LOS is attributable to facility-level factors (51%), time-invariance patient-level factors (5%), factors that vary across admissions (42%), and a correlation between patient-level and facility-level factors (5%).

CONCLUSIONS

About half of the variation in LOS is explained by facility-level factors. Given the vulnerable nature of youth who are in need of inpatient psychiatric care, it may be particularly important to monitor provider-level processes and outcomes. Measuring facility or provider level quality is complicated because of difficulties in adjusting for case-mix severity across providers. The methodology presented here represents a general framework that can be widely used in health services research. Potential applications include broadening models of utilization to simultaneously include patient, provider, geographic and community level variations, as well as provider profiling.

The influence of clinical, treatment, and healthcare system characteristics on psychiatric readmission of adolescents

This study examined predictors of readmission for a sample of 522 adolescents enrolled in Medicaid and admitted to three inpatient psychiatric hospitals in Maryland. Comprehensive data on clinical, treatment, and health care system characteristics were collected from archival sources (medical records, Medicaid claims, and the Area Resource File). Predictors of readmission were examined with bivariate (Kaplan Meier) and multivariate (Cox Regression) survival techniques. One-year readmission rates were 38% with the majority occurring within 3 months after discharge. Adolescent demographic (age and gender), clinical (severity of symptoms, comorbidity, suicidality) and family characteristics (level of family risk) were associated with readmission. However, treatment factors including type of aftercare, postdischarge living environment, medication noncompliance, and hospital provider were among the strongest predictors of readmission. Study findings underscore the importance of careful discharge planning and linkage to appropriate aftercare. The differing rates of readmission across hospitals also suggest that organizational level factors may play a vital role in determining treatment outcomes.

Hospital length of stay for children and adolescents diagnosed with depression: is primary payer an influencing factor?

OBJECTIVE

This study aimed (a) to discern the distribution by primary payer (public vs. private) of U.S. patients aged 5-18 years who were hospitalized with a primary diagnosis of depression and (b) to discern the mean hospital length of stay and mean charge per day by payer type.

METHODS

The 2003 Healthcare Cost and Utilization Project Kids' Inpatient Database was used for this analysis. Depression was defined as International Classification of Diseases, 9th Revision, Clinical Modification codes 296.2-296.36, 300.4 or 311. Differences in hospital length of stay and mean cost per day by payer type were discerned via adjusted least square mean analysis (+/-S.E.).

RESULTS

The adjusted mean hospital length of stay was significantly higher (P<.0001) for patients with a public payer (6.6+/-0.05 days) versus a private payer (5.3+/-0.05 days). Although statistically significant (P<.0001), the adjusted mean charge per day differed little by payer type (public, US$1316.39+/-9.82; private, US$1357.51+/-9.07).

CONCLUSIONS

Further research is required to discern whether observed differences in hospital length of stay are the result of private payers enhancing patient care, thereby discharging patients in a more efficient manner, or the patients being discharged prematurely from the hospital due to constraints in reimbursement by private payers.

Increased rates of bipolar disorder diagnoses among U.S. child, adolescent, and adult inpatients, 1996-2004

BACKGROUND

Volatile, aggressive behavior is the chief complaint that brings children to inpatient psychiatric care. These difficulties are increasingly conceptualized as bipolar disorder (BD). The impact of doing so on clinical diagnoses in clinical care is uncertain.

METHODS

We extracted records from the annual National Hospital Discharge Survey (NHDS) for which a psychiatric diagnosis was primary and examined trends in the rates of hospitalization for BD.

RESULTS

Population-adjusted rates of hospital discharges of children with a primary diagnosis of BD increased linearly over survey years. The rate in 1996 was 1.3 per 10,000 U.S. children and climbed to 7.3 per 10,000 U.S. children in 2004. Bipolar disorder related discharges also increased fourfold among adolescents. Adults showed a more modest, though still marked, rise of 56%. Bipolar disorder related hospitalization was more prevalent among female adolescents and adults, while male children had larger risk than female children. Children's BD diagnoses tended not to specify a prevailing mood state, while depression and psychotic features were the most common codes for adults. Black individuals, especially men, had lower rates of BD diagnoses in early survey years, but more recently their rate of BD related hospitalizations has exceeded other NHDS race groups.

CONCLUSIONS

Higher rates of inpatient admissions among youth associated with BD may reflect greater appreciation of the importance of affective dysregulation in this patient group or "upcoding" to putatively more severe conditions for reimbursement or administrative reasons. Further study is warranted to examine this shift's causes and implications for treatments and outcomes.

Is readmission a valid indicator of the quality of inpatient psychiatric care?

Early return to hospital is a frequently measured outcome in mental health system performance monitoring yet its validity for evaluating quality of inpatient care is unclear. This study reviewed research conducted in the last decade on predictors of early readmission (within 30 to 90 days of discharge) to assess the association between this indicator and quality of inpatient psychiatric care. Only 13 studies met inclusion criteria. Results indicated that risk is greatest in the 30-day period immediately after discharge. There was modest support that attending to stability of clinical condition and preparing patients for discharge can protect against early readmission. A history of repeated admission increases risk, suggesting that special efforts are required to break the revolving door cycle. The authors identified a need for more standardization in measurement of client status at discharge and related care processes, more intervention studies on discharge practices, and studies of the effect of community care on early readmission.

What should non-US behavioral health systems learn from the USA?: US behavior health services trends in the 1980s and 1990s

Several countries, such as the USA, inadvertently created a different behavioral health payment system from the rest of medicine through the introduction of diagnostic-related group exemptions for psychiatric care. This led to isolation in the administration and delivery of care for patients with mental health and substance abuse disorders from other medical services with significant, yet unintended, consequences. To insure an efficient and effective health-care system, it is necessary to recognize the problems introduced by segregating behavioral health from the rest of medical care. In this review, the authors assess trends in behavioral health services during the last two decades in the USA, a period in which independently managed behavioral health care has dominated administrative practices. During this time, behavioral health has been an easy target for aggressive cost cutting measures. There have been no clinically significant improvements in the number of adults receiving minimally adequate treatment or in the percentage of the population with behavior health problems receiving psychiatric care with the possible exception of depression. While decreased spending for behavioral health services has been well documented during this period, these savings are offset by costs shifted to greater medical service use with a net increase in the total cost of health care. Targeting behavioral health for reduction in health-care spending through independent management, starting with diagnostic procedure code or diagnostic-related group exemption may not be the wisest approach in addressing the increasing fiscal burden that medical care is placing on the national economy.

The Effect of a Medicaid Managed Care Program on Patterns of Psychiatric Readmission Among Adolescents: Evidence from Maryland

This study evaluates the effect of Maryland's Medicaid managed care program on patterns of psychiatric readmission for adolescents. Rates and frequency of readmissions are compared before (FY 1997) and after (FY 1998) the implementation of Maryland's Medicaid managed care program. Medicaid claims files were reviewed for 881 adolescents consecutively admitted to three major Maryland psychiatric hospitals between July 1, 1996 and June 30, 1998. Adolescents admitted after the managed care reforms were more likely to experience multiple readmissions. The 1-year cumulative rate of readmission pre- and postmanaged care was 33% and 38%, respectively; the highest risk period fell within the first 15-30 days postdischarge. The high rate of early readmissions raises concern about the quality of care and the adequacy of community-based services. Findings also suggest that youths with serious emotional disturbances who are high users of inpatient care may be adversely affected by the managed care reforms.

A multi-site study of Medicaid-funded managed care versus fee-for-service plans' effects on mental health service utilization of children with severe emotional disturbance

Although Medicaid-funded managed care arrangements are commonly used in the delivery of mental health and substance abuse services to low-income children and youth, little is known about the effectiveness of such efforts. This article examines differences in mental health services utilization between children and youth with severe emotional disturbance covered by Medicaid-funded managed care behavioral health plans and those covered by fee-for-service plans. Data are from a federally funded multi-site study. In multivariate analyses controlling for child and caregiver demographic and clinical factors, enrollment in a managed care behavioral health plan was associated with lower inpatient/residential, psychiatric medication, and nontraditional services utilization. No difference was found in outpatient services utilization. Medicaid-funded managed care behavioral health plans appear to reduce use of some types of mental health services, but it is important to address the question of whether low-income children's enrollment in such programs deprives them of needed services.

A test of mental health parity: comparisons of outcomes of hospital concurrent utilization review

The Mental Health Parity Act of 1996 had as its goal the equity of coverage of mental health care and physical health care. The purpose of this study was to examine the outcomes of hospital concurrent utilization review as a measure of the progress toward the equity goal. The study examined 4 years of denials of certification for reimbursement by payers of inpatient care (1998-2001). Psychiatry was first compared to clinical services with a like number of annual admissions and then compared to clinical services with a like number of concurrent reviews. For each year, psychiatry had the highest numbers of cases denied and patient days denied. The most frequent reason for a psychiatric denial was that the inpatient benefit level had been exceeded. There was only one instance, in 4 years, when this reason (benefit limit exceeded) was given for a patient with a physical illness. This study provides evidence of the current inequity of reimbursement for treatment of mental illness.

Predictors of rehospitalization after total weight recovery in adolescents with anorexia nervosa

OBJECTIVE

The current study analyzed the variables related to rehospitalization after total weight recovery in adolescents with anorexia nervosa.

METHOD

One hundred and one patients first admitted for inpatient treatment, aged 11-19 years, were followed up for 12 months after discharge.

RESULTS

Twenty-five subjects (24.8%) required readmission after complete weight recovery and 76 (75.2%) did not. Duration of disorder, weight loss, body mass index at first admission, and global body image distortion were similar in the two groups. Patients needing readmission had a lower rate of weight gain (p < .001), a lower mean age (p = . 007), a higher mean score on the Eating Attitudes Test (EAT; p = .009), and a higher percentage of hips overestimation (p = .049). In a stepwise logistic regression analysis, these three variables predicted readmission and correctly classified 77.6% of patients. Taken as discrete variables, age younger than 15 years old, EAT score above 55, and a rate of weight gain lower than 150 grams per day were associated with a higher percentage of readmissions.

DISCUSSION

The variables most clearly related to readmission were young age, abnormal eating attitudes, and a low rate of weight gain.

Symptom, family, and service predictors of children's psychiatric rehospitalization within one year of discharge

OBJECTIVE

To investigate predictors of readmission to inpatient psychiatric treatment for children aged 5 to 12 discharged from acute-care hospitalization.

METHOD

One hundred nine children were followed for 1 year after discharge from inpatient care. Time to rehospitalization was the outcome of interest. Predictors of readmission, examined via the Cox proportional hazards model, were symptom and family factors assessed at admission, aspects of psychiatric treatment, and demographic variables.

RESULTS

The Kaplan-Meier rehospitalization risk within 1 year of discharge, taking into account known readmissions and censored observations, was 0.37. Most readmissions (81%) occurred within 90 days of discharge. Four variables contributed simultaneously to predicting readmission risk. More severe conduct problems, harsh parental discipline, and disengaged parent-child relations conferred a higher risk for rehospitalization; these risks were attenuated when parents disclosed higher stress in their parenting roles.

CONCLUSIONS

Findings showed that psychiatric rehospitalization of children is common, most likely in the trimester after discharge, and highly related to both child symptoms and family factors measurable at admission. Results suggest that efforts to improve postdischarge outcomes of children should target the initial period following inpatient care, address vigorously the complex treatment needs of those with severe conduct problems, and aim to improve parent-child relations.

Managing care: utilization review in action at two capitated medical groups

Despite widespread concern about denials of coverage by managed care organizations, little empirical information exists on the profile and outcomes of utilization review decisions. This study examines the outcomes of nearly a half-million coverage requests in two large medical groups that contract with health plans to deliver care and conduct utilization review. We found much higher denial rates than those previously reported. Denials were particularly common for emergency care and durable medical equipment. Retrospective requests were nearly four times more likely than prospective requests were to be denied, and when prospective requests were denied, it was more likely because the service fell outside the scope of covered benefits than because it was not medically necessary.

Medicaid behavioral health care plan satisfaction and children's service utilization

This study examines associations between caregivers' satisfaction with children's Medicaid-funded behavioral health care plans and the likelihood that children with severe emotional disturbance receive mental health services. Data are from a multisite study of managed care versus fee-for-service (FFS) settings. In multivariate logistic regression analyses controlling for demographic, environmental, site, and clinical characteristics, plan satisfaction was associated with greater likelihood of subsequent service use regardless of managed care versus FFS setting. Children in managed care plans were less likely to use intensive residential and non-traditional outpatient services. Efforts to increase plan satisfaction may encourage service use, consequently, improving children's behavioral health outcomes.

From physician to consumer: the effectiveness of strategies to manage health care utilization

Many strategies are commonly used to influence physician behavior in managed care organizations. This review examines the effectiveness of three mechanisms to influence physician behavior: financial incentives directed at providers or patients, policies/procedures for managing care, and the selection/education of both providers and patients. The authors reach three conclusions. First, all health care systems use financial incentives, but these mechanisms are shifting away from financial incentives directed at the physician to those directed at the consumer. Second, heavily procedural strategies such as utilization review and gatekeeping show some evidence of effectiveness but are highly unpopular due to their restrictions on physician and patient choice. Third, a future system built on consumer choice is contradicted by mechanisms that rely solely on narrow networks of providers or the education of physicians. If patients become the new locus of decision making in health care, provider-focused mechanisms to influence physician behavior will not disappear but are likely to decline in importance.

Utilization management: issues, effects, and future prospects

Utilization management encompasses a diverse set of activities designed to influence the use of health care services and thereby constrain health care resource consumption. Utilization management, which has become one of the most widely used cost-containment approaches, has engendered debate and controversy. Physicians have been outspoken critics of utilization management because it has limited their clinical autonomy and has contributed to an intolerable administrative burden. Insurance carriers, managed care plans, and third-party payers have defended the use of utilization management as an imperfect-but necessary-practice that is needed to reduce consumption of unnecessary or inappropriate health care services. This review examines the operation and effects of three widely used utilization management procedures: prospective utilization review, case management, and physician gatekeeping programs. In addition, it explores the future role of utilization management in the health care system and outlines a set of principles that we believe should be used to guide the development of utilization management strategies in the future.

Service system finance: implications for children with depression and manic depression

An estimated 6.2% of children in the United States satisfy the criteria for a depression diagnosis, but approximately half of this group do not receive necessary treatment. Thus it is important to consider potential barriers to use through service system finance. This article reviews three major types of changes affecting access: parity legislation, managed care, and public contracting. How these developments will affect children with depression and manic depression (DMD) is unclear. To better understand the potential effects on children with DMD, this review uses new data from the Medical Expenditure Panel Survey to describe the service use patterns of this population. These children have higher levels of expenditures, higher rates of inpatient use, and higher rates of Medicaid payment than do other children with mental health diagnoses; they also are overrepresented among the costliest cases of mental illness in children. Children with DMD pay a relatively low out-of-pocket share, suggesting that parity efforts focusing only on copayments and deductibles will have little effect on the absolute out-of-pocket burden for these children. Because children with DMD are overrepresented among high utilizers of health services, health care rationing arrangements or techniques, such as utilization review and capitation, may place this population at particular risk.

Changing patterns of inpatient care for children and adolescents at the Menninger Clinic, 1988-1994

The authors describe trends in inpatient psychiatric length of stay (LOS) and admissions for the population of children and adolescents (N = 784) at the Menninger Clinic from 1988 to 1994. During this period. median LOS declined dramatically from 7 months to 3 weeks, whereas admissions increased 4-fold. The diagnostic case mix changed substantially, with a crossover in modal principal diagnosis from personality disorder to affective disorder. Use of medications became almost universal. Diagnosis and medication use became less important determinants of LOS over time. The practical implications of these patterns include higher patient turnover, fewer inpatient clinical contact hours, and heightened importance of continuity with outpatient care. Research should center on the impact of declining LOS on clinical and functional outcomes for children and adolescents.

Changes in inpatient psychiatric utilization and quality of care performance measures in a capitated HMO population, 1989-1999

Managed behavioral health care approaches have significantly reduced inpatient utilization and related cost of care, but the relationship between decreased utilization and cost of care to changes in quality of care performance over time remains in question. The trends in utilization and quality of care performance measures over the course of 10 years of the Tufts Health Plan Designated Facility Program, a model health maintenance organization capitated program for inpatient behavioral health care, are presented. The results indicate that substantial decreases in inpatient utilization were sustained while quality of care measures improved over time. The data support the Tufts Health Plan Designated Facility Program as a successful means of balancing cost containment with quality of care.

The impact of utilization management on readmissions among patients with cardiovascular disease

OBJECTIVE

To determine if prospective utilization reviews that lead to reduced hospital length of stay (LOS) relative to days requested by an attending physician affect the likelihood of readmission for privately insured patients with cardiovascular disease.

DATA SOURCES

Data obtained from a private insurance company on utilization management decisions from 1989 through 1993. During this five-year period, 39,117 inpatient reviews were conducted, 4,326 (11.1 percent) on patients with cardiovascular disease. We selected for analysis all 4,326 reviews performed on patients with cardiovascular disease.

STUDY DESIGN

We used proportional hazard analysis (Cox regression) to investigate the relationship between LOS reductions relative to days requested by a patient's attending physician and the likelihood of readmission within 60 days of discharge. Separate analyses were performed for medical and procedural admissions.

PRINCIPAL FINDINGS

There were 2,813 requests for medical admission, and 1,513 requests for procedural admission. Requests for admission were rarely denied. Length of stay was reduced relative to that requested by the treating physician for 17 percent and 19 percent of medical and procedural admissions, respectively. Cumulative 60-day readmission rates were 9.5 percent for medical admissions and 12.3 percent for procedural admissions. We found no relationship between LOS reduction and the likelihood of readmission for medical admissions. However, patients admitted for procedures who had their length of stay reduced by two or more days were 2.6 times as likely to be readmitted within 60 days as those who had no reduction in their length of stay (95% CI: 1.3-5.1; p < .005).

CONCLUSIONS

Utilization management (UM) rarely denies requests for inpatient treatment of cardiovascular disease. The association between LOS reduction and the likelihood of readmission for patients admitted for cardiovascular procedures raises concern that UM may adversely affect clinical outcome for some patients. Further research is needed to definitively elucidate any relationship that might exist between utilization review decisions and quality of care.