Effect of COVID-19 pandemic on utilisation of community-based mental health care in North-East of Italy: A psychiatric case register study

AIMS

WHO declared that mental health care should be considered one essential health service to be maintained during the coronavirus disease 2019 (COVID-19) pandemic. This study aims to describe the effect of lockdown and restrictions due to the COVID-19 pandemic in Italy on mental health services' utilisation, by considering psychiatric diagnoses and type of mental health contacts.

METHODS

The study was conducted in the Verona catchment area, located in the Veneto region (northeastern Italy). For each patient, mental health contacts were grouped into: (1) outpatient care, (2) social and supportive interventions, (3) rehabilitation interventions, (4) multi-professional assessments, (5) day care. A 'difference in differences' approach was used: difference in the number of contacts between 2019 and 2020 on the weeks of lockdown and intermediate restrictions was compared with the same difference in weeks of no or reduced restrictions, and such difference was interpreted as the effect of restrictions. Both a global regression on all contacts and separate regressions for each type of service were performed and Incidence Rate Ratios (IRRs) were calculated.

RESULTS

In 2020, a significant reduction in the number of patients who had mental health contacts was found, both overall and for most of the patients' characteristics considered (except for people aged 18-24 years for foreign-born population and for those with a diagnosis of schizophrenia. Moreover, in 2020 mental health contacts had a reduction of 57 096 (-33.9%) with respect to 2019; such difference remained significant across the various type of contacts considered, with rehabilitation interventions and day care showing the greatest reduction. Negative Binomial regressions displayed a statistically significant effect of lockdown, but not of intermediate restrictions, in terms of reduction in the number of contacts. The lockdown period was responsible of a 32.7% reduction (IRR 0.673; p-value <0.001) in the overall number of contacts. All type of mental health contacts showed a reduction ascribable to the lockdown, except social and supportive interventions.

CONCLUSIONS

Despite the access to community mental health care during the pandemic was overall reduced, the mental health system in the Verona catchment area was able to maintain support for more vulnerable and severely ill patients, by providing continuity of care and day-by-day support through social and supportive interventions.

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.

The balance of adult mental health care: provision of core health versus other types of care in eight European countries

AIMS

Although many mental health care systems provide care interventions that are not related to direct health care, little is known about the interfaces between the latter and core health care. 'Core health care' refers to services whose explicit aim is direct clinical treatment which is usually provided by health professionals, i.e., physicians, nurses, psychologists. 'Other care' is typically provided by other staff and includes accommodation, training, promotion of independence, employment support and social skills. In such a definition, 'other care' does not necessarily mean being funded or governed differently. The aims of the study were: (1) using a standard classification system (Description and Evaluation of Services and Directories in Europe for Long Term Care, DESDE-LTC) to identify 'core health' and 'other care' services provided to adults with mental health problems; and (2) to investigate the balance of care by analysing the types and characteristics of core health and other care services.

METHODS

The study was conducted in eight selected local areas in eight European countries with different mental health systems. All publicly funded mental health services, regardless of the funding agency, for people over 18 years old were identified and coded. The availability, capacity and the workforce of the local mental health services were described using their functional main activity or 'Main Types of Care' (MTC) as the standard for international comparison, following the DESDE-LTC system.

RESULTS

In these European study areas, 822 MTCs were identified as providing core health care and 448 provided other types of care. Even though one-third of mental health services in the selected study areas provided interventions that were coded as 'other care', significant variation was found in the typology and characteristics of these services across the eight study areas.

CONCLUSIONS

The functional distinction between core health and other care overcomes the traditional division between 'health' and 'social' sectors based on governance and funding. The overall balance between core health and other care services varied significantly across the European sites. Mental health systems cannot be understood or planned without taking into account the availability and capacity of all services specifically available for this target population, including those outside the health sector.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of non-adherence to medication in patients with schizophrenia on health, social care and societal costs. Analysis of the QUATRO study

Aims. For people with schizophrenia, non-adherence to antipsychotic medications may result in high use of health and other services. The objective of our research was to examine the economic consequences of non-adherence in patients with schizophrenia taking antipsychotic medication. Methods. Data were taken from QUATRO, a randomized controlled trial that drew a sample of adults with schizophrenia receiving psychiatric services in four European cities: Amsterdam, Leipzig, London and Verona. Trial inclusion criteria were a clinical diagnosis of schizophrenia, requiring on-going antipsychotic medication for at least 1-year following baseline assessment, and exhibiting evidence of clinical instability in the year prior to baseline. The patient-completed Medication Adherence Questionnaire (MAQ) was used to calculate the 5-point Morisky index of adherence. Generalized linear models (GLM) were developed to determine the effect of adherence on (i) health and social care and (ii) societal costs before and after treatment, taking into account other potential cost-influencing factors. Results. The effect of non-adherence on costs was mixed. For different groups of services, and according to treatment group assignment, non-adherence was both negatively and positively associated with costs. Conclusions. The impact of non-adherence on costs varies across the types of services used by individuals with schizophrenia.

Mortality and cause of death among psychiatric patients: a 20-year case-register study in an area with a community-based system of care

BACKGROUND

Most mortality studies of psychiatric patients published to date have been conducted in hospital-based systems of care. This paper describes a study of the causes of death and associated risk factors among psychiatric patients who were followed up over a 20-year period in an area where psychiatric care is entirely provided by community-based psychiatric services.

METHOD

All subjects in contact with the South Verona Community-based Mental Health Service (CMHS) over a 20-year period with an ICD-10 psychiatric diagnosis were included. Of these 6956 patients, 938 died during the study period. Standardized mortality ratios (SMRs) and Poisson multiple regressions were used to assess the excess of mortality in the sample compared with the general population.

RESULTS

The overall SMR of the psychiatric patients was 1.88. Mortality was significantly high among out-patients [SMR 1.71, 95% confidence interval (CI) 1.6-1.8], and higher still following the first admission (SMR 2.61, 95% CI 2.4-2.9). The SMR for infectious diseases was higher among younger patients and extremely high in patients with diagnoses of drug addiction (216.40, 95% CI 142.5-328.6) and personality disorders (20.87, 95% CI 5.2-83.4).

CONCLUSIONS

This study found that psychiatric patients in contact with a CMHS have an almost twofold higher mortality rate than the general population. These findings demonstrate that, since the closure of long-stay psychiatric hospitals, the physical health care of people with mental health problems is often neglected and clearly requires greater attention by health-care policymakers, services and professionals.

Avoidable mortality of psychiatric patients in an area with a community-based system of mental health care

OBJECTIVE

To ascertain the existence of an excess of avoidable mortality among psychiatric patients in an area with a community-based system of care, to identify predictors of higher risk of avoidable mortality and to provide some possible indication to reduce avoidable mortality in modern psychiatric services.

METHOD

All patients with an ICD-10 psychiatric diagnosis, living in a catchment area of about 75,000 inhabitants, seeking care in 1982-2001 were included (n = 6956). Mortality and causes of death were ascertained using linkage procedures with other local health databases. Standardized mortality ratios (SMRs) were calculated for each avoidable cause of death.

RESULTS

The observed number of deaths for those causes considered avoidable by the European Community was four times greater than the expected (P < 0.01). SMR was higher for deaths preventable with adequate health promotion policies than for those preventable with appropriate health care. Males, alcohol/drug addicted and young patients have the highest avoidable SMRs.

CONCLUSION

These findings urgently call for the implementation of health promotion and preventive programs targeted to psychiatric patients. Moreover, mental health services should improve the capacity to manage medical health problems of their patients.

Which factors affect the costs of psychiatric residential care? Findings from the Italian PROGRES study

In the latest years, mental hospitals have gradually been replaced by a community-based network of facilities, including non-hospital residential facilities (RFs). Little information is still available about their costs. Our aims were to estimate the costs of Italian RFs and to evaluate which factors affect the cost of RFs and their patients.

METHOD

A representative sample of 265 Italian RFs, hosting 2962 patients, was selected for the study. RFs costs and costs of psychiatric, medical and informal care were estimated.

RESULTS

Patients in RFs cost between 7851 and 34 650 US$ per year; to this amount, it should be added from 2032 to 4702 US$ per year for the community psychiatric services (CPS). Significant differences were found by facility type, geographical areas, number of beds and age and diagnosis. About 45% of the variability for RF costs and 19% for CPS costs was explained by the regression models.

CONCLUSION

The results can be useful to inform service planning and resource allocation.

Evaluating a community-based mental health service focusing on severe mental illness. The Verona experience

OBJECTIVE

To describe the development of a community-based mental health service, the patterns of care provided by this new service established in 1978 and its costs.

METHOD

The South-Verona Psychiatric Case Register, the South-Verona Outcome Project and studies designed to assess costs provided process and outcome data.

RESULTS

This paper summarizes descriptive statistics as well as the results of some evaluative studies conducted over the last 25 years in Verona, Italy. It reports patterns of care provided over the years by this new, comprehensive community-based service, targeted to the severely mentally ill but available also to all other residents in the area who need mental health care.

CONCLUSION

Developing community-based mental health care requires a series of coordinated actions that need to be pursued over a long period of time. Service evaluation, including costs assessment, is an important part of this exercise.

Does socioeconomic status affect the use of community-based psychiatric services? A South Verona case register study

OBJECTIVE

To assess the effect of socioeconomic status (SES) on psychiatric service use in an Italian area with a well-developed community-based psychiatric service.

METHOD

An index of SES was calculated from nine census variables and grouped into four categories, ranging from SES-I-affluent to SES-IV-deprived, for each of 328 census blocks (CB). Fifteen indicators of psychiatric service use were collected using the psychiatric case register. All patients resident in the catchment area, who had at least one psychiatric contact in 1996 (n=989), were included in the study.

RESULTS

Indicators of in-patient, day-patient, out-patient and community service use showed an inverse association with SES. Only first-ever and long-term psychotic patients were equally distributed in the four SES groups.

CONCLUSION

The inverse association between SES and most indicators of psychiatric service use suggests that the planning of community-based services and resource allocation should take into account the SES of residents.

Off-label and non-classical prescriptions of antipsychotic agents in ordinary in-patient practice

OBJECTIVE

To estimate the proportion of off-label prescriptions of antipsychotics (APs) in ordinary in-patient practice.

METHOD

From the South-Verona Psychiatric Case Register all admissions to the in-patient unit during 2001-02 were extracted. Prescriptions of APs were defined off-label when dispensed outside the licensed indications. In addition, the proportion of "non-classical prescriptions" was calculated.

RESULTS

During the 2 years surveyed AP agents were prescribed in 311 cases. Nearly 50% of second-generation AP prescriptions were for an off-label indication. In contrast, <15% of first-generation AP prescriptions were for an off-label indication. About 30% of first- and second-generation agents were prescribed for a non-classical indication.

CONCLUSION

Approved labels for second-generation AP agents cover a much narrower range of indications than any of the first-generation agents, and this explains the higher proportion of off-label prescriptions. In contrast, the everyday use of first- and second-generation APs cover a similar range of clinical indications.

The effect of previous psychiatric history on the cost of care: a comparison of various regression models

OBJECTIVE

Many studies conducted in Europe have reported high variance of costs estimated at the individual level. The objectives of the present study were to estimate costs of patients and to evaluate the performance of various regression models.

METHOD

All patients who in the period 1992-1995 had at least one contact with the psychiatric services in South Verona were included in the study and were followed for 1 year after the index contact (n = 1725). Four different groups, classified on the basis of their previous services utilization, were analysed.

RESULTS

First-ever patients and patients with a new episode of care after 3 years were less costly than patients with an ongoing episode of care and patients having a new episode, after an interval between 3 months and 3 years.

CONCLUSION

The regression models allow us to predict cost for a patient with a given set of characteristics. Great care in the interpretation of the values of the individual coefficients should be taken in order to have a broader understanding of the expenditure dynamic.

Provision of services for people with schizophrenia in five European regions

BACKGROUND

An increasing diversity of public, voluntary sector and private providers offer services for the mentally ill in the ongoing process of psychiatric reform. Good service description is one important prerequisite for mental health service research. Aims 1) To describe service provision for the mentally ill in five European centres using the European Service Mapping Schedule (ESMS); and 2) to discuss the use of the instrument in describing service provision.

METHODS

All services providing care for people with severe mental illness in five European catchment areas (in Amsterdam, the Netherlands; Copenhagen, Denmark; London, UK; Santander, Spain; Verona, Italy) were identified through various sources. The identified services were classified, and service provision was quantified in accordance with the ESMS manual. Descriptive information was obtained.

RESULTS

We identified from 10 to 45 different services for catchment areas of between 50,000 (Copenhagen) and 560,000 (Santander) population run by three to 16 providers. They varied in aims, staffing and functioning. Hospital and non-hospital residential services, community-based services, and social support agencies were available in all sites. There was substantial variation across centres in the range, number and activities of services. Collecting comparable data sets on all service types, particularly for day and structured activity services and outpatient and community services required substantial effort.

CONCLUSION

Operationalised description of mental health services across Europe is possible but requires further refinement.

Accessibility and pathways to psychiatric care in a community-based mental health system

BACKGROUND

The careful analysis of pathways to specialist mental health care, within the context of community-based services, is important because it allows a detailed understanding of the inter-relationship between the component parts of the whole system of care. Moreover, it permits a comparison of service functioning to made over time, and is one way to operationalise the measurement of accessibility to services. The aims of this study are to describe: (i) the pathways followed by patients with new episodes of care to community-based mental health services, (ii) the time intervals from onset of the problem to first contact with services, and then to onward referral to specialist care (accessibility), and (iii) to explore the short-term costs associated with different pathways.

METHODS

Using data from the South-Verona Psychiatric Case Register, all new patients referred to any of the facilities which are part of the South-Verona Community Psychiatric Service (CPS) over a 6-month period (November 1999 - May 2000) were eligible to enter the study. Patients were interviewed by telephone using the Italian translation of the WHO Encounter Form. The costs of care provided in the 3 months following the index contact were assessed for all patients.

RESULTS

The most common route to mental health services is via a GP (40%), followed by a referral from a hospital doctor (26%) and self-referral (23%). The median interval from onset to direct contact with the South-Verona CPS (12 weeks) was shorter than the intervals from onset to direct contact with other service providers (the median interval for contact with GPs and hospital doctors was 24 weeks). The intervals varied considerably from 1 week (for attempted suicide), to 1.5 years (for disturbed behaviour). The results of backward regression modelling revealed a significant relationship between patients' characteristics and community costs or total psychiatric costs (44% and 53% of the variance explained respectively).

CONCLUSION

When the results are compared with a directly comparable earlier study in South-Verona, it is apparent that between 1991 and 1999 an increasing proportion of patients with insomnia and somatic disorders presented first to GPs, while a decreasing proportion of patients over the years sought care directly from specialist care. An increase in the role of local GPs as gatekeepers has, therefore, emerged. A prompt assessment by the South-Verona CPS of the patients' presenting problems was also confirmed, and this can be explained by the 'drop-in' approach at the Mental Health Centre, where patients can seek specialist care directly, without previously attending GPs. This method of measuring time intervals along pathways is proposed as a way to operationalise accessibility to services in future.

[For a more rational funding system of mental health services. Analyses of costs for services supplied by community mental health services during a 7-year period]

AIMS

In the last years, in Italy as well as in many other developed countries, there has been a growing interest for health economics by researchers. As for as the psychiatric care is concerned, more recently, many research's groups have pointed their attention on new possible funding systems for mental health services and on their effects on services' functioning. The aim of this study is to define a new list of services' costs based on services actually delivered by a Community Mental Health Service (CMHS).

METHODS

All psychiatric contacts recorded by the South-Verona Psychiatric Case Register during a 7-year period (1992-1998) have been included in the study (125,623 contacts made by 2,819 patients). Contacts were grouped into 19 type of services. The cost function methodology was used to describe, also reporting elasticity values, costs' behaviour in the South-Verona CMHS. The cost of each service includes expenses for professionals involved (directly or indirectly) in the contacts with the patients and capital costs.

RESULTS

For each service were reported a) the cost of the service as it is actually supplied in our CMHS, b) the cost per minute, c) an estimate of the cost of service delivered with standard modalities (duration equal to the mode value registered; staff composition take into account either the actual functioning of the CMHS either indication about a good clinical practice) and, finally, d) cost of the eight services included into the reimbursement system currently in use in Italy.

CONCLUSIONS

Our results showed that services' definition used in this study allow to describe different types of psychiatric care supplied from the South-Verona CMHS. The national list currently adopted for the reimbursement in Italy should allowed to describe only 28% of the registered psychiatric contacts (35,230 vs. 125,632). The urgent need for a new list of psychiatric services, accepted at a national level, was confirmed. Cost values obtained clearly show that the funding system currently used underestimates the true costs of care delivered by the CMHS. The cost function makes available a tool to test a prospective per-capita funding system as provided in the Act No. 229 of the Italian Government.

Client Socio-Demographic and Service Receipt Inventory--European Version: development of an instrument for international research. EPSILON Study 5. European Psychiatric Services: Inputs Linked to Outcome Domains and Needs

BACKGROUND

Cross-cultural comparison of mental health service utilisation and costs is complicated by the heterogeneity of service systems. For data to be locally meaningful yet internationally comparable, a carefully constructed approach to its collection is required.

AIMS

To develop a research method and instrument for the collection of data on the service utilisation and related characteristics of people with mental disorders, as the basis for calculating the costs of care.

METHOD

Various approaches to the collection of service use data and key stages of instrument development were identified in order to select the most appropriate methods.

RESULTS

Based on previous work, and following translation and cross-cultural validation, an instrument was developed: the Client Socio-Demographic and Service Receipt Inventory--European Version (CSSRI-EU). This was subsequently administered to 404 people with schizophrenia across five countries.

CONCLUSION

The CSSRI-EU provides a standardised yet adaptable method for collating service receipt and associated data alongside assessment of patient outcomes.

Community-based mental health care: to what extent are service costs associated with clinical, social and service history variables?

BACKGROUND

The growing movement in many European countries towards capitation-based systems for financing mental health care has generated increasing interest in developing appropriate models capitation formulae. The aims of the study were: to detect and compare any differences in service costs between patients with different diagnoses; and to analyse the associations between patient characteristics and service costs.

METHODS

All patients in contact with the South-Verona Community Mental Health Service during the last quarter of 1996 were included in the study. Clinical and service-related variables were collected at first index contact; 3 months later, patients were interviewed using the Client Services Recipient Interview. For those who completed both the clinical assessments and the services receipt schedule (N = 339), 1-year psychiatric and non-psychiatric direct care costs were calculated. Weighted backward regression analyses were performed.

RESULTS

The most significant variables associated with psychiatric costs were: admission to hospital in the previous year; intensity and duration of previous contacts with South-Verona CMHS; being unemployed; having a diagnosis of affective disorder; and, Global Assessment of Functioning score. The final model explained 66% of the variation in costs of psychiatric care and 13 % of variation in non-psychiatric medical costs.

CONCLUSIONS

The model presented in this study explains a higher degree of cost variance than previously published studies. In community-based services more resources are targeted towards the most disabled patients. Previous psychiatric history (number of admissions in the previous year and intensity of psychiatric contacts lifetime) is strongly associated with psychiatric costs.

Using health production functions to evaluate treatment effectiveness: an application to a community mental health service

The randomized controlled trial (RCT) is the recommended means of evaluating health care effectiveness and cost-effectiveness. Whilst representing a 'gold-standard' in health services research, RCT evidence on the clinical and economic desirability of services and treatments is often absent. Where RCT evidence is lacking, or where it is infeasible to implement randomized controlled comparisons, longitudinal observational and naturalistic data sources when analysed appropriately can yield useful insights regarding the clinical effectiveness and economic efficiency of treatments. In this paper we demonstrate the utility of applying panel estimation methods to data from an Italian psychiatric case register as a means of modelling the mental health outcomes of patients referred to a community-based mental health service. Emphasis is placed on quantifying the clinical effectiveness of consultations with different mental health professionals (including in-patient days) and whether service outcomes are affected by psychiatric diagnosis. The impact of service consultations and their interaction with different types of psychiatric diagnosis on a measure of patient mental health are found to be statistically significant, although the size of these effects are not substantial from a clinical perspective.

Collecting psychiatric resources utilisation data to calculate costs of care: a comparison between a service receipt interview and a case register

BACKGROUND

Economic assessment of interventions and policies is becoming increasingly common, in large measure because of the growing emphasis on cost containment within health care. Comprehensive and reliable outcome and cost data are required to advise policy makers and clinicians as to the best use of their limited resources. The process of costing can be broken down into three connected tasks: the collection of service receipt or utilisation data relative to individual clients or patients over a defined period; the costing of each of the services used; and the combination of these two sets of information in order to calculate individual costs. The aim of this study was to compare two methodologies of collecting data on individual service use - a customized interview schedule, ICAP, and the psychiatric case register (PCR) - and to calculate costs, testing the extent of agreement between them.

METHOD

The agreement between the ICAP and the PCR costs measurement was evaluated using the concordance correlation coefficient rho(c). From all patients (n = 543) who had at least one contact with a psychiatrist or a psychologist during the period October-December 1996, 339 patients were interviewed using the ICAP. The overall number of patients in contact with the South-Verona CPS in the same period was 630.

RESULTS

The agreement between the two sources was very different for each diagnostic group and each professional category. However, the overall agreement on total costs was satisfactory (rho(c) < 0.95). This result is probably due to the effect of the good agreement observed on more costly services: inpatient care and sheltered accommodation.

CONCLUSION

The results suggested practical implications for the use of the service receipt interview: interviewers should be trained in order to avoid misinterpretation of the definitions given in the form; the sources of information should be clearly defined to tease out all the items of services provided for the users; the professionals (i.e. psychiatrists) could influence the reliability of data collection by underestimating services provided by different professionals (nurses, social workers, etc.). The findings confirm that it is possible to use this approach when the aim is to estimate the whole cost of the services; however, the importance of adopting adequate procedures for analysing the complexity of cost components should be pointed out. Only a trained interviewer who thoroughly knows each component of the health and social services provided could guarantee an accurate data collection.

The costs of community-based psychiatric care for first-ever patients. A case register study

BACKGROUND

Analysing costs measures in conjunction with psychiatric case register (PCR) data can provide important epidemiologically-based information on resource utilization. Costing the service use patterns of first-ever patients can indicate the shape and likely resource consequences for mental health services operating within a community-based system of care.

METHODS

Yearly costs were calculated for the 299 first-ever patients and 768 longer-term patients who contacted the South-Verona Psychiatric Case Register between 1 January 1992 and 31 December 1993. Bivariate and multivariate analyses were used to compare costs between these groups and to test the associations between costs and the sociodemographic and diagnostic data recorded on the PCR.

RESULTS

For all diagnostic groups identified, first-ever patients were found to be less costly to support than longer-term patients, even after adjustment for various factors, including whether patients were single consulters. When multivariate analyses were employed, between 20% and 69% of the cost variation for first-ever patients could be explained by patient and other characteristics, and the effect of the contact (first or subsequent) variable was reduced.

CONCLUSION

This study considered only the costs to the specialist psychiatric services but the methodology allows the likely annual resource implications of supporting new patients to be predicted from data collected at first contact. Such information can help ensure that services are adequately funded and that the resources are deployed appropriately between client groups.

Frequency of contact with community-based psychiatric services and the lunar cycle: a 10-year case-register study

The relationship between the lunar cycle and the frequency of contact with community-based psychiatric services was assessed using the South Verona Psychiatric Case Register data. For each day of the study period (January 1982-December 1991) we recorded the number of contacts made by South Verona residents with psychiatric services and the corresponding day of the lunar cycle. First, the synodic month was divided into four interval phases (usually called new moon, first quarter, full moon and third quarter), and interphase differences in the mean number of contacts were tested using one-way analysis of variance. Second. the null hypothesis of no relationship between the lunar cycle and the frequency of contact with psychiatric services was tested against the alternative hypothesis of a sinusoidal distribution according to the lunar phase. The average number of contacts with psychiatric services on each day of the lunar cycle over the 10-year period was obtained and a sine-wave curve was fitted to the data. Both for total and drop-in contacts, no significant differences in mean number of contacts were found between the four interval phases of the synodic month (new moon, first quarter, full moon and third quarter). Similarly, no significant results were found by setting the expected surge in consultations at 1-3 days after the full moon and the period of the sine-wave curve equal to 30 days. When the period of the sine-wave curve was allowed to vary in order to fit the data best, none of the statistical tests reached the level of significance required to dismiss the possibility of false-positive results. These findings did not support the theory that a relationship exists between the lunar cycle and the frequency of contact with community-based psychiatric services.

The use of a case register to evaluate the costs of psychiatric care

The aim of this study was to show the usefulness of adding cost information to a routine data collection provided by a case register for analysing the association between patients' characteristics and the direct costs of the psychiatric care actually provided. All patients (n = 706) who in 1992 had at least one contact with services which report to the South Verona psychiatric case register and who received an ICD-10 diagnosis were included in the study. The costs of specialist psychiatric care provided during the 365 days following the first contact in 1992 were calculated using a unit cost list. A bespoke software, linked to the case register, was designed to produce the individual information on costs directly. For each patient, costs were categorized as in-patient costs, sheltered accommodation costs, day-care costs, out-patient costs and community costs. All costs, grouped by service type, were found to differ significantly (P < 0.01) between diagnostic groups (affective disorders, neurotic and somatoform disorders, schizophrenia and related disorders, and other diagnoses). The multivariate analyses showed that costs are significantly higher for patients with a diagnosis of schizophrenia and related disorders than for patients belonging to the other diagnostic groups. However, only 6% of the variation could be explained by diagnostic group alone. On the other hand, between 40 and 50% of the costs of mental health care was predicted by patients' personal characteristics and other measures recorded on the case register. The results of the present study show that, where service use is monitored regularly, the base from which decisions on community provision and placement are made can be informed by careful analysis of routinely or easily available data on direct costs.

Psychiatric case registers for monitoring service utilisation and evaluating its costs

Psychiatric case registers are systematic health information systems of a geographically delimited area that record the contacts with designated medical and social services of patients or clients from the area. The information is stored in a linked and cumulative file so that the care of any individual or group can be followed over time, no matter how complex the pattern of service attendance (Wing, 1989). They represent the evolution of older systems for recording data of clinical relevance, such asdisease registersto which hospitals and physicians used to report all cases of a certain diagnosis andhospital-based registers, which in general are based on aggregate data concerning patients who received care by a particular hospital or clinic (Häfner & an der Heiden, 1986).

Bennett & Trute (1983) pointed out that the term “information” has substantially wider connotations than the term “data”. In order to become “information”, data have to be placed within a framework and interpreted. This is true for all medical information systems, including those that collect limited data set, such as those about births, deaths, admissions to hospital, etc. (Wing, 1986).

A WHO Working Group held in Mannheim provided an agreed definition of a Psychiatric Case Register (PCR) which resulted in the following: “a Psychiatric Case Register is a patient-centered longitudinal record of contacts with a defined set of psychiatric services, originating from a defined population” (WHO, 1983).

Mortality among patients with psychiatric illness. A ten-year case register study in an area with a community-based system of care

BACKGROUND

Most studies which showed an excess mortality in psychiatric patients have been conducted on hospitalised samples.

METHOD

This was a case register study. All South Verona patients with an ICD diagnosis who had psychiatric contacts with specialist services in 1982-1991 were included. Mortality was studied in relation to sex, age, diagnosis, pattern of care and interval from registration. Standardised Mortality Rates (SMRs) and Poisson regression analysis were calculated.

RESULTS

The overall SMR was 1.63 (95% Cl = 1.5-1.8), which is the lowest value reported so far. Mortality was higher among men (SMR = 2.24; 95% Cl = 1.9-2.6), among patients who were admitted to hospital (SMR = 2.23; 95% Cl = 1.9-2.6), among younger age groups (SMR = 8.82; 95% Cl = 4.9-14.6) and in the first year after registration (SMR = 2.32; 95% CL = 1.8-2.9). Higher mortality was found in patients with a diagnosis of alcohol and drug dependence (SMR = 3.87; 95% Cl = 3.0-4.9). The SMR for suicide was 17.41. Using a Poisson regression model, diagnosis, pattern of care and interval from registration were all found to be significantly associated with mortality. When all these variables were entered together in the model, each maintained its predictive role.

CONCLUSIONS

The overall mortality of psychiatric patients treated in a community-based system of care was higher than expected, but lower than the mortality reported in other psychiatric settings. The highest mortality risk was found in the first year after registration.

Affective and neurotic disorders in community-based services: a comparative study in south Verona and south Manchester

The service utilization by patients with affective and neurotic disorders in two defined populations of south Verona in Italy and south Manchester in England was compared. The composition and function of the two community-based psychiatric services, and the sociodemographic characteristics of the two centers are described and related to epidemiologically based data on service use in the community, outpatient clinic, day hospital and inpatient care. The results suggest that close liaison with primary care in south Manchester results in more referrals, and therefore higher treated incidence and prevalence rates. The close integration between hospital and community staff in south Verona is associated with greater permeability of the filter between inpatient and community care, indicated by higher admission rates for patients known to the service, and shorter length of inpatient stay (only for affective disorders) in south Verona compared with south Manchester.

A comparison of community-based care for schizophrenia in south Verona and south Manchester

BACKGROUND

The community-oriented mental illness services providing care to defined populations in south Verona, Italy (17,628 adults) and south Manchester, England (12,021 adults) have been compared to explore relationships between service organisation and patterns of service use.

METHOD

The composition and function of the two services and the sociodemographic characteristics of the two centres are described and related to epidemiological data on service use in the community, out-patient clinic, day hospital and in-patient care.

RESULTS

Treated incidence of all psychiatric diagnoses and of schizophrenia were significantly higher in south Manchester than south Verona, indicating that the referral filter between primary and secondary care is more permeable in Manchester. Patients known to the service were more likely to be admitted and to have shorter in-patient stays in south Verona, indicating that the filter between in-patient care and the community is more permeable in Verona than Manchester.

CONCLUSIONS

The organisation of services in Verona results in a smaller load on the mental health service; the shorter hospital stays can be related to better integration between hospital and community resources. The organisation of services in Manchester provides care for a greater proportion of the population, but would be likely to require increased resources for the mental health services over time.

[Systolic time intervals at rest in subjects under prolonged stress: a computerized analysis]

Systolic time intervals were measured in 21 endurance-athletes (middle and lung distance runners) with a computerized method. Data from athletes were compared with that obtained in 27 age-matched normal untrained subjects. Endurance athletes showed significantly inferior values than normal untrained subjects of heart rate, total ejection time (TET), rapid ejection time (TER), electromechanical systole duration (QS2). Authors suggest that these results, particularly the reduction of TER at rest, could be due to a more rapid ejection rate primary or secondary to a left ventricular after-load reduction, following the cardiovascular adaptations induced by training in these athletes.