Is the volume-outcome relationship sustained in psychiatric care?

Modelling Volume-Outcome Relationships in Health Care

Despite the ongoing strong interest in associations between quality of care and the volume of health care providers, a unified statistical framework for analyzing them is missing, and many studies suffer from poor statistical modelling choices. We propose a flexible, additive mixed model for studying volume-outcome associations in health care that takes into account individual patient characteristics as well as provider-specific effects through a hierarchical approach. More specifically, we treat volume as a continuous variable, and its effect on the considered outcome is modeled as a smooth function. We take account of different case-mixes by including patient-specific risk factors and clustering on the provider level through random intercepts. This strategy enables us to extract a smooth volume effect as well as volume-independent provider effects. These two quantities can be compared directly in terms of their magnitude, which gives insight into the sources of variability of quality of care. Based on a causal DAG, we derive conditions under which the volume-effect can be interpreted as a causal effect. The paper provides confidence sets for each of the estimated quantities relying on joint estimation of all effects and parameters. Our approach is illustrated through simulation studies and an application to German health care data about mortality of very low birth weight infants.

Inpatient Early Intervention for Serious Mental Illnesses Is Associated With Fewer Rehospitalizations Compared With Treatment as Usual in a High-volume Public Psychiatric Hospital Setting

OBJECTIVE

High-acuity publicly funded inpatient psychiatric settings usually feature short lengths of stay and high readmission rates. This study examined the influence of an early intervention program for serious mental illnesses (SMI) on readmissions at 6 and 12 months postdischarge at a high-volume, urban public inpatient psychiatric hospital.

METHODS

The Early Onset Treatment Program (EOTP) is a cost-free, 90-day inpatient multidisciplinary service intervention program for uninsured patients who are within 5 years of SMI onset, funded as a pilot program by the Texas state legislature. Rehospitalization rates at 6 and 12 months were extracted from electronic medical records for EOTP participants (n=165) and comparison patients matched on demographics and diagnosis (n=155). The comparison group received treatment as usual at the same psychiatric hospital. Group re-admission rates were compared using logistic and Poisson regression analyses.

RESULTS

Group membership was a significant predictor of rehospitalization (P<0.0001) at both 6 and 12 months. Expressed as 1/odds ratio (OR), the EOTP group was less likely to readmit once and more than once at 6 months postdischarge (1/OR=3.82 and 4.74, respectively) compared with the non-EOTP group. The EOTP group was also less likely to readmit once and more than once at 12 months postdischarge (1/OR=2.96 and 3.51, respectively).

CONCLUSIONS

The results suggest that participation in the EOTP service in this high-acuity setting was significantly related to reduced likelihood of rehospitalization at 6 and 12 months. Several variables may account for this observation, including length of stay, longer medication adherence, environmental stability, and more individualized and extensive psychotherapy treatment.

The Effect of Centers for Medicare and Medicaid's Inpatient Psychiatric Facility Quality Reporting Program on the Use of Restraint and Seclusion

BACKGROUND

Patients in inpatient psychiatry settings are uniquely vulnerable to harm. As sources of harm, research and policy efforts have specifically focused on minimizing and eliminating restraint and seclusion. The Centers for Medicare and Medicaid's Inpatient Psychiatric Facility Quality Reporting (IPFQR) program attempts to systematically measure and reduce restraint and seclusion. We evaluated facilities' response to the IPFQR program and differences by ownership, hypothesizing that facilities reporting these measures for the first time will show a greater reduction and that ownership will moderate this effect.

METHODS

Using a difference-in-differences design and exploiting variation among facilities that previously reported on these measures to The Joint Commission, we examined the effect of the IPFQR public reporting program on the use and duration of restraint and seclusion from the end of 2012 through 2017.

RESULTS

There were a total of 9705 observations of facilities among 1841 unique facilities. Results suggest the IPFQR program reduced duration of restraint by 48.96% [95% confidence interval (95% CI), 16.69%-68.73%] and seclusion by 53.54% (95% CI, 19.71%-73.12%). There was no change in odds of zero restraint and, among for-profits only, a decrease of 36.89% (95% CI, 9.32%-56.07%) in the odds of zero seclusion.

CONCLUSIONS

This is the first examination of the effect of the IPFQR program on restraint and seclusion, suggesting the program was successful in reducing their use. We did not find support for ownership moderating this effect. Additional research is needed to understand mechanisms of response and the impact of the program on nontargeted aspects of quality.

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.

Association of high psychiatrist staffing with prolonged hospitalization, follow-up visits, and readmission in acute psychiatric units: a retrospective cohort study using a nationwide claims database

BACKGROUND

The effects of psychiatrist staffing are unclear. The aim of this study was to assess the association of high psychiatrist staffing with prolonged hospitalization, follow-up visits, and readmission in acute psychiatric units.

METHODS

A retrospective cohort study was conducted using the National Database of Health Insurance Claim Information and Specified Medical Checkups. Patients newly admitted to acute psychiatric units between October 2014 and September 2015 were followed up until September 2016. The primary exposure was a patient-to-psychiatrist ratio of 16:1 (high-staffing units) vs 48:1 (low-staffing units). Outcomes were prolonged hospitalization of >90 days, number of follow-up psychiatric visits within 90 days after discharge, and psychiatric readmission within 90 days after discharge. Incidence rate ratios (IRRs) and their 95% confidence intervals (CIs) were estimated by using generalized estimating equations, adjusting for potential covariates.

RESULTS

Among the 24,678 newly admitted patients at 190 hospitals, 13,138 patients (53.2%) were admitted to high-staffing units in 92 hospitals. After adjustment, high-staffing units were associated with a lower risk of prolonged hospitalization (incidence rate, 16.9 vs 21.3%; IRR, 0.79 [95% CI, 0.70, 0.89]), higher number of follow-up visits (incidence rate of ≥7 visits, 16.9 vs 13.4%; IRR, 1.06 [95% CI, 1.01, 1.12]), and lower risk of readmission (incidence rate, 13.0 vs 14.4%; IRR, 0.90 [95% CI, 0.82, 0.99]).

CONCLUSION

High-staffing units are associated with a reduced risk of prolonged hospitalization and readmission and an increased number of follow-up visits. Further research is needed to improve the generalizability of these findings and establish the optimal level of staffing.

Psychiatric readmissions and their association with environmental and health system characteristics: a systematic review of the literature

BACKGROUND

Psychiatric readmissions have been studied at length. However, knowledge about how environmental and health system characteristics affect readmission rates is scarce. This paper systemically reviews and discusses the impact of health and social systems as well as environmental characteristics for readmission after discharge from inpatient care for patients with a psychiatric diagnosis.

METHODS

Comprehensive literature searches were conducted in the electronic bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management and OpenGrey. In addition, Google Scholar was utilised. Relevant publications published between January 1990 and June 2014 were included. No restrictions regarding language or publication status were imposed. A qualitative synthesis of the included studies was performed. Variables describing system and environmental characteristics were grouped into three groups: those capturing regulation, financing system and governance; those capturing capacity, organisation and structure; and those capturing environmental variables.

RESULTS

Of the 734 unique articles identified in the original search, 35 were included in the study. There is a limited number of studies on psychiatric readmissions and their association with environmental and health system characteristics. Even though the review reveals an extensive list of characteristics studied, most characteristics appear in a very limited number of articles. The most frequently studied characteristics are related to location (local area, district/region/country). In most cases area differences were found, providing strong indication that the risk of readmission not only relates to patient characteristics but also to system and/or environmental factors that vary between areas. The literature also points in the direction of a negative association of institutional length of stay and community aftercare with readmission for psychiatric patients.

CONCLUSION

This review shows that analyses of system level variables are scarce. Furthermore they differ with respect to purpose, choice of system characteristics and the way these characteristics are measured. The lack of studies looking at the relationship between readmissions and provider payment models is striking. Without the link to provider payment models and other health system characteristics related to regulation, financing system and governance structure it becomes more difficult to draw policy implications from these analyses.

Readmission rates of South Korean psychiatric inpatients by inpatient volumes per psychiatrist

BACKGROUND

Readmission rates of psychiatric inpatients are higher in South Korea than other Organization for Economic Co-operation and Development (OECD) countries. In addition, the solution for readmission control is deficient based on the characteristics of the South Korean National Health Insurance (NHI) system. Therefore, it is necessary to identify ways to reduce psychiatric inpatient readmissions. This study investigated the relationship between inpatient volume per psychiatrist and the readmission rate of psychiatric inpatients in South Korea.

METHOD

We used NHI claim data (N = 37,796) from 53 hospitals to analyze readmission within 30 days for five diagnosis (organic mental disorders, mental and behavioral disorders due to psychoactive substance use, schizophrenia, mood disorders, neurotic disorders, and stress-related and somatoform disorders) between 2010 and 2013. We performed χ2 and analysis of variance tests to investigate associations between patient and hospital-level variables and readmission within 30 days. Finally, generalized estimating equation (GEE) models were analyzed to examine possible associations with readmission.

RESULTS

Readmissions within 30 days accounted for 1,598 (4.5 %) claims. Multilevel analysis demonstrated that inpatient volume per psychiatrist were inversely related with readmission within 30 days (low odds ratio [OR]: 0.38, 95 % confidence interval [CI]: 0.28-0.51; mid-low OR: 0.48, 95 % CI: 0.36-0.63; mid-high OR: 0.55, 95 % CI: 0.44-0.69; Q4 = ref). The subgroup analysis by diagnosis revealed that both "schizophrenia, schizotypal, and delusional disorders" and "mood disorders" had inverse relationships with readmission risk for all volume groups.

CONCLUSIONS

We observed an inverse association between inpatient volume per psychiatrist and the 30-day readmission rate of psychiatric inpatients, suggesting that it could be a useful quality indicator in mental health care.

Observational study of the relationship between volume and outcomes using data from the National Audit of Cardiac Rehabilitation

OBJECTIVE

Cardiac rehabilitation (CR) is an evidence-based intervention delivered by a wide range of high-volume and low-volume centres; however, the extent of volume-outcome relationship is yet to be studied. There is a lack of consensus about the effect of volume on outcomes, with evidence of mixed effects in acute and chronic care. The aim of this study is, to investigate the extent of association of outcomes in CR with patient volume.

METHODS

Data was validated and extracted from the national audit from 2012 to 2013 for each CR centre. Volume was calculated as the total number of patients entering outpatient CR. Hierarchical multiple regression models were used to test for relationships between volume and outcomes. The outcomes included body mass index, blood pressure, psychosocial well-being, cholesterol, smoking cessation and physical activity. The analyses were adjusted for centre and patient characteristics and confounders.

RESULTS

The number of patients included in the volume analysis was 48 476, derived from 178 CR centres. The average age per centre was 66 years with a 70% male distribution of patients enrolled. Regression analysis revealed no volume-outcome relationship, additionally no statistical significance existed.

CONCLUSIONS

Unlike cardiac surgery this study, after accounting for staffing, age, gender and comorbidity, shows no effect of volume on outcome following CR delivered by high-volume and low-volume programmes. Based on our data there is no support for centralisation of services. Our findings and methodology can be used as a benchmark for future volume-outcome relationship studies in CR.

Determinants of length of stay for psychiatric inpatients: analysis of a national database covering the entire Korean elderly population

OBJECTIVE

In a rapidly aging society, inappropriately long geropsychiatric inpatient hospitalization is a challenging concern for mental health policy-makers and researchers. This study aimed to investigate patient and institutional factors affecting geropsychiatric inpatient length of stay (LOS), providing an overview of current geropsychiatric health care system in South Korea.

METHODS

This retrospective, population-based, cross-sectional study analysed nationwide reimbursement claim databases covering the entire elderly population of Korea between January 2005 and June 2006. Given the nested structure of the data, a multivariate multilevel regression analysis was performed.

RESULTS

The average LOS was 128 days. Males, patients with schizophrenia, and those enrolled in a National Medical Care Aid program tended to have longer hospital stays. Patient age was negatively related to LOS. Institutional variables related to longer hospitalizations included a psychiatric hospital, a higher number of beds, fewer human resource employees, a higher proportion of male, oldest old, and patients with dementia.

CONCLUSIONS

Our results suggest that policies targeting geropsychiatric patients diagnosed with schizophrenia, enrolled in National Medical Care Aid programs, and admitted to psychiatric hospitals could reduce LOS. Additionally, the impact of the patient composition of a medical institution on LOS needs to be closely investigated.