Length of Stay of General Psychiatric Inpatients in the United States: Systematic Review

The effectiveness of the mental health social worker-led multiprofessional program in preventing long-term hospitalization and readmission in acute psychiatric inpatients in Japan: A retrospective analysis

Aim

The large number of new long-stay (NLS) patients and high readmission rates in psychiatric hospitals are longstanding concerns in Japan despite reforms to encourage multidisciplinary support of such patients. Staffing shortages of specialists, especially mental health social workers (MHSWs), may be one of the reasons for these problems to remain unsolved.

Methods

The authors examined the effectiveness of the MHSW-centered multidisciplinary care model in preventing NLSs and rehospitalization in terms of both patient dynamics and cost by retrospective comparison of before and after program implementation.

Results

After our program was introduced, NLS was almost completely prevented. In addition, a significant decrease in readmissions of involuntarily admitted patients was also observed. On the other hand, the resulting decrease in treatment costs and hospital revenues was mismatched by an increase in personnel costs.

Conclusion

While MHSW-centered multidisciplinary care is effective for the community integration of patients, there are cost challenges. State policy changes are needed to resolve staffing problems, along with the introduction of appropriate indicators of community integration.

Socio-demographic Predictors of Hospitalization Duration Among Patients with Borderline Personality Disorder

Borderline personality disorder (BPD) is a complex psychopathology associated with high service utilization rates. In turn, the hospitalization of BPD patients is a controversial challenge for mental health professionals. Prior literature has identified certain socio-demographic factors as linked to an increased risk of BPD. In this study, we examined the possible connection between these socio-demographic factors and hospitalization duration. We analyzed 1077 hospitalization records of 200 BPD-diagnosed patients. Patients' gender, age, education level, employment and marital statuses, and living arrangement were statistically significantly linked with hospitalization duration. Specifically, female gender, age twenty or below, no high-school diploma (or, to a lesser extent, a diploma with no academic education), unemployment status and/or patients who live with parents are strongly associated with longer hospitalizations compared to male gender, older patients, more educated, married/divorced status and/or those who do not live with their parents. Additionally, the results point to a weak, albeit statistically significant, temporal pattern with more advanced hospitalizations generally aligning with the duration of their preceding ones, while being slightly shorter. In order to prevent potentially unnecessary prolonged and regressive hospitalizations, an estimation of the expected hospitalization duration should be explicitly considered when setting hospitalization goals and plans.

Adult psychiatric inpatient admissions and length of stay before and during the COVID-19 pandemic in a large urban hospital setting in Vancouver, British Columbia

Introduction

During the COVID-19 pandemic individuals with mental illnesses faced challenges accessing psychiatric care. Our study aimed to describe patient characteristics and compare admissions and length of stay (LOS) for psychiatric-related hospitalizations before and during the COVID-19 pandemic.

Methods

We conducted a retrospective analysis using health administrative data comparing individuals with an acute psychiatric admission between two time periods: 1st March 2019 to 31st December 2019 (pre-COVID) and 1st March 2020 to 31st December 2020 (during-COVID). Multivariable negative binomial regression was used to model the association between most responsible diagnosis type and the two-time periods to hospital LOS, reporting the Rate Ratio (RR) as the measure of effect.

Results

The cohort comprised 939 individuals who were predominately male (60.3%) with a severe mental illness (schizophrenia or mood-affective disorder) (72.7%) and a median age of 38 (IQR: 28.0, 52.0) years. In the multivariable analysis, anxiety disorders (RR: 0.63, CI: 0.4, 0.99) and personality disorders (RR: 0.52, CI: 0.32, 0.85) were significantly associated with a shorter LOS when compared to individuals without those disorders. Additionally, when compared to hospital admissions for non-substance related disorders the LOS for patients with substance-related disorders were significantly shorter during the COVID period (RR: 0.45, CI: 0.30, 0.67) and pre-COVID period (RR: 0.31, CI: 0.21, 0.46).

Conclusions

We observed a significant difference in the type and length of admissions for various psychiatric disorders during the COVID-19 period. These findings can support systems of care in adapting to utilization changes during pandemics or other global health events.

Post-Disaster Community Transition of Psychiatric Inpatients: Lessons from the Fukushima Nuclear Accident

This study sought to explore factors related to community transition after the mandatory evacuation of psychiatric inpatients to other hospitals owing to the Fukushima Daiichi Nuclear Power Plant accident. A retrospective cohort design was adopted and 391 psychiatric patients were examined. Univariate and multivariate analyses were conducted to confirm the association between the achievement or non-achievement of discharge to community living and their backgrounds (age, gender, evacuation destination, psychiatric diagnoses, and physical complications). Multivariate analysis indicated that patients with psychiatric diagnoses of schizophrenia, schizotypal, and delusional disorders (International Statistical Classification of Diseases and Related Health Problems 10th revision, F20-29), and those with physical diagnoses of the circulatory (I00-95) and digestive (K00-93) systems showed a significant association with the non-attainment of community transition. From these results, we hypothesized that difficulties in the management of medication during and immediately after the extremely chaotic settings of evacuation could have negative effects on the community transitions. Furthermore, another possible concern was that individuals' persistent psychotic status before the accident had been carried over to the destination hospitals. Therefore, pre-disaster daily cooperation across hospitals and challenges for vulnerable psychiatric patients' future community lives are also essential.

Length of hospital stay in involuntary admissions in Greece: a 10-year retrospective observational study

PURPOSE

The treatment of mental disorders has shifted from inpatient wards to community-based settings in recent years, but some patients may still have to be admitted to inpatient wards, sometimes involuntarily. It is important to maintain the length of hospital stay (LoS) as short as possible while still providing adequate care. The present study aimed to explore the factors associated with the LoS in involuntarily admitted psychiatric patients.

METHODS

A ten-year retrospective chart review of 332 patients admitted involuntarily to the inpatient psychiatric ward of the General University Hospital of Ioannina, Northwestern Greece, between 2008 and 2017 was conducted.

RESULTS

The mean LoS was 23.8 (SD = 33.7) days and was relatively stable over the years. Longer-stay hospitalization was associated with schizophrenia-spectrum disorder diagnosis, previous hospitalizations and the use of mechanical restraint, whereas patients in residential care experienced significantly longer LoS (52.6 days) than those living with a caregiver (23.5 days) or alone (19.4 days). Older age at disease onset was associated with shorter LoS, whereas no statistically significant differences were observed with regard to gender.

CONCLUSION

While some of our findings were in line with recent findings from other countries, others could not be replicated. It seems that multiple factors influence LoS and the identification of these factors could help clinicians and policy makers to design more targeted and cost-effective interventions. The optimization of LoS in involuntary admissions could improve patients' outcomes and lead to more efficient use of resources.

Factors influencing the length of stay in forensic psychiatric settings: a systematic review

BACKGROUND

Forensic psychiatry is often associated with long admissions and has a high cost of care. There is little known about factors influencing length of stay (LOS), and no previous systematic review has synthesised the available data. This paper aims to identify factors influencing the LOS in forensic psychiatry hospitals to inform care and interventions that may reduce the length of admissions.

METHODOLOGY

A systematic review was conducted by searching major databases, including PubMed, EMBASE and PsycInfo, from inception until May 2022. Observational studies conducted in forensic hospitals that examined associations between variables of interest and LOS were included. Following data extraction, the Newcastle‒Ottawa Scale was used for quality appraisal. No meta-analysis was conducted due to heterogeneity of information; a quantitative measure to assess the strength of evidence was developed and reported.

RESULTS

A total of 28 studies met the inclusion criteria out of 1606 citations. A detailed quantitative synthesis was performed using robust criteria. Having committed homicide/attempted homicide, a criminal legal status with restrictions, and a diagnosis of schizophrenia-spectrum disorders were all associated with longer LOS. Higher Global Assessment of Functioning (GAF) scores were associated with a shorter LOS.

CONCLUSION

High-quality research examining factors associated with LOS in forensic psychiatry is lacking, and studies are heterogeneous. No modifiable characteristics were identified, and thus, practice recommendations were not made. There is an increasing necessity to understand the factors associated with longer admissions to inform care and increase success in reintegration and rehabilitation. This paper provides recommendations for future research.

Analysis of England's incident and mental health nursing workforce data 2015-2022

WHAT IS KNOWN ON THE SUBJECT?: Mental health services report adverse incidents in different ways and the relationship between adverse incidents and the workforce is uncertain. In England, there are national datasets recording all incidents and workforce statistics though there is no peer-reviewed evidence examining recent trends. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Although there has been an overall increase in the number of mental health nurses, more are working in the community and the number of nurses relative to adverse incidents has decreased. There have been service-provision changes but the role of mental health nurses has not significantly changed in this period, and we can therefore assume that their current practice is saturated with risk or increased reporting. To help understand the relationship between nurses and incidents, we need to transform how incidents are recorded in England. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: English mental health services report greater levels of patient-related factors such as self-harm or aggression rather than missed or erroneous care. This makes it difficult to understand if a rise in incident frequency is linked to reporting behaviour, patient risk, unsafe/ineffective care or other reasons and therefore planning workforce deployment to improve care quality is problematic.

ABSTRACT

INTRODUCTION: There is a paucity of empirical data examining incidents and mental health nurses and the relationship between the two remains uncertain.

AIM

Comparison of English national data for incidents and nursing workforce to examine recent trends.

METHOD

Descriptive analysis of two national datasets of incidents and workforce data for England between 2015 and 2022.

RESULTS

A 46% increase in incidents was found; the leading causes are self-harm and aggressive behaviour. Despite the rise in adverse incident reporting, a 6% increase in mental health nurses was found, with more nurses in community settings than hospitals.

DISCUSSION

Current services are incident reporting at greater concentrations than in previous years. Patient-related behaviour continues to be most prominently reported, rather than possible antecedent health services issues that may contribute to reporting. Whilst staffing has increased, this does not seem to have kept pace with the implied workload evident in the increase in incident reports.

IMPLICATIONS FOR PRACTICE

Greater emphasis should be placed on health service behaviour in reporting mechanisms. Self-harm and aggression should continue to be considered adverse outcomes, but causal health service factors, such as missed care, should be present in pooled reporting to help reduce the occurrence of adverse outcomes.

Adult Psychiatric Hospitalizations in Ontario, Canada Before and During the COVID-19 Pandemic

OBJECTIVE

The impacts of the COVID-19 pandemic on psychiatric hospitalizations in Ontario are unknown. The purpose of this study was to identify changes to volumes and characteristics of psychiatric hospitalizations in Ontario during the COVID-19 pandemic.

METHODS

A time series analysis was done using psychiatric hospitalizations with admissions dates from July 2017 to September 2021 identified from provincial health administrative data. Variables included monthly volumes of hospitalizations as well as proportions of stays <3 days and involuntary admissions, overall and by diagnosis (mood, psychotic, addiction, and other disorders). Changes to trends during the pandemic were tested using linear regression.

RESULTS

A total of 236,634 psychiatric hospitalizations were identified. Volumes decreased in the first few months of the pandemic before returning to prepandemic volumes by May 2020. However, monthly hospitalizations for psychotic disorders increased by ∼9% compared to the prepandemic period and remained elevated thereafter. Short stays and involuntary admissions increased by approximately 2% and 7%, respectively, before trending downwards.

CONCLUSION

Psychiatric hospitalizations quickly stabilized in response to the COVID-19 pandemic. However, evidence suggested a shift towards a more severe presentation during this period.

Associations Between Psychiatric Diagnoses on Length of Stay and Mortality After Rib Fracture: A Retrospective Analysis

INTRODUCTION

Concurrent psychiatric diagnoses adversely impact outcomes in surgical patients, but their relationship to patients with rib fracture after trauma is less understood. We hypothesized that psychiatric comorbidity would be associated with increases in hospital length of stay (LOS) and mortality risk after rib fracture.

MATERIALS AND METHODS

The 2017 National Inpatient Sample was queried for adult patients who were admitted with rib fracture after trauma. Mental health disorders were categorized into 34 psychiatric diagnosis groups (PDGs) using clinical classifications software refined for International Classification of Diseases-10. Outcomes of interest were LOS and mortality. Bivariable analysis determined associations between PDGs, patient demographics, hospital characteristics, and outcomes. Logistic regression was performed to identify adjusted effects on mortality, and linear regression was performed to identify effects on LOS.

RESULTS

Of 32,801 patients, median age was 61 y (IQR 46-76), and median LOS was 5 d (IQR 3-9). No PDGs were associated with increased odds of mortality. Concurrent diagnosis of schizophrenia spectrum (Coeff. 3.5, 95% CI 2.7-4.4, P < 0.001) or trauma- or stressor-related (Coeff. 1.6, 95% CI 0.9-2.5, P < 0.001) disorders demonstrated the greatest association with prolonged LOS. Increased odds of death and prolonged hospital stay were also associated with male sex, non-White patient race, and surgery occurring at urban and public hospitals.

CONCLUSIONS

Psychiatric comorbidities are associated with death after rib fracture but are associated with increased LOS. These findings may help promote multidisciplinary patient management in trauma.

Evaluation of a Pathway team for homeless mental health in-patients

AIMS AND METHOD

The Pathway model is an enhanced care coordination model for homeless people in hospital. We aimed to evaluate the first attempt to apply it on psychiatric wards, which started in 2015 in South London. We developed a logic model which expressed how the Pathway approach might work. Two predictions from this model were tested, using propensity scores and regression to estimate the effect of the intervention among people who were eligible for it.

RESULTS

The Pathway team theorised that their interventions would reduce length of stay, improve housing outcomes and optimise the use of primary care - and, more tentatively, reduce readmission and emergency presentations. We were able to estimate effects on length of stay (-20.3 days; 95% CI -32.5 to -8.1; P = 0.0012) and readmission (a non-significant reduction).

CLINICAL IMPLICATIONS

The marked reduction in length of stay, explicable in terms of the logic model, constitutes preliminary support for the Pathway model in mental health services.

Length and associated characteristics of short-term detentions: an analysis of detentions under the Mental Health Act in Scotland, 2006-2018

PURPOSE

The Mental Health Act in Scotland is under review. Previous iterations increased patients' rights but the maximum time for short-term detentions remains unchanged, despite evolving psychiatric treatment models. We explored length, mode of ending and factors of influence on the application of short-term detention certificates (STDCs), which can last up to 28 days, across Scotland between 2006 and 2018.

METHODS

Data on age, gender, ethnicity, date of commencement and ending of the STDC and detention site from all 42,493 STDCs issued to 30,464 patients over 12 years were extracted from the national repository for detentions under the Mental Health (Care and Treatment) (Scotland) Act 2003 and analysed using mixed models.

RESULTS

One in five STDCs lapsed on day 28. Two in five were revoked and the remainder extended to a treatment order. STDCs that were not extended averaged 19 days, and revoked STDCs 14 days. The probability of a detention lapsing varied across hospitals and increased with patient age. The odds of a detention lapsing on day 28 were 62% lower and revoked detentions 10% shorter in 2018 relative to 2006. The odds of a detention extending decreased significantly from 2012 to 2018. Extended STDCs were associated with increased patient age, male gender, and ethnicity other than White Scottish. There was little initiation of or active revocation of STDCs on weekend days.

CONCLUSION

The length of STDCs reduced over time, fewer detentions lapsed, and weekday patterning was evident in each year. These data can inform legislative and service reviews.

Food choking incidents in the hospital: incidents, characteristics, effectiveness of interventions, and mortality and morbidity outcomes

AIM

Foreign body airway obstruction (FBAO) due to food can occur wherever people eat, including in hospitals. We characterized in-hospital FBAO incidents and their outcomes.

METHODS

We searched the Japan Council for Quality Health Care nationwide in-hospital adverse events database for relevant events from 1,549 institutions. We included all patients with FBAO incidents due to food in the hospital from January 2010 to June 2021 and collected data on the characteristics, interventions, and outcomes. FBAO from non-food materials were excluded. Our primary outcomes were mortality and morbidity from FBAO incidents.

RESULTS

We identified 300 patients who had a FBAO incident from food. The most common age group was 80 - 89 years old (32.3%, n = 97/300). One-half (50.0%, n = 150/300) were witnessed events. Suction was the most common first intervention (31.3%, n = 94/300) and resulted in successful removal of foreign body in 17.0% of cases (n = 16/94). Back blows (16.0%, n = 48/300) and abdominal thrusts (8.1%, n = 24/300) were less frequently performed as the first intervention and the success rates were 10.4% (n = 5/48) and 20.8% (n = 5/24), respectively. About one-third of the patients (31%, n = 93/300) died and 26.7% (n = 80/300) had a high potential of residual disability from the incidents.

CONCLUSION

FBAO from food in the hospital is an uncommon but life-threatening event. The majority of patients who suffered from the in-hospital FBAO incidents did not receive effective interventions initially and many of them died or suffered residual disability.

Profiles, correlates, and risk of death among patients with mental disorders hospitalized for psychiatric reasons

This study identified profiles of hospitalized patients with mental disorders (MD) based on their 3-year hospitalization patterns and clinical characteristics and compared sociodemographic profiles and other service use correlates as well as risk of death within 12 months after hospitalization. Quebec (Canada) medical administrative databases were used to investigate a 5-year cohort of 4,400 patients hospitalized for psychiatric reasons. Latent class analysis, chi-square tests and survival analysis were produced. Three profiles of hospitalized patients were identified based on hospitalization patterns and other patient characteristics. Profile 3 patients had multiple hospitalizations and early readmissions, worst health and social conditions, and used the most outpatient services. Profiles 2 and 1 patients had only one hospitalization, of brief duration in the case of Profile 2 patients, who had mainly common MD and made least use of psychiatric care. All Profile 1 patients were hospitalized for serious MD but received least continuity of physician care and fewest biopsychosocial interventions. Risk of death was higher for Profiles 3 and 2 versus Profile 1 patients. Interventions like early follow-up care after hospitalization for Profile 3, collaborative care between general practitioners and psychiatrists for Profile 2, and continuous biopsychosocial care for Profile 1 could be greatly improved.

Demographic, clinical and biochemical correlates of the length of stay for different polarities in Chinese inpatients with bipolar disorder: A real-world study

Introduction: Many patients with bipolar disorder (BD) need hospitalization, while the number of hospital beds for these patients is limited. Managing the length of stay (LOS) is an effective solution to this issue. Research on LOS and its influencing factors in BD is limited in China. This study aimed to identify the factors relevant to LOS in different polarities in Chinese patients with BD. Method: This was a real-world, cross-sectional study. Data were obtained from the electronic medical record system. Patients admitted to Beijing Anding Hospital between Jan 2014 and Dec 2017 and diagnosed with BD were included. Demographic information, clinical characteristics, and biochemical variables were collected. Patients were classified into short and long LOS groups based on a cutoff value. A univariate study and a multivariate logistic regression analysis were performed to identify variables related to LOS in various BD polarities. The receiver operating characteristic (ROC) analysis was utilized to evaluate the discrimination accuracy of the regression model. Result: Four thousand six hundred and seventy-five visits from 4,451 individuals were included in the analysis. For the whole sample, unmarried status, psychotic features, and family history of mental disorders were positively associated with long LOS (all p < 0.05). There was an additive interaction between a family history of mental disorders and polarities (p < 0.05). For manic episodes, unmarried status, psychotic features, and family history of mental disorders were positively associated with long LOS (all p < 0.05). For depressive episodes, psychotic features and high-density lipoprotein cholesterol (HDLC) levels were positively associated with long LOS (all p < 0.05). For mixed states, unmarried status was positively associated with long LOS, while low-density lipoprotein cholesterol (LDLC) levels were negatively associated with LOS (all p < 0.05). The area under the curve (AUC) values for depressive episodes, manic episodes, and mixed states in the combined model were 0.587, 0.553, and 0.619, respectively (all p < 0.05). Discussion: The findings suggested that LOS correlates differed by polarity, with marital status, psychotic features, a family history of mental disorders, and lipid levels strongly linked with LOS in patients with BD.

Analysis of hospital costs by morbidity group for patients with severe mental illness

OBJECTIVES

The goal of this study is to analyse hospital costs and length of stay of patients admitted to psychiatric units in hospitals in a European region of the Mediterranean Arc. The aim is to identify the effects of comorbidities and other variables in order to create an explanatory cost model.

METHODS

In order to carry out the study, the Ministry of Health was asked to provide data on access to the mental health facilities of all hospitals in the region. Among other questions, this database identifies the most important diagnostic variables related to admission, like comorbidities, age and gender. The method used, based on the Manning-Mullahy algorithm, was linear regression. The results were measured by the statistical significance of the independent variables to determine which of them were valid to explain the cost of hospitalization.

RESULTS

Psychiatric inpatients can be divided into three main groups (psychotic, organic and neurotic), which have statistically significant differences in costs. The independent variables that were statistically significant (p <.05) and their respective beta and confidence intervals were: psychotic group (19,833.0 ± 317.3), organic group (9,878.4 ± 276.6), neurotic group (11,060.1 ± 287.6), circulatory system diseases (19,170 ± 517.6), injuries and poisoning (21,101.6 ± 738.7), substance abuse (20,580.6 ± 514, 6) and readmission (19,150.9 ± 555.4).

CONCLUSIONS

Unlike most health services, access to psychiatric facilities does not correlate with comorbidities due to the specific nature of this specialization. Patients admitted to psychosis had higher costs and a higher number of average staysKEY MESSAGESThe highest average hospital expenditure occurred in patients admitted for psychotic disorders.Due to the particularities of psychiatry units and unlike other medical specialties, the number of comorbidities did not influence the number of hospital stays or hospital expenditure.Apart from the main diagnostic group, the variables that were useful to explain hospital expenditure were the presence of poisoning and injuries as comorbidity, diseases of circulatory system as comorbidity, history of substance abuse and readmission.

Predictors of Length of Hospitalization and Impact on Early Readmission for Mental Disorders

Length of hospitalization, if inappropriate to patient needs, may be associated with early readmission, reflecting sub-optimal hospital treatment, and translating difficulties to access outpatient care after discharge. This study identified predictors of brief-stay (1-6 days), mid-stay (7-30 days) or long-stay (≥31 days) hospitalization, and evaluated how lengths of hospital stay impacted on early readmission (within 30 days) among 3729 patients with mental disorders (MD) or substance-related disorders (SRD). This five-year cohort study used medical administrative databases and multinomial logistic regression. Compared to patients with brief-stay or mid-stay hospitalization, more long-stay patients were 65+ years old, had serious MD, and had a usual psychiatrist rather than a general practitioner (GP). Predictors of early readmission were brief-stay hospitalization, residence in more materially deprived areas, more diagnoses of MD/SRD or chronic physical illnesses, and having a usual psychiatrist with or without a GP. Patients with long-stay hospitalization (≥31 days) and early readmission had more complex conditions, especially more co-occurring chronic physical illnesses, and more serious MD, while they tended to have a usual psychiatrist with or without a GP. For patients with more complex conditions, programs such as assertive community treatment, intensive case management or home treatment would be advisable, particularly for those living in materially deprived areas.

Lengths of inpatient stay and sick leave of patients with mental diseases: disorder-specific effects of flexible and integrated treatment programs in Germany

Mental disorders pose a worldwide growing public health burden. One of the major challenges for healthcare systems remains to respond to the need of patients with mental disorders for continuous and flexible treatment. The EVA64 study evaluates novel programs of flexible and integrative treatment (FIT) in hospitals. This manuscript presents results from the evaluation of FIT hospitals in comparison to hospitals from regular routine care. In addition to data from adult patients, we also present data from affiliated child and adolescent psychiatric wards employing FIT programs. Using comprehensive claims data, primary outcomes are the utilization of inpatient care and sick leave for a priori defined clusters of mental disorders. We stratify between patients already under treatment (ongoing treatment) and patients with incident treatment cases (initial treatment) at the point of inclusion in the study. In the initial treatment group, we found a significant reduction in the length of inpatient stay of 4.1 days in FIT hospitals compared to routine care. While patients with mood affective disorders (-1.8 days) and patients with neurotic, stress-related, and somatoform disorders (-3.6 days) showed an even stronger effect of the reduction of inpatient lengths of stay, the effect was significantly weaker in patients with mental and behavioral disorders due to use of alcohol (+3.3 days). Regarding the duration of sick leave, we found no significant treatment effect of FIT programs compared to routine care. In the ongoing treatment group of adult patients, we found a significantly lower utilization of inpatient treatment by 1.3 days as well as a shorter duration of sick leave by 4.3 days in FIT hospitals compared to routine care. In the cohort of children and adolescent patients, we also did not observe a significant treatment effect in either the initial treatment group or the ongoing treatment group. Registration: this study was registered in the database "Health Services Research Germany" (trial number: VVfD_EVA64_15_003713).

A quarter of century after: The changing ecology of psychiatric emergency services

INTRODUCTION

Previous studies demonstrated a trend of increasing common mental disorders among the Emergency Department (ED) visitors in Western countries. Little is known about the current conditions of the emergency psychiatric services in Asian countries. This study aims to survey the current epidemiology and the changing ecology of emergency psychiatry services in Taiwan.

METHODS

A total of 804 psychiatry consultations were initiated at the ED during the 1-year period from July 1, 2014 to June 30, 2015 in a medical center in northern Taiwan. Clinical data of gender, age, chief complaints, tentative diagnoses, dispositions, and ED staying hours were compared to a previous report in the same hospital in 1988.

RESULTS

Psychiatry consultation was initiated in 0.72% of all ED visits (804/111,923). Among these visits, females were 1.73 times of the males. The most common chief complaints were psychosis/mania (33.5%) and suicide/self-harm (33.2%), followed by homicide/violence (12.8%) and anxiety/depression (10.3%). Top tentative diagnoses were schizophrenia spectrum and other psychotic disorders (31.3%), trauma- and stressor-related disorders (17.5%), bipolar disorders (15.9%), and depressive disorders (14.2%). Compared to 1988, there are three major changes: (1) over-representation of female patients, (2) an increase of "neurosis" patients, and (3) an increase of suicide/self-harm as chief problem.

DISCUSSION

This study portrays the current epidemiology and changing ecology of psychiatric emergency in Taiwan. The increase of neurotic and suicide/self-harm patients requires more services and clinical training in managing common mental disorders and suicide in the ED.

Hospital Admission Rate, Cumulative Hospitalized Days, and Time to Admission Among Older Persons With Substance Use and Psychiatric Conditions

Background

Substance use among older persons occurs with medical and psychiatric comorbidities. This study examined the associations of substance use disorder (SUD), psychiatric, and dual diagnoses with 12-month cumulative hospitalized days, hospital admission rate and number of days to first hospitalization.

Methods

The cohort of 3,624 individuals (28.2% women) aged 50 years or older was assessed for substance use severity in 65 Swedish municipalities during March 2003-May 2017. Addiction Severity Index data were linked to hospital discharge records and crime statistics. The outcomes were (a) 12-month cumulative hospitalized days; (b) Hospital admission rate, and (c) days to first hospitalization. Generalized linear regression techniques investigated associations between outcomes and SUD, psychiatric and dual diagnoses at admission.

Results

During 2003-2017, 73.5% of the participants were hospitalized. Twelve-month hospitalized days were positively associated with SUD (Incidence rate ratio (IRR) = 1.41, 95%CI: 1.26-1.58), dual diagnosis (IRR = 2.03, 95%CI: 1.74-2.36), and psychiatric diagnoses (IRR = 2.51, 95%CI: 2.09-3.01). Hospital admission rate was positively associated with SUD (IRR = 4.67, 95%CI: 4.28-5.08), dual diagnosis (IRR = 1.83, 95%CI: 1.64-2.04), and psychiatric diagnoses (IRR = 1.73, 95%CI: 1.55-1.92). Days to first hospitalization were negatively associated with SUD (IRR = 0.52, 95%CI: 0.47-0.58), dual diagnosis (IRR = 0.57, 95%CI: 0.50-0.65), and psychiatric diagnoses (IRR = 0.83, 95%CI: 0.73-0.93). The marginal effects of SUD and/or mental disorders increased with age for all outcomes, except for days to first hospitalization.

Conclusion

Three of four older persons assessed for substance use severity were later hospitalized. Substance use disorders, dual diagnoses and other mental disorders were the primary reasons for hospitalization and were associated with longer stays, earlier hospitalization, and repeated admissions. Sensitizing service providers to old age substance use and sharing data across the care continuum could provide multiple points of contact to reduce the risk of hospitalizations among older persons with problematic substance use.

Impact of Diabetes on Inpatient Length of Stay in Adult Mental Health Services in a Community Hospital Setting: A Retrospective Cohort Study

OBJECTIVE

Our aim in this study was to characterise the relationship between comorbid mental health diagnosis and diabetes type on inpatient length of stay (LOS).

METHODS

This retrospective, chart review study was conducted at a community hospital in Ontario, Canada. Individuals admitted to the inpatient mental health unit with a reported diagnosis of type 1 or type 2 diabetes were included in the analysis. Relevant data related to mental health conditions at admission and LOS were collected from the electronic health record. Analyses of variance and coviariance were used to determine the impact on LOS.

RESULTS

A total of 249 encounters were included in the analyses. Overall, individuals with type 2 diabetes (mean, 14.70 days; standard deviation, 15.75 days) had a significantly longer LOS than individuals with type 1 diabetes (mean, 8.01 days; standard deviation, 7.27 days). Upon including sociodemographic factors, individuals older in age and with a most recent admission of <1 year also had a longer LOS. There was no significant relationship between the most responsible mental health diagnosis and LOS.

CONCLUSIONS

Individuals with type 2 diabetes may be more likely to have a longer LOS in inpatient mental health settings than those with type 1 diabetes. More dedicated support would be beneficial for this population. Future work should focus on in-depth exploration of the challenges that lead to the observed LOS.

Psychiatric hospital experiences that support and frustrate emerging adults' psychological needs: A self-determination theory perspective

AIM

There are international efforts to implement developmentally appropriate and youth-oriented mental health services for emerging adults to increase treatment engagement and the success of early intervention. While significant progress has been made in developing community service models, limited research has focused on how to design psychiatric inpatient settings that promote the recovery of emerging adults. The present study attempts to address this knowledge gap through a qualitative exploration of hospital experiences that influence psychological need satisfaction and frustration, as defined by self-determination theory (SDT).

METHODS

Inpatients (N = 104) from an emerging adult psychiatry unit were interviewed regarding hospital experiences that related to satisfaction or frustration of SDT needs for autonomy, competence, and relatedness.

RESULTS

A basic interpretative qualitative analysis highlighted six key aspects of the hospital experience relevant to these needs: (a) social interactions, (b) freedom of behaviour and access, (c) programs and activities, (d) treatment collaboration and choice, (e) restraining/unpleasant hospital practices, and (f) progress, symptoms, and functioning. The findings support SDT's emphasis on the importance of autonomy support, structure, and involvement for need satisfaction.

CONCLUSIONS

The study sheds light on aspects of the hospital milieu that may be essential to recovery-oriented inpatient care and on experiences that may be distinctly important for emerging adults, such as support for independence and the opportunity to relate to same-age co-patients experiencing similar mental health problems and life circumstances.

The Danish OPUS Early Intervention Services for First-Episode Psychosis: A Phase 4 Prospective Cohort Study With Comparison of Randomized Trial and Real-World Data

OBJECTIVE

The Danish OPUS trial showed significant efficacy of early intervention services for first-episode schizophrenia spectrum disorders compared with standard treatment, leading to implementation of the OPUS intervention in clinical practice. The authors sought to determine whether the effectiveness of OPUS treatment in real-world clinical practice is comparable to the efficacy seen in the trial.

METHODS

The study compared patients who received OPUS treatment as part of the original randomized trial to those who received standard treatment in the trial (the control group) and those who received OPUS treatment after it was implemented in Denmark. The authors investigated whether the three groups differed on register-based outcomes, such as use of secondary health care, functional outcomes, and death. Analyses were adjusted for relevant confounders.

RESULTS

Compared with trial study participants, patients who received OPUS treatment after implementation (N=3,328) had a tendency toward lower mortality (hazard ratio=0.60, 95% CI=0.33, 1.09), fewer and shorter psychiatric admissions, and possibly fewer filled prescriptions of antipsychotics and other psycholeptics after 4 or 5 years. While at first less likely to be working or studying, patients who received postimplementation OPUS treatment eventually had higher odds of working than did those in the OPUS trial (after 5 years, odds ratio=1.49, 95% CI=1.07, 2.09). The odds of being in a couple relationship were also higher among patients in the postimplementation group than those in the trial. Other outcomes showed less clear associations with treatment group. Generally, the control group in the trial fared worse than both of the OPUS treatment groups.

CONCLUSIONS

Not only did OPUS treatment maintain its efficacy after it was implemented as a standard treatment, it paralleled or surpassed many of the effects observed when the OPUS intervention was delivered in a randomized trial. The study results provide further evidence in support of implementation and funding of early intervention services worldwide.

Perspectives on Recruitment and Representativeness in Forensic Psychiatric Research

Participant representativeness and statistical power are crucial elements of robust research with human participants, both of which relate to the successful recruitment of research participants. Nevertheless, such core features may often not be fully reported or duly considered in psychiatric research. Building on our experiences of collecting data in the context of forensic mental health services, we discuss issues regarding participant recruitment and representativeness in our field with its particular characteristics. A quick sampling and brief overview of the literature in four specialized forensic mental health journals is presented, demonstrating that published manuscripts rarely describe the data in sufficient detail for the reader to assess sample representativeness and statistical power. This lack of transparency leads not only to difficulties in interpreting the research; it also entails risks relating to the already meager evidence base of forensic mental health services being relevant only to a subset of patients. Accordingly, we provide suggestions for increased transparency in reporting and improved recruitment of research participants. We also discuss the balance of ethical considerations pertinent to the pursuit of increased participation rates in forensic mental health research.

AI in patient flow: applications of artificial intelligence to improve patient flow in NHS acute mental health inpatient units

Introduction

Growing demand for mental health services, coupled with funding and resource limitations, creates an opportunity for novel technological solutions including artificial intelligence (AI). This study aims to identify issues in patient flow on mental health units and align them with potential AI solutions, ultimately devising a model for their integration at service level.

Method

Following a narrative literature review and pilot interview, 20 semi-structured interviews were conducted with AI and mental health experts. Thematic analysis was then used to analyse and synthesise gathered data and construct an enhanced model.

Results

Predictive variables for length-of-stay and readmission rate are not consistent in the literature. There are, however, common themes in patient flow issues. An analysis identified several potential areas for AI-enhanced patient flow. Firstly, AI could improve patient flow by streamlining administrative tasks and optimising allocation of resources. Secondly, real-time data analytics systems could support clinician decision-making in triage, discharge, diagnosis and treatment stages. Finally, longer-term, development of solutions such as digital phenotyping could help transform mental health care to a more preventative, personalised model.

Conclusions

Recommendations were formulated for NHS trusts open to adopting AI patient flow enhancements. Although AI offers many promising use-cases, greater collaborative investment and infrastructure are needed to deliver clinically validated improvements. Concerns around data-use, regulation and transparency remain, and hospitals must continue to balance guidelines with stakeholder priorities. Further research is needed to connect existing case studies and develop a framework for their evaluation.

Looking for the Good Timing: Predictors of Length of Stay and Therapeutic Outcomes in Adolescent Inpatients with Severe or Treatment-Refractory Mood Disorders

Objectives: While hospitalization is an essential aspect of the therapeutic strategy for adolescents with severe or treatment-refractory mood disorders, little is known about the outcome predictors during inpatient treatment. Methods: A retrospective chart review was conducted in a university tertiary referral hospital to determine the factors associated with the length of stay, symptom improvement (based on the Clinical Global Impression-Improvement [CGI-I] scale), and the change in the overall level of functioning during the stay (based on the Children-Global Assessment Scale [CGAS]). Over 2 years, 106 adolescents were diagnosed with mood disorders (mean age = 15.0 ± 0.16; 43% girls), with a particular high rate of associated adverse psychosocial factors, and an average length of stay longer than most psychiatric hospital settings (mean = 100.7 ± 9.57 days). Results: Multivariate analysis concluded that longer duration of current episode and worse functioning at admission (CGAS score) were independent predictors for length of stay. Greater functional improvement (CGAS score change from admission to discharge) was best predicted by the diagnosis of bipolar disorder, lower functioning, and greater illness severity on admission. Symptom improvement (CGI-I) did not have any independent predictors. Conclusion: This finding supports the value of measuring symptoms duration in predicting the hospitalization outcomes of adolescents with severe or treatment-refractory mood disorders, in view of addressing maintenance factors at an early stage. Bipolar symptoms should be sought not only at admission but also regularly during the stay.

Clinical Profile and Length of Hospital Stay in a Sample of Psychogeriatric Patients Referred to Consultation Liaison Psychiatric Unit

Background and objectives: There has been a recent increase in older patients admitted to general hospitals. A significant percentage of hospitalized older patients are ≥75 years old, which differ from the patients aged 65 to 74 years old in terms of functional status at patient discharge. This study aims to compare sociodemographic, clinical features, and factors associated with length of hospital stay in youngest-old and oldest-old populations of inpatients referred to the consultation liaison psychiatry unit. Material and methods: This is an observational, cross-sectional, retrospective, and comparative study. We obtained data from a sample of 1017 patients (≥65 years) admitted to a general hospital and referred from different services (medicine, surgery, etc.) to the consultation liaison psychiatry unit. The sample was divided into two groups of patients: youngest-old (65–74 years) and oldest-old (≥75 years). Psychiatric evaluations were performed while the patients were on wards at the hospital. Psychopharmacs were started as needed. A comparative analysis was carried out and predictive factors related to length of hospital stay were calculated. Results: The reference rate to consultation liaison psychiatry unit was 1.45% of the total older patients hospitalized. Our study demonstrates differences between the groups of older people: the oldest-old group were mainly female (p < 0.001), had more previous psychiatric diagnoses (p < 0.001), physical disabilities (p = 0.02), and neurocognitive disorders (p < 0.001), they used more antipsychotics (p < 0.001), and more frequently had a discharge disposition to a nursing home (p = 0.036). The presence of physical disability (beta = 0.07, p < 0.001) and logtime to referral to consultation liaison psychiatry unit (beta = 0.58, p < 0.001) were associated with increased length of hospital stay. Conclusions: Youngest-old and oldest-old people should be considered as two different types of patients when we consider clinical features. The time to referral to consultation liaison psychiatry unit seems to be a relevant factor associated with length of hospital stay.

Predictors of the length of stay of psychiatric inpatients: protocol for a systematic review and meta-analysis

BACKGROUND

Length of stay (LOS) for inpatient psychiatric services is an important factor with serious drawbacks when it is extended more than needed. Impacts on economy, social functioning, and stigma can hamper improvement and affect the patients' experiences on future mental healthcare. Predictions of which patients have a higher chance for prolonged LOS have been extensively researched. Previous systematic reviews found consistent predictors of both longer and shorter LOS. However, they do not provide an estimate from the pooled effect sizes. Furthermore, to our knowledge, there is no meta-analysis on the influence of these factors. The primary objective of this study will be to provide point estimates on the effect sizes of all studied predictors of the LOS of psychiatric inpatients.

METHODS

We will conduct a systematic search in PubMed, MEDLINE, EMBASE, and PsycINFO for observational studies evaluating the effect size of independent factors on the length of stay of psychiatric inpatients. Prospective and retrospective cohorts that assess the influence of predictors through the reporting of standardized regression coefficients will be included. We will provide a qualitative synthesis of the findings from each study and perform a meta-analysis from pooled regression coefficients that were adjusted for other variables or confounders in order to obtain a point estimate and confidence interval for all factors extracted from the included studies.

DISCUSSION

The results from this study may provide more accurate predictions for mental health institutions, psychiatrists, mental health service providers, patients, and families on the prognosis regarding the length of stay for needed inpatient care. This information may be used to anticipate individuals with a higher chance for prolonged hospitalization to plan the necessary interventions for these specific situations. Considering both the benefits and disadvantages of longer and shorter stays, the pooled estimates for independent factors may be used by mental healthcare providers and patients for informed decision-making. The results from this study will also update results presented in previous studies and identify the strengths and limitations from the current available evidence.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID CRD42020172840.

Schizophrenia Related Hospitalizations - a Big Data Analysis of a National Hospitalization Database

Schizophrenia is a mental disorder characterized by long hospitalizations and frequent need for chronic/acute psychiatric care. Hospitalizations represent a valuable quality of care indicator in schizophrenia patients. The aim of this study was to describe a nationwide perspective of schizophrenia related hospitalizations. We performed a retrospective observational study using a nationwide hospitalization database containing all hospitalizations registered in Portuguese public hospitals from 2008 to 2015. Hospitalizations with a primary diagnosis of schizophrenia were selected based on the definition by CCS - Clinical Classification Software diagnostic single-level 659. Schizophrenia subtypes were identified based on International Classification of Diseases version 9, Clinical Modification (ICD-9-CM) codes of diagnosis 295.xx. A total of 25,385 hospitalizations were registered belonging to 14,279 patients. 68.0% of the hospitalizations occurred in male patients and the median length of stay was 18.0 days. In male patients' hospitalizations, the most frequent age group was 31-50 years followed by the age group of 18-30 years (55.9 and 24.0% respectively). For female patients, the most frequent age group was 31-50 years followed by 51-70 years (54.1 and 22.6%, respectively). There were 73 hospitalization with a deadly outcome (0.29%). Paranoid type was the most frequent subtype of schizophrenia (50.5%). The mean hospitalization charges were 3509.7€ per episode, with a total charge of 89.1 M€ in the 8-year period. This is a nationwide study using Big Data analysis giving a broad perspective of schizophrenia hospitalization panorama at a nationwide level. We found differences in hospitalization characteristics according to patients' gender, age and primary diagnosis.

The Impact of Demographic, Clinical, and Institutional Factors on Psychiatric Inpatient Length-of-Stay

The average length of inpatient stay (LOS) for psychiatric care has declined substantially across Canada and the United States during the past two decades. Although LOS is based presumably on patient, hospital, and community factors, there is little understanding of how such factors are linked with LOS. The purpose of this study was to explore potential individual and systemic factors associated with LOS in a large-scale, longitudinal dataset. Study participants consisted of individuals 11 years of age and older admitted for psychiatric conditions to a New Brunswick hospital between April 1, 2003 and March 31, 2014 (N = 51,865). The study used a retrospective cohort design examining data from the New Brunswick Discharge Abstract Database, administrative data comprised of all inpatient admissions across provincial hospitals. Hierarchical regression analysis was used to estimate the association of individual, facility, and system-level factors with psychiatric LOS. Results indicated that hospital-level factors and individual-level characteristics (i.e., discharge disposition, aftercare referral, socioeconomic status (SES)) account for significant variability in LOS. Consistent with extant literature, our results found that hospital, clinical, and individual factors together are associated with LOS. Furthermore, our results highlight demographic factors surrounding living situation and available financial supports, as well as the match or mismatch between preferred language and language in which services are offered.

Violent Behavior Prior to Admission Is Not a Factor in Further Prolonged Length of Stay: A Retrospective Cohort Study in a Japanese Psychiatric Hospital

Background: This study assessed the hypothesis that violent behavior prior to admission prolongs psychiatric hospitalization and evaluated the likelihood of hospital discharge to a community care setting based on demographic and clinical factors, with an emphasis on violent behavior. Methods: We retrospectively selected 362 patients who were involuntarily admitted to a psychiatric hospital in Japan from December 1, 2015 to November 30, 2017, stayed longer than planned, and underwent review by a multidisciplinary team. We assessed (a) education and marital status and history of substance abuse, (b) the presence/absence and type of violent behavior that led to hospital admission, and (c) the discharge criteria. We divided the subjects into groups according to whether they had demonstrated violent behavior prior to admission and compared demographic and clinical variables between the groups using bivariate analysis. We also analyzed data using the Cox proportional hazard model, defining discharge to the community as the outcome. Age, sex, and variables that were significant at a level of P < 0.05 based on Cox univariate analysis were included in the multivariate models using the forced entry method. Results: The Violent group included 94 patients (26%). There were no significant between-group differences in age, sex, educational background, marital history, career history, or the history of substance abuse. However, hospitalization was significantly longer in the Non-violent group. The Cox proportional multivariate hazard ratios revealed that violent behavior prior to admission resulted in a higher probability of hospital discharge. Conclusion: Violent behavior prior to admission did not significantly contribute to prolonged hospitalization in patients who deviated from the treatment plan and had exceeded the planned hospitalization duration. Our findings recommend caution when using violence and impulsiveness observed during the acute stage to predict the difficulty of long-term treatment.

Factors Related to 30-day Readmission following Hospitalization for Any Medical Reason among Patients with Mental Disorders: Facteurs liés à la réhospitalisation à 30 jours suivant une hospitalisation pour une raison médicale chez des patients souffrant de troubles mentaux

OBJECTIVE

This study evaluated the contributions of clinical, sociodemographic, and service use variables to the risk of early readmission, defined as readmission within 30 days of discharge following hospitalization for any medical reason (mental or physical illnesses), among patients with mental disorders in Quebec (Canada).

METHODS

In this longitudinal study, 2,954 hospitalized patients who had visited 1 of 6 Quebec emergency departments (ED) in 2014 to 2015 (index year) were identified through clinical administrative databanks. The first hospitalization was considered that may have occurred at any Quebec hospital. Data collected between 2012 and 2013 and 2013 and 2014 on clinical, sociodemographic, and service use variables were assessed as related to readmission/no readmission within 30 days of discharge using hierarchical binary logistic regression.

RESULTS

Patients with co-occurring substance-related disorders/chronic physical illnesses, serious mental disorders, or adjustment disorders (clinical variables); 4+ outpatient psychiatric consultations with the same psychiatrist; and patients hospitalized for any medical reason within 12 months prior to index hospitalization (service use variables) were more likely to be readmitted within 30 days of discharge. Patients who made 1 to 3 ED visits within 1 year prior to the index hospitalization, had their index hospitalization stay of 16 to 29 days, or consulted a physician for any medical reason within 30 days after discharge or prior to the readmission (service use variables) were less likely to be rehospitalized.

CONCLUSIONS

Early hospital readmission was more strongly associated with clinical variables, followed by service use variables, both playing a key role in preventing early readmission. Results suggest the importance of developing specific interventions for patients at high risk of readmission such as better discharge planning, integrated and collaborative care, and case management. Overall, better access to services and continuity of care before and after hospital discharge should be provided to prevent early hospital readmission.

Factors associated with length of stay and readmission in acute psychiatric inpatient services in Portugal

Assessing the factors that influence duration and number of hospitalizations may support mental health services planning and delivery. This study examines the factors associated with length of stay and readmission in Portuguese psychiatric inpatient services during 2002, 2007 and 2012. Data from all admissions were extracted from clinical files. Logistic regression models estimated the association between length of stay (<17 vs ≥17 days) and number of admissions per year (1 vs >1 admission) with sociodemographic, clinical, and contextual factors. Older age, a diagnosis of psychosis, and compulsory admission were associated with higher odds of longer length of stay. Being married, secondary education, suicide attempt, a diagnosis of substance use and "other mental disorders", being admitted in 2012, and two of the psychiatric inpatient services associated with lower odds of longer length of stay. Being retired (or others), a diagnosis of psychosis, compulsory admission, and psychiatric service were associated with increased odds of readmission. Older age, and secondary and higher education were associated with lower odds of readmission. The findings indicate that multiple factors influence length of stay and readmission. Identifying these factors provides useful evidence for clinicians and policy makers to design more targeted and cost-effective interventions.

Start low, go fast? Antipsychotic titration patterns at an inpatient psychiatric hospital

Introduction

Antipsychotics are commonly used to treat psychotic symptoms and severe mental illnesses. Treatment guidelines recommend antipsychotics be titrated quickly to therapeutic effect in the acute setting but acknowledge that determining the optimal dose is complicated by a delay between treatment initiation and therapeutic response. The purpose of this study was to evaluate antipsychotic titration patterns in an inpatient psychiatric hospital.

Methods

This study is a retrospective chart review of adult patients admitted to a teaching hospital and initiated on an antipsychotic for treatment of psychosis between January and December 2018. Patients were excluded if they had substance-induced psychosis, delirium, were prescribed >1 antipsychotic, or had no antipsychotic dose changes. The primary outcome was the average titration rate of the newly initiated antipsychotic. Secondary outcomes included differences in titration rate between involuntary and voluntary admissions and other antipsychotic characteristics.

Results

Of 149 patients included, the majority had a primary diagnosis of schizophrenia. Antipsychotics were titrated on average every 2 days regardless of admission type. Eighteen percent of patients were titrated to guideline-recommended maximum doses, and it took, on average, 3 days for patients to reach their final dose during hospitalization. Average length of stay was 9 days, and 43.6% of patients were readmitted within 1 year.

Discussion

Antipsychotics are titrated rapidly in the inpatient setting despite a lack of evidence regarding the impact of titration rate on clinical outcomes. Further studies comparing slow versus rapid titration strategies are needed to elucidate the impact of this on patient outcomes.

Patterns of Prescribing Antiretroviral Therapy Upon Discharge to Psychiatry Inpatients With HIV/AIDS at a Large Urban Hospital

BACKGROUND

HIV infection is more prevalent among people with severe mental illness (SMI) than in the general population. People with SMI may lack access to recommended antiretroviral therapy (ART), and inpatient psychiatric admissions may be opportunities to ensure that individuals receive recommended treatment.

OBJECTIVE

To evaluate ART prescription patterns on an inpatient psychiatry service.

METHODS

In this retrospective, observational study, patient and admission characteristics and ART prescriptions were obtained for 248 HIV-positive inpatients between 2006 and 2012. Receipt of any ART, any recommended ART regimen, and ART with potentially harmful adverse events and drug interactions were examined. General estimating equation models were used to evaluate prescription patterns in relation to patient and admission characteristics.

RESULTS

ART was prescribed at 39% of discharges and increased by 51% during the study. Prescription was more common in admissions with an AIDS diagnosis and age greater than 29 years and less common in admissions associated with a psychotic diagnosis and shorter inpatient stays. When ART was prescribed, regimens were consistent with guideline recommendations 91% of the time. Prescription of potentially harmful regimens was limited.

CONCLUSION AND RELEVANCE

In an acute inpatient psychiatry setting in an urban HIV/AIDS epicenter, where psychotic disorders and brief and involuntary admissions were the norm, guideline-recommended ART regimens were prescribed at almost 60% of discharges by the end of the study. Future studies should explore interventions to increase ART for high-risk subpopulations with SMI, including younger individuals or those with brief inpatient psychiatry hospitalizations.

Shifting Trends in Admission Patterns of an Acute Inpatient Psychiatric Unit in the State of New York

Introduction Deinstitutionalization has led to various changes in the utilization of healthcare services. The increased focus on treating patients within the community has led to variations in the utilization patterns of inpatient units. Shifts in demographic variables and disease-related, system-based, and economic factors have been observed. Due to the paucity of recent literature, this study was planned to assess the characteristics and treatment patterns in an acute inpatient psychiatric unit of a university hospital. Methods A retrospective observational study reviewing electronic medical records of patients in the context of demographic, disease-related, treatment-related, and system-based data was conducted over five years. Quantitative data were analyzed through descriptive statistics. Linear regression was used to study each variable across time. Results There was an increase in neurodevelopmental disorders (p = 0.024), substance use disorders (p = 0.041), and trauma and stressor-related disorders (p = 0.012), with a decrease in depressive disorders (p = 0.047). The use of restraints (p = 0.035) has increased significantly during the same period. Conclusion This study gives us an insight into the changing trends in patient characteristics which have the potential to inform the creation of improved services.

Hospital costs associated with post-traumatic stress disorder in somatic patients: a retrospective study

BACKGROUND

Post-traumatic stress disorder is likely to affect clinical courses in the somatic hospital ward when appearing as comorbidity. Thus, this study aimed to assess the costs associated with comorbid post-traumatic stress disorder in a somatic hospital and to analyze if reimbursement appropriately compensated additional costs.

METHODS

The study used data from a German university hospital between 2011 and 2014, analyzing 198,819 inpatient episodes. Inpatient's episodes were included for analysis if they had a somatic primary diagnosis and a secondary diagnosis of post-traumatic stress disorder. Costs were calculated based on resource use and compared to reimbursement. Analyses were adjusted for sex, age and somatic comorbidities.

RESULTS

N = 219 Inpatient's episode were found with primary somatic disorder and a comorbid post-traumatic stress disorder. Inpatients episodes with comorbid post-traumatic stress disorder were compared to 34,229 control episodes, which were hospitalized with the same main diagnosis. Post-traumatic stress disorder was associated with additional hospital costs of €2311 [95%CI €1268 - €3355], while reimbursement rose by €1387 [€563 - €2212]. Results indicate that extra costs associated with post-traumatic stress disorder are not fully reimbursed. Male patients showed higher hospital costs associated with post-traumatic stress disorder. On average, post-traumatic stress disorder was associated with an extra length of stay of 3.4 days [2.1-4.6 days].

CONCLUSION

Costs associated with post-traumatic stress disorder were substantial and exceeded reimbursement, indicating an inadequate reimbursement for somatic patients with comorbid post-traumatic stress disorder.

Feature sensitivity criterion-based sampling strategy from the Optimization based on Phylogram Analysis (Fs-OPA) and Cox regression applied to mental disorder datasets

Digital datasets in several health care facilities, as hospitals and prehospital services, accumulated data from thousands of patients for more than a decade. In general, there is no local team with enough experts with the required different skills capable of analyzing them in entirety. The integration of those abilities usually demands a relatively long-period and is cost. Considering that scenario, this paper proposes a new Feature Sensitivity technique that can automatically deal with a large dataset. It uses a criterion-based sampling strategy from the Optimization based on Phylogram Analysis. Called FS-opa, the new approach seems proper for dealing with any types of raw data from health centers and manipulate their entire datasets. Besides, FS-opa can find the principal features for the construction of inference models without depending on expert knowledge of the problem domain. The selected features can be combined with usual statistical or machine learning methods to perform predictions. The new method can mine entire datasets from scratch. FS-opa was evaluated using a relatively large dataset from electronic health records of mental disorder prehospital services in Brazil. Cox's approach was integrated to FS-opa to generate survival analysis models related to the length of stay (LOS) in hospitals, assuming that it is a relevant aspect that can benefit estimates of the efficiency of hospitals and the quality of patient treatments. Since FS-opa can work with raw datasets, no knowledge from the problem domain was used to obtain the preliminary prediction models found. Results show that FS-opa succeeded in performing a feature sensitivity analysis using only the raw data available. In this way, FS-opa can find the principal features without bias of an inference model, since the proposed method does not use it. Moreover, the experiments show that FS-opa can provide models with a useful trade-off according to their representativeness and parsimony. It can benefit further analyses by experts since they can focus on aspects that benefit problem modeling.

Determinants of Length of Stay in a Psychiatric Ward: a Retrospective Chart Review

Considering the limited resources for providing inpatient services, identification of the factors influencing length of stay (LOS) is of great importance. The current study is a retrospective chart review which was planned to investigate the determinants of LOS in two gender-specific psychiatric wards within Baqiatallah Hospital (BQH) located in Tehran. The observation period was between March 21, 2011 and March 19, 2016. 3203 patients were recruited in terms of inclusion and exclusion criteria. Next, required data on 25 explanatory variables were extracted from their case-files. Descriptive measures were used for analysis and Independent Samples T-test, one-way ANOVA, Pearson's correlation coefficient and Bonferroni's post-hoc test for inferential analysis. Lastly, a multiple linear regression model was run to determine significant predictors of psychiatric LOS. Variables significantly correlated with patients' LOS included gender, age, employment status, marital status, number of divorces, disability rate, discharge diagnosis, physical comorbidity, number of previous hospitalizations, suicide ideation, number of suicide attempts, history of assault, tobacco consumption, a history of narcotic drug abuse and number of ECT sessions. Through the analysis of multiple linear regression, it came to light that significant predictors of LOS in the final model could account for 37.9% of the variance in LOS. From the findings of current study, it can be inferred that clinical aspects as well as treatment procedures have major effects on LOS. Although the factors examined here could not explain an acceptable variance in LOS, the results are useful for the treatment team when they want to devise a care plan or give discharge to a patient.

Retrospective Analysis of Factors Associated with Long-Stay Hospitalizations in an Acute Psychiatric Ward

Purpose

To evaluate the longest hospitalizations in an acute psychiatric ward [Service of Psychiatric Diagnosis and Treatment (SPDT)] and the related demographic, clinical and organizational variables to understand the factors that contribute to long-stay (LOS) phenomenon. The term “long stay” indicates clinical, social and organizational problems responsible for delayed discharges. In psychiatry, clinical severity, social dysfunction and/or health-care system organization appear relevant factors in prolonging stays.

Patients and Methods

We divided all the SPDT hospitalizations from 1 January 2010 to 31 December 2015 into two groups based on the 97.5^th percentile of duration: ≤36 day (n=3254) and >36 day (n=81) stays, in order to compare the two groups for the selected variables. Comparisons were made using Pearson’s chi-square for categorical data and t-test for continuous variables, the correlation between the LOS, as a dependent variable, and the selected variables was analyzed in stepwise multiple linear regression and in multiple logistic regression models.

Results

The longest hospitalizations were significantly related to the diagnosis of “schizophrenia and other psychosis” (Pearson Chi²=17.24; p=0.045), the presence of moderate and severe aggressiveness (Pearson chi²=29; p=0.000), compulsory treatment (Pearson Chi²=8.05; p=0.005), parenteral or other route administration of psycho-pharmacotherapy (Pearson Chi²=12.91; p=0.007), poli-therapy (Pearson Chi²=6.40; p=0.041), complex psychiatric activities (Pearson Chi²=12.26; p=0.002) and rehabilitative programs (Pearson Chi²=37.05; p=0.000) during the hospitalization and at discharge (Pearson Chi²=29.89; p=0.000). Many demographic and clinical variables were statistically significantly correlated to the LOS at our multiple linear and logistic regression model.

Conclusion

In our sample, clinical illness severity and need for complex therapeutic and rehabilitative treatments were associated with prolonged psychiatric hospitalizations. Understanding this phenomenon can have not only economic but also clinical, ethical and social relevance.

Power, powerlessness and the politics of mobility: Reconsidering mental health geographies

We use a qualitative, longitudinal study of 25 individuals with mental illness in the UK to better understand the relationships among mental health, power/lessness and im/mobility. Framed by the rise of the new mobilities paradigm and more specifically Cresswell's (2010) politics of mobility, we find that the extent to which the respective mobilities were expressions of internal free will or were undertaken as a result of external compulsion is a key demarcator of mental health. A key contribution is understanding the involuntary nature of (forced) immobility, or what we call entrapment. Entrapment is a punishing phenomenon, which causes distress to those unfortunate to experience it, and which can often be deepened rather than alleviated by those statutory bodies charged with providing care and support. The results speak to the need to recognize that (1) mobility is always relational and contextual, (2) (im)mobility is as much involuntary as voluntary, and that this has crucial implications for (mental) health, and (3) that the experience of individuals suffering from mental illness very much overlaps with what Philo (2017) called 'less-than-human geographies', providing a much-needed rebalance to the over-emphasis on well-being within health geography and (mental) health policy.

Use of psychiatric hospitals and social integration of patients with psychiatric disorders: a prospective cohort study in five European countries

PURPOSE

Long lengths of stay (LoS) in psychiatric hospitals or repeated admission may affect the social integration of patients with psychiatric disorders. So far, however, studies have been inconclusive. This study aimed to analyse whether long LoS or repeated admissions in psychiatric wards were associated in different ways with changes in the social integration of patients.

METHODS

Within a prospective cohort study, data were collected on 2181 patients with a main ICD-10 diagnosis of psychotic, affective, or anxiety disorder, hospitalised in the UK, Italy, Germany, Poland, and Belgium in 2015. Social integration was measured at baseline and 1 year after admission using the SIX index, which includes four dimensions: employment, housing, family situation, and friendship. Regression models were performed to test the association between LoS, the number of admissions, and the change in social integration over the study period, controlling for patients' characteristics (trial registration ISRCTN40256812).

RESULTS

A longer LoS was significantly associated with a decrease in social integration (β = - 0.23, 95%CI - 0.32 to - 0.14, p = 0.03), particularly regarding employment (OR = 2.21, 95%CI 1.18-3.24, p = 0.02), housing (OR = 3.45, 95%CI 1.74-5.16, p < 0.001), and family situation (OR = 1.94, 95%CI 1.10-2.78, p = 0.04). In contrast, repeated admissions were only associated with a decrease in friendship contacts (OR = 1.15, 95CI% 1.08-1.22, p = 0.03).

CONCLUSIONS

Results suggest that a longer hospital LoS is more strongly associated with a decrease in patients' social integration than repeated admissions. Special attention should be paid to helping patients to find and retain housing and employment while hospitalised for long periods.

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.

Impact of the carer on length of hospital stay for mental health: Results from two Australian surveys

Informal carers play a vital role in supporting Australians living with a mental illness, including during the acute phases of illness; however, little is known about their impact on length of hospital stay. We aimed to investigate the impact of having a carer and of carer burden on length of hospital stay for mental health. Two Australian datasets were used. Data from the 2010 National Survey of High Impact Psychosis (n = 1825) were used to investigate the impact of having versus not having a carer on length of hospital stay for mental health. Data from the UQ Carer Survey 2016 (n = 105), a convenience sample of mental health carers, were used to investigate the impact of weekly hours of care (a measure of objective carer burden) on length of stay. Multiple logistic regression and correlation analyses were performed to investigate the association between carer status/burden and length of stay. Having a carer was associated with a significantly longer length of hospital stay; however, this relationship was no longer significant after adjusting for diagnosis, global functioning, depressive symptoms, deliberate self-harm, mental health outpatient contacts and type of admission. Weekly hours of care did not significantly impact on length of stay. Patients with carers had poorer functioning which may be related to longer stays. Our analysis was not able to look at subgroups of carers with different needs. Future work is required to determine other components of the admission and discharge process where having a carer is influential.

Factors associated with long length of stay in an inpatient psychiatric unit in Lilongwe, Malawi

PURPOSE

Studies of factors affecting length of stay during psychiatric hospitalization in sub-Saharan Africa are sparse. A better understanding of such factors may lead to interventions resulting in quicker patient stabilization and discharge, freeing up needed psychiatric beds and reducing health care system expenditures. Therefore, we sought to identify factors associated with long length of stay in Malawi.

METHODS

We reviewed the charts of 417 patients hospitalized at Kamuzu Central Hospital's Bwaila Psychiatric Unit in Lilongwe, Malawi from January 1 to December 31, 2011. Multivariate logistic regression analysis was employed to test for associations between patient factors and long length of stay (defined as more than 28 days).

RESULTS

Mean length of stay was 22.08 ± 27.70 days (range 0-243). 21.82% (91/417) of patients stayed longer than 28 days. Long length of stay was associated with living outside of Lilongwe district [aOR: 3.65 (1.66-8.01), p = 0.001] and treatment for antipsychotic extrapyramidal side effects (EPS) during hospitalization [aOR: 3.45 (1.32-9.03), p = 0.012]. Patients who had more interactions with medical providers for this episode of illness prior to presentation at the unit were less likely to have a long length of stay [aOR: 0.35 (0.16-0.76), p = 0.008].

CONCLUSIONS

Our findings demonstrate areas of possible intervention to reduce length of stay, including securing means for patient transport home, rapid identification and treatment of EPS, and reducing the risk of EPS by decreased use of high potency first-generation antipsychotics.

The association between comorbid psychiatric diagnoses and hospitalization-related factors among individuals with schizophrenia

BACKGROUND

Though schizophrenia is associated with substantial psychiatric comorbidity, data pertaining to multiple comorbid psychiatric disorders among individuals with schizophrenia is missing. Furthermore, despite abundant research indicating that the course of schizophrenia is characterized by relapses, often leading to psychiatric emergency room visits and consequent hospitalizations, data regarding the association between different comorbid psychiatric diagnoses among schizophrenia patients, and these hospitalization-related factors is lacking. The aim of this study was to describe the number and types of comorbid psychiatric diagnoses of inpatients diagnosed with schizophrenia, and to explore whether these are associated with hospitalization-related factors.

METHODS

Registry data from the years 1997-2017 was analyzed from a large psychiatric hospital database. We compared the annual mean number of psychiatric emergency room visits and hospitalizations, as well as mean length of hospitalizations, among individuals with schizophrenia and no additional psychiatric diagnosis, to those with one or more comorbid psychiatric diagnoses. Furthermore, we compared these hospitalization-related based on the different types of the comorbid diagnoses.

RESULTS

Among inpatient individuals with schizophrenia, the greater the number of comorbid psychiatric diagnoses, the higher the increase in number of emergency room visits and hospitalizations, as well as in the mean length of hospitalizations. Furthermore, all comorbid psychiatric disorders explored were found to be associated with an increase in the mentioned hospital-related factors. Such diagnoses include substance use disorders, bipolar, personality and depressive disorders, which were the most common disorders associated with schizophrenia.

CONCLUSIONS

Comorbid psychiatric disorders among inpatients with schizophrenia are associated with greater utilization of hospital-related services. These comorbid disorders should be addressed in the assessment and treatment of patients suffering from schizophrenia.

Assessing quality indicators related to mental health emergency room utilization

Background

This descriptive study compared 2014–15 to 2005–06 data on the quality of mental health services (MHS) in relation to emergency room (ER) use to assess the impact of the 2005 Quebec MH reform regarding access, continuity and appropriateness of care for patients with mental illnesses (PMI).

Methods

Data emanated from the Quebec Integrated Chronic Disease Surveillance System (Quebec/Canada). Participants (865,255 for 2014–15; 817,395 for 2005–06) were age 12 or over, with at least one MI, including substance use disorders (SUD), diagnosed during an ER visit, outpatient treatment or hospitalization. Variables included: access (ER use/frequency, hospitalization rates, outpatient consultations preceding an ER visit), care continuity (outpatient consultations following an ER visit/hospitalization, consecutive returns to the ERs), and care appropriateness (high ER use, recurrence of yearly ER visits, length of hospitalization). Frequency distributions were calculated on sex, age and geographic area for ER visits/hospitalizations in 2014–15, and between 2014 and 15 and 2005–06.

Results

PMI accounted for 12 % of the Quebec population in 2014–15 (n = 865,255), of whom 39% visited an ER for any reason. Amount and frequency of ER use and number/length of hospitalizations were almost twice as high for PMI versus patients without MI; 17% of PMI were also high/very high ER users and were frequently hospitalized. Among PMI, ER users were also frequent users of outpatient services despite a lack of follow-up appointments after ER visits or hospitalizations. Findings revealed some positive changes over time, such as decreased ER and hospitalization rates; yet overall access, continuity and appropriateness of care, as measured in this study, remained low.

Conclusions

This study demonstrated that the Quebec reform did not produce a substantial impact on ER use or substantially improved care, as hypothesized. Better access and continuity of care should be promoted to reduce the high prevalence of ER use among PMI. Quality improvement in MHS may be realized if ERs are supported by substantial and well-integrated community MH networks.

Health care utilization and cost after discharge from a mental health hospital; an RCT comparing community residential aftercare and treatment as usual

BACKGROUND

Community residential aftercare (step-down) services can ease the transition after a mental health hospital stay for patients with severe mental illness (SMI).

AIMS

To investigate use of community and specialised mental health care services and costs in patients with SMI the first 12 months after discharge from a mental health hospital (MHH), comparing community residential aftercare (CRA) and treatment as usual.

METHODS

An open parallel group randomised controlled trial with 41 participants. Data on use of specialist services (hospital, ambulant treatment and outpatient treatment) and community services (residential stays, home help, home care nursing, mental health consultation) were collected from specialist and community registers and health records.

RESULTS

For the primary outcome, utilisation of community mental health services, the intervention group used, on average, 29% fewer hours (mean differences - 21.6 h, 95% CI -93.1 to 44.9, p = .096) with a cost saving of 29% (mean differences - 1845 EUR, 95% CI -8267 to 4171, p = .102), but the estimates were imprecise. For the secondary outcome, the study groups had the same total number of inpatient days (66 days), but the intervention group had on average of 13.4 fewer inpatient days in the mental health hospital (95% CI -29.9 to 0.9. p = .008). The number of inpatient admissions (mean difference - 0.9 admissions, 95% CI -3.5 to 1.5, p = .224) and readmissions (- 0.8, 95% CI -2.5 to 0.9. p = .440) was lower in the intervention group. The intervention group had on average a total cost saving of 38.5% (mean differences - 23,071 EUR, 95% CI -45,450 to 3027. p = .057). A post hoc multivariable regression analysis controlling for baseline characteristics gave a reduction in total cost in favour of the intervention group of - 19,781 EUR (95% CI -44,072 to 4509, p=,107).

CONCLUSION

In this study, it was not possible to draw a definite conclusion about the effect, due to the small sample and imprecision of the estimates. The direction of the results and size of the point estimate, in addition to findings in other studies, indicates that transferring patients ready for discharge from mental hospital to community residential aftercare can have the potential to reduce total consumption of health services and costs without increased hospital admissions.

TRIAL REGISTRATION

Registered in clinicaltrials.gov ( NCT01719354 ).