Using national electronic health care registries for comparing the risk of psychiatric re-hospitalisation in six European countries: Opportunities and limitations

Factors associated with readmissions in psychiatric inpatient care: a prospective cohort study based on hospital registers

BACKGROUND

Readmissions in psychiatric inpatient care may reflect problems in the provision of care, but the underlying factors are not well known. We examined the associations of patient characteristics (sociodemographic factors, diagnoses), treatment (duration, previous episodes, neuromodulation) and ward overload with psychiatric inpatient readmissions and multiple readmissions in Finland.

METHODS

We used a routinely collected data pool from one hospital district and followed all 2052 hospitalizations that started in 2018. The outcomes were readmission within 30 days and one year, and among those with readmission, the number of readmissions.

RESULTS

Of the patients, 11% had readmission within 30 days and 33% had readmission within one year. Women, those with previous hospitalizations, those with an ICD-10 diagnosis from the 'behavioural syndromes associated with physiological disturbances and physical factors / disorders of adult personality and behaviour' group, those with a diagnosis from the 'neurotic, stress-related and somatoform disorders' group, those with psychotic disorders, and those who received neuromodulation treatment were more likely to have readmissions. Having a diagnosis of 'disorders of psychological development' or 'behavioural and emotional disorders with onset usually occurring in childhood and adolescence' was associated with a lower likelihood of readmission. The duration of treatment and ward overload during the index period were not associated with readmission.

CONCLUSIONS

The findings of this study suggest possible risk factors for readmission and can be used to plan psychiatric care. To some degree, the risk factors varied between different readmission types. It is important to examine whether there are unmet treatment needs in psychiatric inpatient care for children and adolescents.

Importance of GP contact on readmission rate following psychiatric acute care: A Danish Nationwide study

Insufficient acute psychiatric care substantially impacts patient well-being and healthcare quality. Early readmissions after discharge from psychiatric care are common, and preventing these is important for the patients as well as appropriate resource allocation. The relationship between post-discharge general practitioner (GP) contact and readmission rates remains to be explored, as does the association between pre-hospital GP contact and post-discharge engagement.

AIM

This study examines post-discharge GP contact and its association with outpatient revisits and inpatient readmissions among unplanned psychiatric hospital contacts, including the impact of pre-visit GP contact on post-discharge care within 14 days.

METHODS

Utilizing data from the Danish healthcare system (2019-2023), unplanned psychiatric hospital contacts and subsequent 14-day GP encounters were analyzed.

RESULTS

Of 298,085 unplanned psychiatric hospital contacts, 12.6% had a 14-day revisit as an outpatient and 13.6% had a 14-day readmission as an inpatient. During regular business hours, GP contact was associated with a decreased risk of unplanned outpatient revisits (HR 0.45, 95% CI 0.44-0.47) and inpatient readmissions (HR 0.43, 95% CI 0.41-0.44). Similarly, utilizing GP on-call services was linked to a reduced risk of unplanned revisits (HR 0.87, 95% CI 0.81-0.94) and readmissions (HR 0.81, 95% CI 0.76-0.87). Having a GP contact within two days before an unplanned psychiatric hospital contact increased the likelihood of having a GP contact within 14 days post-discharge.

CONCLUSION

Post-discharge GP encounters were associated with lower rates of 14-day outpatient revisits and inpatient readmissions following unplanned psychiatric hospital contacts. GP contact before psychiatric hospital contact enhances attendance at post-discharge appointments, suggesting a potential efficacy of promoting GP appointments for mental health care.

Factors contributing to readmission in patients with psychotic disorders, with a special reference to first follow-up visit in outpatient care

BACKGROUND

Timely outpatient follow-up and readmission after discharge are common quality indicators in psychiatric care, but their association varies in previous research. We aimed to examine whether the impact of outpatient follow-up and other factors on readmission risk evolves over time in people with non-affective psychotic disorder (NAP).

METHODS

The Finnish Quality of Care Register includes all people diagnosed with NAP since January 2010. Here, we followed patients with a hospital discharge between 2017 and 2021 until readmission, death, or up to 365 days. Time of the first outpatient follow-up appointment, length of stay (LOS), number of previous hospitalizations, psychosis diagnosis, substance use disorder (SUD), residential status, economic activity, gender, age, year, and region were included. Follow-up time was divided into five periods: week 1, weeks 2-4, weeks 5-13, weeks 14-25, and weeks 26-52, and each period was analyzed separately with Cox regression.

RESULTS

Of the 29 858 discharged individuals, 54.1% had an outpatient follow-up within a week. A total of 10 623 (35.6%) individuals were readmitted. Short LOS increased the readmission risk in the first four weeks, whereas lack of outpatient follow-up raised the risk (adjusted HRs between 1.15 (95% CI 1.04-1.26) and 1.53 (1.37-1.71) in weeks 5-52. The number of previous hospitalizations remained a consistent risk factor throughout the follow-up, while SUD increased risk after 4 weeks and living without family after 13 weeks.

CONCLUSIONS

Risk factors of readmission vary over time. These temporal patterns must be considered when developing outpatient treatment programs.

Enhancing the accuracy of register-based metrics: Comparing methods for handling overlapping psychiatric register entries in Finnish healthcare registers

OBJECTIVES

Healthcare registers are invaluable resources for research. Partly overlapping register entries and preliminary diagnoses may introduce bias. We compare various methods to address this issue and provide fully reproducible open-source R scripts.

METHODS

We used all Finnish healthcare registers 1969-2020, including inpatient, outpatient and primary care. Four distinct models were formulated based on previous reports to identify actual admissions, discharges, and discharge diagnoses. We calculated the annual number of treatment events and patients, and the median length of hospital stay (LOS). We compared these metrics to non-processed data. Additionally, we analyzed the lifetime number of individuals with registered mental disorders.

RESULTS

Overall, 2,130,468 individuals had a registered medical contact related to mental disorders. After processing, the annual number of inpatient episodes decreased by 5.85%-10.87% and LOS increased by up to 3 days (27.27%) in years 2011-2020. The number of individuals with lifetime diagnoses reduced by more than 1 percent point (pp) in two categories: schizophrenia spectrum (3.69-3.81pp) and organic mental disorders (1.2-1.27pp).

CONCLUSIONS

The methods employed in pre-processing register data significantly impact the number of inpatient episodes and LOS. Regarding lifetime incidence of mental disorders, schizophrenia spectrum disorders require a particular focus on data pre-processing.

Enhancing identification of nonaffective psychosis in register-based studies

The Finnish Quality of Psychosis Care Register assesses nonaffective psychosis (NAP) care, acknowledging treatment outside specialized psychiatric services. This approach, while providing a holistic view, raises concerns about diagnostic inaccuracies. Here, we studied situations where the register-based diagnosis might be inaccurate, and whether the first episode can be reliably identified using a 14-year wash-out period. People with first register-based NAP (ICD-10 F20-F29) between years 2010 and 2018 and without NAP diagnoses in 1996-2009 were identified from the Care Register for Health Care. A diagnosis of NAP was deemed unreliable before age 7, when dementia preceded NAP diagnosis, and when a NAP diagnosis had been assigned at admission or during psychiatric hospitalization but was not confirmed by discharge diagnosis. Despite a 14-year follow-back the first register diagnosis may miss the first treatment episode in older patients. Register-based studies on psychotic disorders should pay attention to exclusion criteria and to the definition of treatment onset.

Relapse in clinically stable adult patients with schizophrenia or schizoaffective disorder: evidence-based criteria derived by equipercentile linking and diagnostic test accuracy meta-analysis

BACKGROUND

There is no consensus on defining relapse in schizophrenia, and scale-derived criteria with unclear clinical relevance are widely used. We aimed to develop an evidence-based scale-derived set of criteria to define relapse in patients with schizophrenia or schizoaffective disorder.

METHODS

We searched the Yale University Open Data Access (YODA) for randomised controlled trials (RCTs) in clinically stable adults with schizophrenia or schizoaffective disorder, and obtained individual participant data on Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression Severity (CGI-S), Personal and Social Performance (PSP), and Social and Occupational Functioning Assessment Scale (SOFAS). Our main outcomes were PANSS-derived criteria based on worsening in PANSS total score. We examined their relevance using equipercentile linking with CGI-S and functioning scales, and their test-performance in defining relapse with diagnostic test accuracy meta-analysis against CGI-S worsening (≥1-point increase together with a score ≥4 points) and psychiatric hospitalisation.

FINDINGS

Based on data from seven RCTs (2354 participants; 1348 men [57·3%] and 1006 women [42·7%], mean age of 39·5 years [SD 12·0, range 17-89]; 303 Asian [12.9%], 255 Black [10.8%], 1665 White [70.7%], and other or unspecified 131 [5.6%]), an increase of 12 points or more in PANSS total (range 30-210 points) corresponded to clinically important deterioration in global severity of illness (≥1 point increase in CGI-S, range 1-7) and functioning (≥10 points decline in PSP or SOFAS, range 1-100). The interpretation of percentage changes varied importantly across different baseline scores. An increase of 12 points or more in PANSS total had good sensitivity and specificity using CGI-S as reference standard (sensitivity 82·1% [95% CI 77·1-86·4], specificity 86·9% [82·9-90·3]), as well as good sensitivity but lower specificity compared to hospitalisation (sensitivity 81·7% [74·1-87·7], specificity 69·2% [60·5-76·9]). Requiring either an increase in PANSS total or in specific items for positive and disorganization symptoms further improved test-performance. Cutoffs for situations where high sensitivity or specificity is needed are presented.

INTERPRETATION

An increase of either 12 points or more in the PANSS total score, or worsening of specific positive and disorganisation symptom items could be a reasonable evidence-based definition of relapse in schizophrenia, potentially linking symptoms used to define remission and relapse. Percentage changes should not be used to define relapse because their interpretation depends on baseline scores.

FUNDING

German Research Foundation (grant number: 428509362).

Impact of the workforce allocation on the technical performance of mental health services: the collective case of Helsinki-Uusimaa (Finland)

BACKGROUND

Long-term mental health (MH) policies in Finland aimed at investing in community care and promoting reforms have led to a reduction in the number of psychiatric hospital beds. However, most resources are still allocated to hospital and community residential services due to various social, economic and political factors. Despite previous research focussing on the number and cost of these services, no study has evaluated the emerging patterns of use, their technical performance and the relationship with the workforce structure.

OBJECTIVE

The purpose of this study was to observe the patterns of use and their technical performance (efficiency) of the main types of care of MH services in the Helsinki-Uusimaa region (Finland), and to analyse the potential relationship between technical performance and the corresponding workforce structure.

METHODS

The sample included acute hospital residential care, non-hospital residential care and outpatient care services. The analysis was conducted using regression analysis, Monte Carlo simulation, fuzzy inference and data envelopment analysis.

RESULTS

The analysis showed a statistically significant linear relationship between the number of service users and the length of stay, number of beds in non-hospital residential care and number of contacts in outpatient care services. The three service types displayed a similar pattern of technical performance, with high relative technical efficiency on average and a low probability of being efficient. The most efficient acute hospital and outpatient care services integrated multidisciplinary teams, while psychiatrists and nurses characterized non-hospital residential care.

CONCLUSIONS

The results indicated that the number of resources and utilization variables were linearly related to the number of users and that the relative technical efficiency of the services was similar across all types. This suggests homogenous MH management with small variations based on workforce allocation. Therefore, the distribution of workforce capacity should be considered in the development of effective policies and interventions in the southern Finnish MH system.

Are early post-discharge physician contacts associated with 30-day psychiatric re-hospitalisation? A nationwide claims data based retrospective cohort study in Austria free of immortal time bias

OBJECTIVES

Cost containment and quality of care considerations have increased research interest in the potential preventability of early re-hospitalisations. Various registry-based retrospective cohort studies on psychiatric re-hospitalisation have focused on the role of early post-discharge service contacts, but either did not consider their time-dependent nature ('immortal time bias') or evaded the issue by analysing late re-hospitalisations. The present study takes care of the immortal time bias in studying early psychiatric re-hospitalisations.

METHODS

In a retrospective cohort study using nationwide electronic claims data in Austria, 10,689 adults discharged from acute psychiatric inpatient wards were followed up for 30 days. Cox regression analyses were performed with post-discharge psychiatric and general practitioner contacts as time-dependent covariates and time to first psychiatric re-hospitalisation as outcome.

RESULTS

Post-discharge ambulatory physician contacts were significantly associated with a decreased psychiatric re-hospitalisation rate (hazard ratio 0.77 [95% CI 0.69; 0.87], p < 0.0001), with similarly strong contributions to this association by general practitioners and psychiatrists.

CONCLUSIONS

Despite avoiding the immortal time bias and controlling for several confounders, we suggest to be cautious with a causal interpretation of the identified association, since potentially relevant confounders, such as disease severity, were unavailable in our claims data base.

Risk of hospital admission after discharge from postpartum psychiatric emergency department visits: A focus on the social determinants of health

OBJECTIVE

Of those with postpartum psychiatric emergency department (ED) visits, a minority of receive hospital admission at their initial visit. Among those discharged, we aimed to determine subsequent risk of psychiatric admission, and understand how social determinants of health (SDOH) - individually and collectively - impact this risk.

METHOD

From all postpartum individuals discharged from psychiatric ED visits in Ontario, Canada (2008-2020)(n = 13,130), we generated adjusted relative risks (aRR) for psychiatric inpatient admission within 365 days post-ED visit by four SDOH (age, neighbourhood income, community size, immigration) and other clinical factors. Using latent class analysis (LCA) to identify subgroups based on clustering of SDOH, we then compared adjusted risk across subgroups.

RESULTS

Psychiatric admission occurred for 9.5% (n = 1242) within 365 days. Across SDOH, risk was lower among adolescents (vs. ≥35 years aRR 0.80, 95%CI 0.65-0.97) and immigrants (<5 years in Canada vs. Canadian-born/long-term residents 0.70, 0.51-0.96; ≥5 years in Canada 0.79, 0.65-0.95). Among four identified subgroups, compared to the "older/urban/high-income" subgroup (11.1% admission), the "urban/immigrant/low-income" (7.6%; 0.68, 0.55-0.82) and "young/rural/low-income" subgroups (9.7%; 0.78, 0.63-0.96), but not the "semi-urban/middle-income" subgroup (9.5%; 0.86, 0.73-1.01), were at lower admission risk.

CONCLUSIONS

Future research is needed to explore reasons for SDOH-based differences in admission risk, and inform equitable postpartum services.

The relationship between psychological characteristics of patients and their utilization of psychiatric inpatient treatment: A cross-sectional study, using machine learning

High utilizers (HU) are patients with an above-average use of psychiatric inpatient treatment. A precise characterization of this patient group is important when tailoring specific treatment approaches for them. While the current literature reports evidence of sociodemographic, and socio-clinical characteristics of HU, knowledge regarding their psychological characteristics is sparse. This study aimed to investigate the association between patients’ psychological characteristics and their utilization of psychiatric inpatient treatment. Patients from the University Psychiatric Clinics (UPK) Basel diagnosed with schizophrenia spectrum or bipolar affective disorders participated in a survey at the end of their inpatient treatment stay. The survey included assessments of psychological characteristics such as quality of life, self-esteem, self-stigma, subjective experience and meaning of psychoses, insight into the disease, and patients’ utilization of psychiatric inpatient treatment in the last 30 months. The outcome variables were two indicators of utilization of psychiatric inpatient treatment, viz. “utilization pattern” (defined as HU vs. Non-HU [NHU]) and “length of stay” (number of inpatient treatment days in the last 30 months). Statistical analyses included multiple regression models, the least absolute shrinkage and selection operator (lasso) method, and the random forest model. We included 112 inpatients, of which 50 were classified as HU and 62 as NHU. The low performance of all statistical models used after cross-validation suggests that none of the estimated psychological variables showed predictive accuracy and hence clinical relevance regarding these two outcomes. Results indicate no link between psychological characteristics and inpatient treatment utilization in patients diagnosed with schizophrenia spectrum or bipolar affective disorders. Thus, in this study, the examined psychological variables do not seem to play an important role in patients’ use of psychiatric inpatient treatment; this highlights the need for additional research to further examine underlying mechanisms of high utilization of psychiatric inpatient treatment.

In Search for Comparability: The PECUNIA Reference Unit Costs for Health and Social Care Services in Europe

Improving the efficiency of mental healthcare service delivery by learning from international best-practice examples requires valid data, including robust unit costs, which currently often lack cross-country comparability. The European ProgrammE in Costing, resource use measurement and outcome valuation for Use in multi-sectoral National and International health economic evaluAtions (PECUNIA) aimed to harmonize the international unit cost development. This article presents the methodology and set of 36 externally validated, standardized reference unit costs (RUCs) for five health and social care services (general practitioner, dentist, help-line, day-care center, nursing home) in Austria, England, Germany, Hungary, The Netherlands, and Spain based on unambiguous service definitions using the extended DESDE PECUNIA coding framework. The resulting PECUNIA RUCs are largely comparable across countries, with any causes for deviations (e.g., country-specific scope of services) transparently documented. Even under standardized methods, notable limitations due to data-driven divergences in key costing parameters remain. Increased cross-country comparability by adopting a uniform methodology and definitions can advance the quality of evidence-based policy guidance derived from health economic evaluations. The PECUNIA RUCs are available free of charge and aim to significantly improve the quality and feasibility of future economic evaluations and their transferability across mental health systems.

Psychiatric readmission rates in a multi-level mental health care system - a descriptive population cohort study

BACKGROUND

Readmission rates are frequently used as a quality indicator for health care, yet their validity for evaluating quality is unclear. Published research on variables affecting readmission to psychiatric hospitals have been inconsistent. The Norwegian specialist mental health care system is characterized by a multi-level structure; hospitals providing specialized -largely unplanned care and district psychiatric centers (DPCs) providing generalized -more often planned care. In certain service systems, readmission may be an integral part of individual patients' treatment plan. The aim of the present study was to describe and examine the task division in a multi-level health care system. This we did through describing differences in patient population (age, sex, diagnosis, substance abuse comorbidity and length of stay) and admissions types (unplanned vs. planned) treated at different levels (hospital, DPC or both), and by examining whether readmission risk differ according to type and place of treatment of index-admission and travel-time to nearest hospital and DPC.

METHODS

In this population-based cohort study using administrative data we included all individuals aged 18 and older who were discharged from psychiatric inpatient care with an ICD-10 diagnosis F2-F6 ("functional mental disorders") in 2012. Selecting each individual's first discharge during 2012 as index gave N = 16,185 for analyses following exclusions. Analysis of readmission risk were done using Kaplan-Maier failure curves.

RESULTS

Overall, 15.1 and 47.7% of patients were readmitted within 30 and 365 days, respectively. Unplanned admission patients were more likely to be readmitted within 30 days than planned patients. Those transferred between hospital and DPC during index admission were more likely to be readmitted within 365 days, and to experience planned readmission. Patients with short travel time were more likely to have unplanned readmission, while patients with long travel time were more likely to have planned readmission.

CONCLUSIONS

DPCs and hospitals fill different purposes in the Norwegian health care system, which is reflected in different patient populations. Differences in short term readmission rates between hospitals and DPCs disappeared when type of admission (unplanned/planned) was considered. The results stress the importance of addressing differences in organisation and task distribution when comparing readmission rates between mental health systems.

'If we would change things outside we wouldn't even need to go in…' supporting recovery via community-based actions: A focus group study on psychiatric rehospitalization

BACKGROUND

Psychiatric rehospitalization is a complex phenomenon in need of more person-centred approaches. The current paper aimed to explore how community-based actions and daily life influence mental health and rehospitalization.

DESIGN, SETTING AND PARTICIPANTS

The qualitative study included focus group data from six European countries including 59 participants. Data were thematically analysed following an inductive approach deriving themes and subthemes in relation to facilitators and barriers to mental health.

RESULTS

Barriers consisted of subthemes (financial difficulty, challenging family circumstances and stigma), and facilitators consisted of three subthemes (complementing services, signposting and recovery). The recovery subtheme consisted of a further five categories (family and friends, work and recreation, hope, using mental health experience and meaning).

DISCUSSION

Barriers to mental health largely related to social determinants of mental health, which may also have implications for psychiatric rehospitalization. Facilitators included community-based actions and aspects of daily life with ties to personal recovery. By articulating the value of these facilitators, we highlight benefits of a person-centred and recovery-focused approach also within the context of psychiatric rehospitalization.

CONCLUSIONS

This paper portrays how person-centred approaches and day-to-day community actions may impact psychiatric rehospitalization via barriers and facilitators, acknowledging the social determinants of mental health and personal recovery.

PATIENT OR PUBLIC CONTRIBUTION

The current study included participants with experience of psychiatric rehospitalization from six different European countries. Furthermore, transcripts were read by several of the focus group participants, and a service user representative participated in the entire research process in the original study.

Predicting Patients' Readmission: Do Clinicians Outperform a Statistical Model? An Exploratory Study on Clinical Risk Judgment in Mental Health

This study explores whether clinicians or a statistical model can better identify patients at risk of early readmission and investigates variables potentially associated with clinicians' risk judgment. We focus on a total of 142 patients discharged from acute psychiatric wards in the Verona Mental Health Department (Italy). Psychiatrists assessed patients' risk of readmission at 30 and 90 days postdischarge, predicted their postdischarge compliance, and assessed their Global Assessment of Functioning (GAF) score at admission and discharge. Clinicians' judgment outperformed the statistical model, with the difference reaching statistical significance for 30-day readmission. Clinicians' readmission risk judgment, both for 30 and 90 days, was found to be statistically associated with predicted compliance with community treatment and GAF score at discharge. Clinicians' superior performance might be explained by their risk judgment depending on nonmeasurable factors, such as experience and intuition. Patients with a poorer GAF score at discharge and poor assumed compliance were predicted to have a higher risk of readmission.