Shifts in case mix and locus of mental health care for Washington State adults with severe mental illness

The author describes outcomes of interventions that were aimed at decreasing high use of state hospitals. Research focused on changes in state hospital case mix and dynamics of use by individuals identified as "high utilizers" before and after the Washington State Mental Health Division (MHD) implemented a series of interventions designed to reduce use. A set of recommendations are offered for policymakers who plan interventions that shift the locus of care for severely and persistently mentally ill adults.

Characteristics of assaultive psychiatric inpatients in an era of managed care

Prior to managed care, extensive research documented the characteristics of assaultive inpatients in traditional state mental hospital settings as primarily older, male, psychotic patients with histories of violence toward others and of substance abuse. Recent early studies in rural and urban hospital settings have suggested that the characteristics of assaultive patients may be changing to include younger, more frequently female, patients with personality disorders and histories of personal victimization. This two-points-in-time study sought to assess the nature of assaultive patients in a suburban traditional state mental hospital after the implementation of managed care initiatives, and compared to the nature of the assaultive patients before and after the downsizing of this state mental health facility. Before census reduction, the assaultive patients were of the traditional type. After census reduction, the assaultive patients reflected more recent trends. The implications of the findings are discussed, and strategies for fostering facility safety in light of the newer violent patient are outlined.

Factors associated with state hospital utilisation among Thai elderly who had illnesses which needed hospitalisation

Of the 4,480 elderly subjects in a multistage random sampling household survey of a National Survey of the Welfare of the Elderly in Thailand (SWET), 669 (14.9%) reported that they had been hospitalised during the last year and were recruited in an analysis which aimed to examine associated factors of state hospital utilisation among Thai elderly. Seventy eight per cent had been admitted once during the last year. Mean (standard deviation) duration of hospital stay during the last year was 11.9 (20.1) days. For the last period of hospitalisation, 532 elderly (79.5%) were admitted to state hospitals. One hundred and nineteen elderlies (17.8%) used private hospitals. Only 18 elderly (2.3%) used both state and private hospitals. According to the causes of hospitalisation, the elderly who used state hospitals were not more severely ill than those who used private hospitals. Nine univariate factors associated with state hospital utilisation were entered in a logistric regression model in which five independent determinants were identified including 'do not have electricity', 'heads of the family are not their children', 'do not have own savings', 'live in rural area', and 'have heard about free health care programme'. The Ministry of Public Health and organisations which are concerned with the elderly should allocate more resources to advertising a free health care programme for Thai elderly.

How septum deformations in newborns occur

The authors have examined the nasal septum in 273 newborns. Nasal septal deformations have been divided into anterior, posterior and anterior-posterior groups. Newborns have been divided into age groups within 12-h time sections. The incidence of nasal septal deviations in the group of newborns born by spontaneous labour has been compared with the incidence of nasal septal deviations in the group of newborns born by Caesarean section. A much more frequent occurrence of anterior nasal septal deviation has been found in children born by spontaneous labour. It testifies to the importance of birth injury, which leads to anterior nasal septal deformation. The incidence of nasal septal deviations in the particular 12-h age groups has been compared. It has been proved by means of linear and exponential regression that the septum is straightened spontaneously in its anterior section during the first 3 days of life. Therefore a decision about surgical intervention should be taken in the case of older newborns.

Prevalence of physical illness among psychiatric inpatients who die of natural causes

OBJECTIVE

The state psychiatric hospital is experiencing an increase in medically sick and aging patients who die of natural causes while hospitalized. This study explored the "medicalization" of the state hospital by examining the prevalence of medical illness and its relationship with psychiatric illness and age among state hospital psychiatric inpatients who died of natural causes--deaths that were not accidents, homicides, or suicides.

METHODS

A total of 179 inpatients who died of natural causes at Western State Hospital in Washington State between 1989 and 1994 were studied retrospectively through case file review. Their demographic and institutional characteristics and psychiatric diagnoses were compared with those of others treated at the hospital (N=9,258). The medical diagnoses of patients who died were analyzed by age and psychiatric condition.

RESULTS

The patients who died were much older than the other patients treated during the study period. Two-thirds of those who died had organic mental disorders, mostly dementia, whereas only a fifth of the other patients had these disorders. The patients who died had a mean of eight physical illnesses, with a range from none to 21. Circulatory and respiratory conditions were most prevalent, affecting half to two-thirds of patients; these conditions had high rates of comorbidity with organic mental disorders.

CONCLUSIONS

The characteristics of the state hospital population and the services provided are shifting in response to mental health reform and new policies on patient self-determination. Increased emphasis on medical care added to traditional psychiatric services will require increased financial and personnel resources.

Psychiatric hospital utilization in patients treated with clozapine for up to 4.5 years in a state mental health care system

OBJECTIVE

We wished to study long-term psychiatric hospital utilization in a large sample of patients with schizophrenia and/or schizoaffective disorders who were treated with clozapine for up to 4.5 years, and to determine whether or not the reduction in hospital utilization we previously observed in smaller groups for up to 2.5 years was sustained with larger groups and in the longer term.

METHOD

Patients in Texas state hospitals who had schizophrenia and/or schizoaffective disorder took either clozapine or traditional antipsychotics for 1.5 to 4.5 years. The number of patients in the clozapine group ranged from 383 (1.5 years of treatment) to 29 (4.5 years). The group of patients who took traditional antipsychotics was made up of all patients (N = 233) with similar diagnoses, symptom severity, and duration of illness present in Texas state hospitals on an index day.

RESULTS

The clozapine group showed a rapid and continuing decrease in hospital bed-days compared with controls who took traditional antipsychotics. The number of clozapine-treated patients who required little or no hospitalization during successive 6-month periods became significant (p < .0001) within 1.5 years, and continued to increase. Conversely, the number of patients taking clozapine who required virtually continuous state hospitalization decreased markedly compared with those taking traditional antipsychotics.

CONCLUSION

Potential hospital cost savings are substantial, even though overall group results are diluted by clozapine nonresponders. Most treatment costs for clozapine nonresponders were related to hospital care; most or all of such costs would have been present in any event had these patients remained on traditional antipsychotic therapy. We believe a trial of clozapine therapy provides a low-cost opportunity for a highly effective and highly cost-saving outcome in those patients who will favorably respond to this therapy. We discuss clinical, social, and economic advantages of modern pharmaceutical treatments over traditional drugs.

Predictors of psychiatric hospitalization: a multivariate analysis

Inpatient treatment continues to be the most expensive form of mental health service. This study sought to improve the methodological weaknesses, e.g., poor statistical controls, in the literature by using multivariate statistics to predict hospitalization. Results revealed that aftercare, i.e., outpatient treatment, is an important factor in reducing the utilization of inpatient resources, even when controlling for demographic and psychiatric history variables. Further, background characteristics, while easily measured, are not important predictors of hospitalization.

The use of state and general hospitals for inpatient psychiatric care

OBJECTIVES

This paper explores the relationship of state hospital and general hospital psychiatric caseloads in a statewide system of care.

METHODS

Probabilistic population estimation was applied to general hospital and state hospital data sets.

RESULTS

General hospitals provide inpatient psychiatric services to more people than do state hospitals, and a significant number are served in both sectors. There were notable differences in use patterns related to patient gender and age.

CONCLUSIONS

These results demonstrate that probabilistic methodologies can significantly enhance the value of existing databases for epidemiological research.

ECT in Texas: 19 months of mandatory reporting

BACKGROUND

Texas law requires that all non-federal clinical facilities providing electroconvulsive therapy (ECT) report every treatment to the state's mental health agency. The resulting data provide total population information about treating physicians and hospitals; payment source; patient age, sex, ethnicity, diagnosis, and admission/consent status; symptom severity and response; numbers and types of treatments; and untoward events occurring within 14 days after treatment.

METHOD

We reviewed all reports of ECT between September 1993 and April 1995 (2583 reports, approximately 15,240 treatments).

RESULTS

About 6% (N = 117) of Texas psychiatrists performed ECT during the period, at 50 hospitals. One of 13 state-funded mental institutions performed ECT on-site; some occasionally contracted with private hospitals. Almost all patients (88.1%) were white. Some older age groups received proportionately more ECT than younger groups, but no sharp increase was associated with eligibility for Medicare. Five patients were less than 18 years of age; 70.3% were female. Virtually all patients (99.0%) consented to the treatment themselves (rather than by guardian), including committed-but-consenting patients (1.5%). Reports (5.8%) described multiple-monitored treatment (MMECT, not depatterning). Group data indicated generally good-to-excellent response, as measured by a five-point symptom-severity scale. Eight patients died within 14 days of a treatment, 2 possibly of anesthesia complications and 3 others in accidents or by suicide. Four were receiving maintenance treatments (generally about every other week). No death appeared related to ECT stimulus or seizure.

CONCLUSION

ECT in Texas is performed by a small minority of psychiatrists and is unavailable to many patients who need it. It is most accessible to white patients who receive care outside the public sector. Our data support the common finding that ECT is generally safe and effective.

The new state mental hospitals in the community

OBJECTIVE

The study examined a 95-bed locked community facility (an institute for mental disease), one of 40 such facilities in California to which patients with increasingly difficult problems in management have been referred over the past few years as an alternative to more highly structured state hospitals. The purpose was to determine the characteristics of patients admitted to such facilities and assess whether the facilities are adequate for treating them.

METHODS

A hundred and one randomly selected patients in one institute for mental disease were studied by record review and by discussion of each case with staff.

RESULTS

The patients were characterized by psychotic diagnoses; the presence of psychotic symptoms even though they took antipsychotic medications in the facility; and histories of previous hospitalizations, serious violence against persons, poor medication compliance, and substance abuse. Ninety-nine percent had been admitted under psychiatric conservatorship. Forty-four percent had been violent toward persons during the current admission, and the level of bizarre, socially inappropriate behavior in the facility was high.

CONCLUSIONS

Despite a high-quality rehabilitation program, treating and rehabilitating difficult-to-manage patients normally treated in state hospitals in a facility that had a considerably lower degree of structure had become increasingly difficult and dangerous. The use of community alternatives to state hospitalization, which is often driven by lower costs and an ideology that highly structured care is seldom needed, is not suitable for all patients.

The moderating effects of race on return visits to the psychiatric emergency room

OBJECTIVE

Racial differences in variables that predict return to the psychiatric emergency room were examined.

METHODS

A random sample of 319 clients was obtained from the logs of a psychiatric emergency room of a state-operated, acute care psychiatric hospital. The dependent variable was a return visit to the psychiatric emergency room within 18 months of the index visit. Separate logistic regression equations were calculated for African Americans (N = 163) and Caucasians (N = 156) to estimate the moderating effects of race.

RESULTS

Four variables predicted return to the emergency room for both African Americans and Caucasians: previous visits to the psychiatric emergency room, previous psychiatric hospitalizations, current receipt of outpatient treatment, and nonreceipt of aftercare following the index visit to the emergency room. Three unique predictors were found for African Americans: never having been married, not living in stable housing, and not being admitted at the index visit.

CONCLUSIONS

Generally, repeat visitors from both racial groups tended to be chronic users of psychiatric services who may be using the psychiatric emergency room for routine psychiatric care. However, race was also an important moderator variable; several risk factors predicted a return visit only for African Americans.

Measuring nonmedical psychiatric treatment interventions with statistical software

This article addresses, from both research and political perspectives, the issue of quantifying data on nonmedical psychiatric treatment activity in large residential treatment settings. It presents a method of collecting this type of data that includes the use of readily available statistical software. It describes the methodology in detail and examines the variables. The system has had an impact on treatment, administration, and personnel at the facility.

Emergency commitment and legislative reform in New Jersey

The effects of a state commitment law that combines use of the dangerousness criterion, screening for less restrictive alternatives, and a new mental health structure were investigated. A time-series analysis of the number of commitments in a 12-year period at one screening center revealed that the expected outcome of the legislation--a decrease in state-hospital commitments--was not realized.

A retrospective study of determinants of length of stay in a geropsychiatric state hospital

This pilot study investigated the importance of social, clinical, and discharge factors in predicting extended length of stay (LOS) in a state geropsychiatric hospital. The authors reviewed medical records of all first time admissions during a 22 month period. A total of 272 patients age 60 and older were admitted for the first time during this period. Nine variables comprised of medical, demographic, social, and discharge information were examined in retrospective analysis to assess their relationship to LOS. The mean and standard deviation of days spent in hospital was 392.3 +/- 752.81. The median number of days of hospitalization was 72.0. Single marital status, type of living arrangement, polypharmacy, and limited functional status were predictive of LOS. Our findings underscore the challenge within geropsychiatry of treating patients with coexisting medical conditions who also have significant behavioral, mood, and/or cognitive disturbances.

Not guilty by reason of insanity of murder: clinical and neuropsychological characteristics

We examined archivally clinical status, neuropsychological functioning, and perpetrator-victim relationships of 28 adult patients who had committed homicide and had been subsequently involuntarily committed to a forensic hospital. We divided patients into two groups: (1) not guilty by reason of insanity (NGRI) acquittees (n = 13) and (2) convicted murderers (n = 15). In comparison with convicted murderers, NGRI acquittees were more likely to be seen as psychotic at the time of the index offense and also were more likely to have killed blood relatives, especially a parent. By contrast, convicted murderers were more likely to have killed a significant other, mainly a spouse or lover. At the time of the index offense, substance abuse was more likely to have occurred in the convicted murderers than in the NGRI acquittees. NGRI acquittees and convicted murderers did not differ on neuropsychological tests, with both groups generally scoring within normal limits on all tests. Taken together, these results suggested that NGRI murderers may be driven by acute psychosis directed toward blood relatives and occurring against a backdrop of relatively preserved neuropsychological functioning.

Old and new: a comparison of state psychiatric hospitals

The study examined whether state hospitals in operation before deinstitutionalization still carry vestiges of older models of psychiatric care. Using a national database, the authors compared 166 state hospitals built before 1949 with 80 state hospitals built after that time. The old hospitals treated fewer children and adolescents, received more state funding and less third-party funding, had fewer professional clinical staff, spent less on salaries and maintenance, and had more beds, a lower turnover rate, and a longer average length of stay. Findings suggest that planners and policymakers should take into account a facility's history when attempting to introduce innovations.

[Limb amputations carried out in hospitals of the national health service in the years from 1990 to 1993]

This study was to assess the number of limbs amputations in Portugal State Hospitals over a four years period (1990 to 1993), analysing their incidence according to etiology, sex, average age, duration of hospitalization, level of amputation and mortality rate. The authors emphasise the levels of amputation which are mot favourable for an effective rehabilitation.

Polydipsia and water intoxication in a long-term psychiatric hospital

This cross-sectional survey attempts to establish the prevalence of polydipsia and water intoxication at a state hospital (N = 360) using staff diagnosis, specific gravity of the urine (SPGU), weight changes, and chart review. There were 150 [42%, 95% confidence interval (CI) 37-47%] patients diagnosed as polydipsic by the staff or by SPGU. At least 93 (26%, CI 21-30%) had primary polydipsia not explained by other causes. Chart review identified 17 (5%, CI 3-7%) patients with a history of water intoxication. Using a case-control study design, schizophrenia, extended duration of hospitalization, and heavy smoking were associated with primary polydipsia in a logistic regression analysis (respective odds ratios were 1.6, 1.8, and 3.6). All patients with a history of water intoxication were Caucasian (versus 83% in those without a history) and had significantly more extended hospitalizations (94 vs. 49%). Future case-control studies should combine longitudinal identification of true cases and controls and exhaustive collections of clinical information in a standardized way.

Physician caseloads at public mental hospitals

OBJECTIVE

The purpose of the study was to gather baseline data on physician caseloads, particularly psychiatric caseloads, at public mental hospitals.

METHOD

A 26-item survey was sent to medical directors of public mental hospitals in the United States and its territories. Questions focused on hospital demographics, programs, and medical staffing. Survey data were analyzed and descriptive statistics were determined.

RESULTS

Of 295 surveys mailed, 195 (66%) usable surveys were returned. The hospitals had a mean bed capacity of 347 (SD=301, range=10-1,926), a mean current patient population of 321 (SD=277, range=7-1,815), and 950 mean annual admissions (SD=891, range=3-5,100). Acute care was the most common treatment program (81%), followed by long-term care (71%). A wide range of psychiatric caseloads by type of program existed, with approximately equal mean and median amounts.

CONCLUSIONS

The caseloads reported were, overall, reasonable and expected by the type of treatment program. The range of caseloads, however, included extremely high outliers that raise concerns about the quality of care delivered.

Hospital violence

The author discusses the problem of healthcare violence, including factors that contribute to it, how to identify high-risk individuals, the socioeconomic impact of assault injuries, violence associated with prisoners as patients, and psychiatric ward violence. He also provides an outline of emergency department security survey procedures, as well as guidelines for improving hospital security.

Responses within nonfederal hospitals in Pennsylvania to the Americans with Disabilities Act of 1990

BACKGROUND AND PURPOSE

This study described responses within nonfederal hospitals in Pennsylvania to the Americans With Disabilities Act of 1990 (ADA).

SUBJECTS

The target population consisted of all 277 nonfederal hospitals licensed by the Pennsylvania Department of Health and Department of Public Welfare.

METHODS

Questionnaires were mailed to the 270 chief administrators for the 277 hospitals.

RESULTS

One hundred seventeen questionnaires (43.3%) were returned. More facilities had trained their managers regarding the ADA versus their nonmanagerial employees. Overall, 80.3% of the hospitals had an ADA committee or coordinator. Fifty-four percent of the respondents reported that job accommodations cost less than $500. Approximately 45% of the participants cited that the percentage of new construction costs spent to increase accessibility in their hospitals was less than 4.9%. More complaints and legal matters were received by facilities regarding the employment provisions of the ADA rather than the accessibility provisions.

CONCLUSION AND DISCUSSION

The results suggest that hospitals need to monitor ADA-related expenses, more employee training is needed to ensure the ADA's success, and more representation is needed on hospital committees by rehabilitation personnel and individuals with disabilities.

Treatment of casualties of military conflicts at the Critical Medicine Clinic of the Central Hospital in Georgia

INTRODUCTION

Local military conflicts continue in many areas of the world. These conflicts produce multiple casualties to military personnel and civilians. This paper describes one aspect of the medical care required for victims of the civil conflict in the Republic of Georgia.

METHODS

Interviews with patients and their accompanying persons and abstraction of medical records.

RESULTS

Data were acquired on 108 victims admitted to the Center for Critical Medicine in Tbilisi. Three stages in the care of these victims are described: 1) battlefield and transportation; 2) regional, front-line hospitals; and 3) the Central Hospital. The performance of each stage is described. Distribution of injuries and procedures performed in the third stage of treatment are described and survivors are defined. For illustration, two cases are reviewed in detail.

CONCLUSIONS

The results are encouraging. Major problems existed in the treatment and evacuation of the wounded. Furthermore, many of the victims were injured because of their carelessness and lack of experience on the battlefield.

A national survey on seclusion and restraint in state psychiatric hospitals

OBJECTIVES

State psychiatric hospitals across the U.S. were surveyed to develop national normative data on the incidence of seclusion and restrain and of injuries to patients and staff resulting from aggression by patients.

METHODS

A survey instrument was sent to 225 state hospitals requesting information for a one-year period on the number of patients placed in seclusion or restraint, the number of discrete incidents of seclusion and restraint, the number of hours patients spent in seclusion or restraint, and the number of injuries to patients and staff attributable to aggression by patients. Rates of seclusion, restraint, and injuries were calculated to control for variation in hospital censuses. Percentile ranks for the various rates were calculated to allow hospitals to compare their rates.

RESULTS AND CONCLUSIONS

A total of 101 state hospitals in 44 states and the District of Columbia returned the survey. In general, smaller hospitals had higher rates of seclusion and restraint. However, large standard deviations in the mean rates suggested considerable variability between hospitals in the sample. Small positive correlations between rates of seclusion and rates of restraint suggested that the hospitals did not use of the two interventions exclusively.