Validity of the Severity of Psychiatric Illness rating scale in a sample of inpatients on a psychogeriatric unit

Risk factors for repeated emergency compulsory psychiatric admissions

BACKGROUND

The characteristics of patients who have repeated compulsory psychiatric admissions are largely unknown.

AIMS

To investigate the frequency and risk factors for repeated emergency compulsory psychiatric admission (ECPA); and to identify targets for interventions to reduce repeated ECPA.

METHOD

Data were collected from a database of electronic patient files (EPFs) held by three psychiatric emergency services (PES) in the Netherlands. Analyses were based on the data for adult patients (aged 18-75 years) with a first PES contact in 2010-2015. Using descriptive statistics and regression analysis, we studied the associations between baseline patient factors and repeated ECPA and time to readmission, within a 2-year follow-up period.

RESULTS

We included 6059 patients: 15.6% had two or more ECPAs. In total, 66% of second ECPAs had occurred within 6 months of the first. About 30% of all ECPAs were repeated ECPAs. Two baseline factors were associated with a higher frequency of a second ECPA: history of receiving any mental healthcare treatment, whether in-patient or out-patient or both, and a lower level of self-care. Three were associated with a lower frequency: ethnicity (other than Dutch), older age and suicidality. Lower Global Assessment of Functioning (GAF) scores and housing problems were associated with a shorter time to compulsory readmission and persistent psychiatric problems with a longer time to compulsory readmission.

CONCLUSIONS

We found that 15.6% of patients had two or more ECPAs. Two-thirds of the second ECPAs had occurred within 6 months of the first. Like earlier studies, the risk factors we identified suggest that interventions to reduce the risk of repeated compulsory psychiatric admission should seek to improve self-care, general daily functioning and homelessness.

Predicting hospitalization following psychiatric crisis care using machine learning

BACKGROUND

Accurate prediction models for whether patients on the verge of a psychiatric criseis need hospitalization are lacking and machine learning methods may help improve the accuracy of psychiatric hospitalization prediction models. In this paper we evaluate the accuracy of ten machine learning algorithms, including the generalized linear model (GLM/logistic regression) to predict psychiatric hospitalization in the first 12 months after a psychiatric crisis care contact. We also evaluate an ensemble model to optimize the accuracy and we explore individual predictors of hospitalization.

METHODS

Data from 2084 patients included in the longitudinal Amsterdam Study of Acute Psychiatry with at least one reported psychiatric crisis care contact were included. Target variable for the prediction models was whether the patient was hospitalized in the 12 months following inclusion. The predictive power of 39 variables related to patients' socio-demographics, clinical characteristics and previous mental health care contacts was evaluated. The accuracy and area under the receiver operating characteristic curve (AUC) of the machine learning algorithms were compared and we also estimated the relative importance of each predictor variable. The best and least performing algorithms were compared with GLM/logistic regression using net reclassification improvement analysis and the five best performing algorithms were combined in an ensemble model using stacking.

RESULTS

All models performed above chance level. We found Gradient Boosting to be the best performing algorithm (AUC = 0.774) and K-Nearest Neighbors to be the least performing (AUC = 0.702). The performance of GLM/logistic regression (AUC = 0.76) was slightly above average among the tested algorithms. In a Net Reclassification Improvement analysis Gradient Boosting outperformed GLM/logistic regression by 2.9% and K-Nearest Neighbors by 11.3%. GLM/logistic regression outperformed K-Nearest Neighbors by 8.7%. Nine of the top-10 most important predictor variables were related to previous mental health care use.

CONCLUSIONS

Gradient Boosting led to the highest predictive accuracy and AUC while GLM/logistic regression performed average among the tested algorithms. Although statistically significant, the magnitude of the differences between the machine learning algorithms was in most cases modest. The results show that a predictive accuracy similar to the best performing model can be achieved when combining multiple algorithms in an ensemble model.

Suicide risk, personality disorder and hospital admission after assessment by psychiatric emergency services

BACKGROUND

The main objectives of the mobile Psychiatric Emergency Services (PES) in the Netherlands are to assess the presence of a mental disorder, to estimate risk to self or others, and to initiate continuity of care, including psychiatric hospital admission. The aim of this study was to assess the associations between the level of suicidality and risk of voluntary or involuntary admission in patients with and without a personality disorder who were presented to mobile PES.

METHODS

Observational data were obtained in three areas of the Netherlands from 2007 to 2016. In total, we included 71,707 contacts of patients aged 18 to 65 years. The outcome variable was voluntary or involuntary psychiatric admission. Suicide risk and personality disorder were assessed by PES-clinicians. Multivariable regression analysis was used to explore associations between suicide risk, personality disorder, and voluntary or involuntary admission.

RESULTS

Independently of the level of suicide risk, suicidal patients diagnosed with personality disorder were less likely to be admitted voluntarily than those without such a diagnosis (admission rate .37 versus .46 respectively). However, when the level of suicide risk was moderate or high, those with a personality disorder who were admitted involuntarily had the same probability of involuntary admission as those without such a disorder.

CONCLUSIONS

While the probability of voluntary admission was lower in those diagnosed with a personality disorder, independent of the level of suicidality, the probability of involuntary admission was only lower in those whose risk of suicide was low. Future longitudinal studies should investigate the associations between (involuntary) admission and course of suicidality in personality disorder.

Development and evaluation of Intensive Case Management Screening Sheet in the Japanese population

Background

In Japan, the mental health system has been shifting from hospitalization-based to community-based care; some organizations have gradually begun providing intensive case management (ICM) services. We developed an Intensive Case Management Screening Sheet (ICMSS) to screen for the need for ICM in people with mental illness.

Methods

The aim of this study was to examine the psychometric properties and discriminative ability of ICMSS. Subjects consisted of 911 people with mental illness. The ICMSS score was rated by a professional such as a nurse, social worker, or occupational therapist.

Results

Exploratory factor analysis showed a one-factor structure with 14 items. The factor structure was supported by confirmatory factor analysis (comparative fit index, 0.98; Tucker–Lewis index, 0.97; root mean square error test of close fit, 0.05). In the receiver operating characteristic analysis for discriminating between users and non-users of ICM services, the area under the curve (AUC) for ICMSS was significantly larger than for Global Assessment of Functioning and Personal and Social Performance Scale, indicating better discriminative ability. However, the AUC for ICMSS was moderate. Thus, we suggest that the need for ICM services is determined by quantitative assessment (i.e., ICMSS) and clinical judgment.

Conclusion

ICMSS is a brief tool for mental health professionals that will be useful in routine clinical practice. We expect that ICMSS will be used as a measure that reflects the views of professionals from various disciplines in Japanese institutions.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Amsterdam Studies of Acute Psychiatry I (ASAP-I); a prospective cohort study of determinants and outcome of coercive versus voluntary treatment interventions in a metropolitan area

BACKGROUND

The overall number of involuntary admissions is increasing in many European countries. Patients with severe mental illnesses more often progress to stages in which acute, coercive treatment is warranted. The number of studies that have examined this development and possible consequences in terms of optimizing health care delivery in emergency psychiatry is small and have a number of methodological shortcomings. The current study seeks to examine factors associated with compulsory admissions in the Amsterdam region, taking into account a comprehensive model with four groups of predictors: patient vulnerability, social support, responsiveness of the health care system and treatment adherence.

METHODS/DESIGN

This paper describes the design of the Amsterdam Study of Acute Psychiatry-I (ASAP-I). The study is a prospective cohort study, with one and two-year follow-up, comparing patients with and without forced admission by means of a selected nested case-control design. An estimated total number of 4,600 patients, aged 18 years and over, consecutively coming into contact with the Psychiatric Emergency Service Amsterdam (PESA) are included in the study. From this cohort, a randomly selected group of 125 involuntary admitted subjects and 125 subjects receiving non-coercive treatment are selected for further evaluation and comparison.First, socio-demographic, psychopathological and network characteristics, and prior use of health services will be described for all patients who come into contact with PESA. Second, the in-depth study of compulsory versus voluntary patients will examine which patient characteristics are associated with acute compulsory admission, also taking into account social network and healthcare variables. The third focus of the study is on the associations between patient vulnerability, social support, healthcare characteristics and treatment adherence in a two-year follow-up for patients with or without involuntarily admittance at the index consultation.

DISCUSSION

The current study seeks to establish a picture of the determinants of acute compulsory admissions in the Netherlands and tries to gain a better understanding of the association with the course of illness and patient's perception of services and treatment adherence. The final aim is to find specific patient and health care factors that can be influenced by adjusting treatment programs in order to reduce the number of involuntary admissions.

Adult Needs and Strengths Assessment–Abbreviated Referral Version to Specify Psychiatric Care Needed for Incoming Patients: Exploratory Analysis

The present study examined the Adult Needs and Strengths Assessment-Abbreviated Referral Version ratings for a group of 272 incoming psychiatric patients over a 2-yr. period to assess whether the rating scale was useful in predicting clinical placement for psychiatric treatment. Participants were patients (125 women) admitted to Regional Mental Health Care, St. Thomas, Canada between April 2004 and June 2006. Most participants were Euro-Canadian and ranged in age from 16 to 87 years. Clinical cutoff scores were established using observed mean differences in the patients' total scores and are expected to help guide psychiatric triage and longer term rehabilitation placement decisions. A canonical discriminant function analysis showed 85.9% of original level of care placements were correctly classified. The rating scale is a valid and reliable tool to specify level of psychiatric care needed for adults with mental disorders.

Do psychiatric patients improve their competency to consent to hospitalization after admission? A prospective study in an acute inpatient ward

OBJECTIVES

Competency to consent to hospitalization has important clinical and ethical implications. However, there are no follow-up studies that evaluate improvement in competency during psychiatric hospitalization. The authors sought to determine whether patients admitted to a psychiatric ward as incompetent to consent to hospitalization improve their competency during hospitalization.

METHOD

A total of 160 consecutively admitted patients were administered the Competency Questionnaire (CQ), a structured scale designed to assess competency to consent to psychiatric hospitalization. The CQ was administered both upon admission and at discharge. Severity and acuity of the psychiatric disorder were assessed with the Severity of Psychiatric Illness Scale and the Acuity of Psychiatric Illness Scale.

RESULTS

Of the 160 assessed patients, 70 (43.8%) were rated incompetent. Forty-five of these 70 incompetent patients completed the admission-to-discharge follow-up. Twenty-one of these 45 patients (46.6%) remained incompetent at discharge. Participation in the treatment process was the only variable that predicted improvement on competency during hospitalization. Severity of psychiatric illness at admission did not predict improvement on competency.

CONCLUSIONS

Nearly half of the patients who upon admission were incompetent remained incompetent at discharge.

Validity and reliability of an inpatient severity of psychiatric illness measure

Inpatient psychiatric severity measures are often used but few psychometric data are available. This study evaluated the psychometric properties (reliability and validity) of a measure used to assess severity of psychiatric illness among inpatients. Using the severity measure, minimally trained raters conducted retrospective patient record reviews to assess medical necessity for psychiatric hospitalization. The data analysis compared 135 civilly committed psychiatric inpatients with a heterogeneous group of 248 psychiatric inpatients at a general hospital. The severity measure showed acceptable inter-rater reliability in both populations. Two-way analysis of variance showed that the intra-class correlation coefficient for the total score was 0.65 for general hospital subjects and 0.63 for civilly committed subjects. Differences in mean scores were substantial (15 out of a possible 75 points for general hospital subjects versus 42 for civilly committed subjects, Mann-Whitney U = 562, p < 0.001). As expected, all civilly committed subjects were well above admission cut-off score of 12, versus only 64% of the general hospital patients. The measure is appropriate for retrospective severity assessment and may also be useful for pre-admission screening.

Determinants of geropsychiatric inpatient length of stay

Despite efforts to decrease lengths of acute psychiatric hospital stays, some geriatric inpatients continue to have extended stays. This research examined factors related to length of stay (LOS), including legal and administrative factors not traditionally included in prior studies. The charts of 384 patients, representing all 464 discharges from an inpatient geropsychiatric unit over a one-year period, were evaluated retrospectively and analyzed using logistic regression and logarithmic transformation. The LOS of over 12% of the inpatients was 26 days or more (average LOS 14.1). Factors significantly associated with longer LOS were: receiving electroconvulsive therapy (ECT), higher Brief Psychiatric Rating Scale (BPRS) positive symptoms scores, falling, pharmacology complications, multiple prior psychiatric hospitalizations, requiring court proceedings to continue hospitalization or medicate against will, consultation delays and not performing ECT on weekends. Neither demographics nor diagnoses alone had influence on length of stay. Incorporation of LOS predictors into Medicare Inpatient Prospective Payment System (IPPS) would more accurately account for the complexity in the cost of caring for geropsychiatry patients.

Recurrent falls are associated with increased length of stay in elderly psychiatric inpatients

OBJECTIVES

To identify factors which may contribute to prolonged length of stay in an elderly psychiatric inpatient setting.

DESIGN

Retrospective case note study.

METHODS

A list of all patients over the age of 65 discharged from a private psychiatric hospital over a three-year period excluding those with a length of stay of over 365 days was obtained (n = 1147). A random sample of 150 patients was selected from the study population. A case note study was then performed looking at a number of variables which have been postulated to affect length of stay. The resulting data was analysed using multivariate statistics.

RESULTS

There was no statistically significant association found between baseline factors (including age, gender, cognitive impairment, marital status, order of admission and preadmission living arrangement) and length of stay. Having recurrent falls whilst an inpatient was associated with prolonged hospital stay (p = 0.0006).

CONCLUSION

Experiencing recurrent falls whilst an inpatient is associated with prolonged length of stay. Recurrent falls in the elderly may be associated with both physical illness and the use of psychotropic medications. A prospective study examining factors contributing to falls would be important in decreasing fall risk and reducing length of stay.

Needs-based planning for persons with serious mental illness residing in intermediate care facilities

This study examined the association of clinical status to mental health service use among persons with mental illness living in residential care. Two hundred residents with a chart diagnosis of schizophrenia were randomly selected from four intermediate care facilities. The severity of psychiatric illness-community mental health (SPI-CMH) scale was used to assess clinical status and symptom severity according to three dimensions: symptoms and functioning, risk behaviors, and complication to illness. Lower levels of severity of psychiatric illness were associated with participation in workshops, family contact, and admitting to mental health problems. Results suggest that residents of the intermediate care facilities have clinical needs consistent with habilitation and rehabilitation services. While residents infrequently engage in high-risk behavior such as suicide and violence, they have considerable living skills and vocational needs. Future research should consider the relationship over time of mental health service utilization, severity of psychiatric illness, and psychosocial factors.

Needs-based planning: evaluation of a level-of-care planning model

With the closure of a number of provincial psychiatric hospitals planned, the Ministry of Health of Ontario has commissioned a series of planning projects to identify alternative placements for current hospital patients. The goal is to match need to care in the least restrictive setting. A systematic, clinically driven planning process was implemented that involved three steps: development of a continuum of levels of care representing increasingly intensive and more restrictive supports, development of criteria and decision rules for placement, and comprehensive needs assessment of current patients using the Colorado Client Assessment Record. Results showed that only 10% of current inpatients need to remain in the hospital, and over 60% could live independently in the community with appropriate supports. Evidence supports concurrent validity of the planning model, but further work is needed to assess whether recommended levels of care effectively meet consumer needs in the least restrictive setting.

The effectiveness of old age psychiatry services

The objective of this study was to review outcomes of acute service delivery in old age psychiatry. Sources of data included Medline, PsycINFO and Cochrane Collaboration databases of English language papers to 1998 on service delivery evaluation in 'old age psychiatry', 'psychogeriatrics' and 'geriatric psychiatry', supplemented by a manual search of references from relevant literature. All controlled trials, audits, and surveys of the outcomes of service delivery in old age psychiatry located in acute hospitals and community settings were included. Service delivery by medical, adult psychiatry and consultation/liaison services were included. With the exception of outreach services to nursing homes, long term institutional care was excluded. All data were extracted by the author. Data quality was assessed by applying an evidence hierarchy. Evaluation strategies were qualitatively reviewed. Controlled trials, audits and surveys were each found to provide important data in the evaluation of service delivery. There is better quality evidence to support the effectiveness of components of old age psychiatry services than other service types. The majority of studies indicate that old age psychiatry services have positive acute treatment outcomes, particularly with depression. There is insufficient evidence to determine which processes of care are associated with better outcomes. Pluralistic evaluations indicate that carers often have unmet needs and are not as positive about outcomes. There have been no controlled comparisons of service delivery provided by other services. In conclusion, controlled trials and audits indicate that old age psychiatry services are effective. Further pluralistic evaluations and comparisons with other services are required.

Clinical trials versus mental health services research: contributions and connections

The growing emphasis on using empirical data to guide mental health policy decision making has contributed, in part, to a developing dichotomy along the continuum of research on mental health interventions. At one end of the continuum is research on the efficacy of mental health interventions, traditionally referred to as clinical trials research. The goal of clinical trials research is to determine whether or not a specific intervention can be shown to be efficacious for a specific problem. At the other end of the continuum is research on the implementation and evaluation of mental health interventions, traditionally referred to as mental health services research. The goals of mental health services research are to understand the access to, organization and financing of, and outcomes of mental health interventions. The conceptual, methodological, and measurement features of both types of research are presented and suggestions are offered to bridge the gap between the two paradigms. The purpose of this article is to highlight each discipline's unique contributions to mental health research and, in so doing, facilitate a discussion that fosters scientific integration and collaboration between clinical trials and mental health services investigators.

Classifying psychiatric inpatients: seeking better measures

BACKGROUND

Use of case-mix reimbursement in psychiatric inpatients has been limited as a result of a lack of systems which effectively group patients according to required resource needs. In recognition of the fact that many patient factors, in addition to diagnosis influence delivery of care in psychiatry, new measures of patient need are emerging.

OBJECTIVE

This study compared improvement realized by using a multidimensional measure of patient severity, the Computerized Severity Index (CSI), to predict length of stay (LOS) in psychiatric inpatients over that achieved by using patient variables routinely collected in the discharge abstract.

METHOD

Through retrospective chart review, severity ratings were made on 355 psychiatric discharges with primary diagnoses of psychotic or major depressive disorders. Those ratings were combined with demographic and diagnostic data available in discharge abstracts and were then entered into multivariate regression analyses to model LOS.

RESULT

CSI ratings significantly contributed to prediction models, which accounted for an additional 9% to 11% of variation in LOS over discharge abstract data. Among patients with psychotic disorders, maximum severity during hospitalization was the best predictor of LOS, whereas among patients with depressive disorders, it was an increase in severity following admission.

CONCLUSION

Severity ratings, based on chart review, improved prediction of LOS over discharge abstract variables for psychiatric inpatients in two diagnostic groups. Further research is needed to estimate the impact of incorporating severity ratings into a grouping system for all psychiatric inpatients. Estimation of predictive accuracy is important to determine the amount of risk passed on to providers in a payment system based on psychiatric case mix.

INTERMED--an assessment and classification system for case complexity. Results in patients with low back pain

STUDY DESIGN

Cross-sectional investigation and follow-up of patients with low back pain.

OBJECTIVES

To evaluate the capacity of the INTERMED--a biopsychosocial assessment and classification system for case complexity--to identify patients with a chronic, disabling course of low back pain and to predict treatment outcome.

SUMMARY OF BACKGROUND DATA

An impressive number of biologic and nonbiologic factors influencing the course of low back pain have been identified. However, the lack of a concise, comprehensive, reliable and validated classification system of this heterogeneous patient population hampers preventive and therapeutic progress.

METHODS

The INTERMED was used to assess patients with low back pain, who participated in a functional rehabilitation program (n = 50) and patients with low back pain who applied for disability compensation (n = 50). Patients of the rehabilitation program were observed to assess the effects of treatments.

RESULTS

The INTERMED distinguished between patients in different phases of disability and provided meaningful information about the biopsychosocial aspects of low back pain. In hierarchical cluster analysis two distinct clusters emerged that differed in the degree of case complexity and treatment outcomes.

CONCLUSIONS

This first application of the INTERMED indicates its potential utility as a classification system for patients with low back pain.

"INTERMED": a method to assess health service needs. I. Development and reliability

The purpose of this paper is to describe the development and to test the reliability of a new method called INTERMED, for health service needs assessment. The INTERMED integrates the biopsychosocial aspects of disease and the relationship between patient and health care system in a comprehensive scheme and reflects an operationalized conceptual approach to case mix or case complexity. The method is developed to enhance interdisciplinary communication between (para-) medical specialists and to provide a method to describe case complexity for clinical, scientific, and educational purposes. First, a feasibility study (N = 21 patients) was conducted which included double scoring and discussion of the results. This led to a version of the instrument on which two interrater reliability studies were performed. In study 1, the INTERMED was double scored for 14 patients admitted to an internal ward by a psychiatrist and an internist on the basis of a joint interview conducted by both. In study 2, on the basis of medical charts, two clinicians separately double scored the INTERMED in 16 patients referred to the outpatient psychiatric consultation service. Averaged over both studies, in 94.2% of all ratings there was no important difference between the raters (more than 1 point difference). As a research interview, it takes about 20 minutes; as part of the whole process of history taking it takes about 15 minutes. In both studies, improvements were suggested by the results. Analyses of study 1 revealed that on most items there was considerable agreement; some items were improved. Also, the reference point for the prognoses was changed so that it reflected both short- and long-term prognoses. Analyses of study 2 showed that in this setting, less agreement between the raters was obtained due to the fact that the raters were less experienced and the scoring procedure was more susceptible to differences. Some improvements--mainly of the anchor points--were specified which may further enhance interrater reliability. The INTERMED proves to be a reliable method for classifying patients' care needs, especially when used by experienced raters scoring by patient interview. It can be a useful tool in assessing patients' care needs, as well as the level of needed adjustment between general and mental health service delivery. The INTERMED is easily applicable in the clinical setting at low time-costs.

Characteristics of short-stay admissions to a psychiatric inpatient service

Since the rapid expansion of managed care coupled with dramatic reductions in lengths of inpatient stay, there is widespread concern that the emphasis on cost containment is eclipsing attention to patient care. The present study was undertaken to evaluate speculations that the majority of short-stay (less than 48 hours) admissions to a psychiatric inpatient service at a large teaching hospital in the midwestern United States consisted of public pay patients who were rapidly transferred to area state hospitals. Using two cases mix measures, severity of illness and changes in acuity and clinical outcomes of a sample of short-stay (n = 77) and longer stay (n = 145) admissions were compared. Short-stay admissions, although similar to longer stay patients in terms of demographics, Axis I diagnosis, payer status, and appropriateness of admission, are clinically distinct. The use of nonhospital alternatives in treating a subsample of suicidal patients and the implications for improved mental health services delivery are discussed.

Predicting psychiatric emergency admissions and hospital outcome

OBJECTIVES

A decision support tool for psychiatric hospital admissions was developed and validated to provide reliable, clinically relevant information to providers and case managers.

METHODS

Using the Severity of Psychiatric Illness rating system, an empirical model of psychiatric emergency decision-making was constructed and validated on a spilt sample of 254 crisis cases.

RESULTS

Three dimensions of the Severity of Psychiatric Illness system-Suicide Potential, Danger to Others, and Severity of Symptoms-were used to construct a model that successfully predicted 73% of decisions about level of care (inpatient or outpatient). Clear misses, patients with a 0.20 probability of being hospitalized who were admitted, and patients with an 0.80 probability or greater of being hospitalized who were not admitted were reviewed to allow for utilization review. This decision support tool then was validated by predicting hospital outcomes in two additional samples. First, a random sample of consecutive admissions to a not-for-profit psychiatric hospital were studied. Second, a panel of admissions from a large managed care firm were evaluated.

CONCLUSIONS

Results demonstrate that the decision to hospitalize patients in psychiatric hospitals is rational and that models predicting admission also can predict in-hospital outcomes.

The treatment of dangerous patients in managed care. Psychiatric hospital utilization and outcome

The legal criteria for civil commitment dictates that individuals must be mentally ill, and either a danger to themselves, a danger to others, or substantially impaired in their ability to provide for their basic needs. These criteria, which have been adopted as medical necessity criteria by managed care programs, may result in a change in the clinical mix of the psychiatric inpatient population. The present study assesses the incidence of dangerousness among psychiatric inpatients and compares dangerous and nondangerous patients in terms of characteristics and treatment outcomes. The results indicate that for a large regional managed care program, 30% of psychiatric inpatients have a history of dangerousness in the past year. Patients who are rated as dangerous to others during admission have higher rates of complications for treatment and psychiatric disorders such as residential and vocational instability, family disruption, and higher premorbid dysfunction. They are also more likely to engage in disruptive and aggressive behavior during their hospital stays. Despite the higher incidence of acute and long-term dysfunction for dangerous patients, their hospitalization length of stay was comparable to that of patients not rated as dangerous.