Predictors for readmission risk of new patients: the Nordic Comparative Study on Sectorized Psychiatry

Functioning, psychiatric symptoms and quality of life of individuals with severe mental disorders after psychiatric rehabilitation

PURPOSE

Psychiatric disorders may have a negative effect on individuals' living, forming intimate relationships, education, and employment. The aim of psychiatric rehabilitation is to promote recovery - finding ways to cope with mental disorders despite debilitating symptoms. This study aimed to explore the outcomes of accommodation, social inclusion, psychiatric symptoms, substance and service use, quality of life and subjective recovery of young adults with severe mental illness after psychiatric rehabilitation.

MATERIALS AND METHODS

The study population consisted of individuals who had been in residential psychiatric rehabilitation between the ages of 18-29 years. Data on outcomes were collected using a questionnaire after a flexible follow-up period (mean 29 months). The questionnaire was answered by 32 eligible persons. We analysed multiple outcomes and compared the proportion of persons living independently at the start, after psychiatric rehabilitation, and at the follow-up point.

RESULTS

At the start of the rehabilitation, 33%, at the end, 69%, and at follow-up, 78% lived independently. However, most had not reached competitive employment nor were studying. Cognitive symptoms were the most common psychiatric symptoms, followed by depressive symptoms. More than 80% of the sample felt that they had partly recovered from their severe mental illness.

CONCLUSION

According to the results of this study residential psychiatric rehabilitation may have positive effects on functioning and independent living at follow-up. Reaching competitive employment is difficult for persons with severe mental disorders and effective rehabilitation interventions need to be implemented. However, this study had limitations, and these results should be considered preliminary.

The revolving door phenomenon in severe psychiatric disorders: A systematic review

BACKGROUND

The treatment of psychiatric patients has suffered a major change over the last decades, with long-term hospitalizations being replaced by short-term stays and appropriate aftercare in outpatient services. Some chronically ill patients exhibit a pattern of multiple hospitalizations, designated as the Revolving Door (RD) phenomenon.

AIMS

This review aims to analyse the existing literature regarding sociodemographic, clinical and other factors associated with multiple hospitalizations in psychiatric facilities.

METHOD

The search performed in the PubMed database for the terms revolving[Title] AND (psyc*[Title] OR schizo*[Title] OR mental[Title]) presented 30 citations, 8 of which met the eligibility criteria. Four other studies found in references of these articles were also included in the review.

RESULTS

Albeit the use of different criteria to define the RD phenomenon, it is more likely to be associated with patients who are younger, single, with low educational level, unemployed, diagnosed with a psychotic disorder, particularly schizophrenia, and with alcohol and/or substance use. It is also associated with a younger age on disease onset, suicidality, noncompliance and voluntary type of admission.

CONCLUSION

Recognizing patients with a RD pattern of admissions and prediction of rehospitalization can help the development of preventive intervention strategies and identify potential limitations in existing health care delivery systems.

Searching for factors associated with the "Revolving Door phenomenon" in the psychiatric inpatient unit: A 5-year retrospective cohort study

The revolving door (RD) phenomenon refers to subjects who undergo frequent rehospitalizations in psychiatric units. The main aim of this study was to analyze clinical factors associated with RD in acute inpatient psychiatric ward. In a 5-year cohort study, subjects hospitalized three or more times in 12 months (revolving door subjects-RDS) were identified. A total of 1,324 subjects were hospitalized. RDS represented 6.3% (n = 84) of the entire sample with a total of 337 RD hospitalizations (revolving door hospitalizations-RDH) (16.7% of all admissions). RDS were younger, unmarried, with comorbid substance related disorders, with mood or psychotic disorders and affected by comorbid medical conditions. After controlling for age, sex and marital status, the most strongly associated variable with RDH was the comorbidity between mood and substance use disorders. Other associated factors were the presence of a comorbid medical condition and a longer length of stay. The commitment to community residential facilities and the treatment with a first generation long-acting antipsychotic were also associated with RDH. On the contrary, admissions to the psychiatric unit for manic/hypomanic episode or for self-directed harmful behavior were inversely associated with RDH. Attention should be given to these clinical variables in order to reduce RD.

Life after hospital discharge for people with long-term mental disorders in South Korea: Focusing on the "revolving door phenomenon"

PURPOSE

The purpose of this study was to explore the lives of Koreans with long-term mental disorders who had experienced multiple readmissions after hospital discharges.

METHODS

In-depth interviews were conducted with 11 participants and thematic analysis was used to examine their data.

FINDINGS

Four themes emerged from the data, describing their lives: they suffered in the aspects of social maladjustment, loneliness, causing shame to their families, and managing mental illnesses.

PRACTICAL IMPLICATIONS

After patients with mental disorders are discharged from the hospital, they need transitional care before systematic community-based care to enhance their autonomy and reduce the burden on their families.

Factors associated with 30-days and 180-days psychiatric readmissions: A snapshot of a metropolitan area

Psychiatric re-hospitalization rate is a widely used quality indicator within mental health care. This study aims to investigate which variables are implied in determining readmissions over two intervals after the index event, 30 days and 6 months. The study sample included 798 inpatients, it was divided into two groups: not readmitted patients (NRP) and readmitted patients (RP), which has been further split into: Readmitted within 30 days (RP30dd) and Readmitted during the 150-day period (between 31 and 180 days) after the index discharge (RP150). A multivariate logistic regression with backward selection method was performed in order to find variables independently associated with readmission. The overall incidence of readmissions was 16.04%. Discharge to a Psychiatric Nursing Home was found to be a protective factor for all the groups. In adds, for the overall readmission, compulsory index admission and higher education (this lasts as in RP30dd group) were protective factors; whereas higher length of stay (as for readmission within 31-180 days) and a diagnosis of Personality Disorder were risk factors. The patient-specific factors significantly associated with likelihood of rehospitalization in the final model do identify some high-risk groups toward to whom possibly address prevention strategies.

Clinical and organizational factors predicting readmission for mental health patients across Italy

PURPOSE

The aims of our study are: to explore rehospitalization in mental health services across Italian regions, Local Health Districts (LHDs), and hospitals; to examine the predictive power of different clinical and organizational factors.

METHODS

The data set included adult patients resident in Italy discharged from a general hospital episode with a main psychiatric diagnosis in 2012. Independent variables at the individual, hospital, LHD, and region levels were used. Outcome variables were individual-level readmission and LHD-level readmission rate to any hospital at 1-year follow-up. The association with readmission of each variable was assessed through both single- and multi-level logistic regression; descriptive statistics were provided to assess geographical variation. Relevance of contextual effects was investigated through a series of random-effects regressions without covariates.

RESULTS

The national 1-year readmission rate was 43.0%, with a cross-regional coefficient of variation of 6.28%. Predictors of readmission were: admission in the same LHD as residence, psychotic disorder, higher length of stay (LoS), higher rate of public beds in the LHD; protective factors were: young age, involuntary admission, and intermediate number of public healthcare staff at the LHD level. Contextual factors turned out to affect readmission only to a limited degree.

CONCLUSIONS

Homogeneity of readmission rates across regions, LHDs, hospitals, and groups of patients may be considered as a positive feature in terms of equity of the mental healthcare system. Our results highlight that readmission is mainly determined by individual-level factors. Future research is needed to better explore the relationship between readmission and LoS, discharge decision, and resource availability.

The association between family dysfunction and admission to an acute mental health inpatient unit: a prospective study

OBJECTIVES

With the shift from deinstitutionalization to community care in mental health services, relatives of persons with severe and enduring mental illnesses have had to take over the role as primary caregivers. Disturbed family dynamics have been observed within families with an 'ill' member. Although schizophrenia and related mental illnesses are biologically based disorders, environmental stress (including stress within family relationships) plays a major role in the onset and maintenance of symptoms. With this study, we assume that family dynamics play a central role in the course of severe psychiatric illness and hypothesized that dysfunction within family systems is a prognostic indicator of hospitalization in the course of schizophrenia/bipolar and schizoaffective disorders.

METHODS

Prospective, observational cohort study evaluating family functioning of 121 patients (schizophrenia/bipolar and schizoaffective disorder) from community at baseline and followed-up over 12-month period after recruitment. Measurements included demographics, diagnosis, Family Assessment Device - General Functioning, Perceived Criticism Scale, Brief Psychiatric Rating Scale, Global Assessment of Functioning and Social Support Questionnaire-6.

RESULTS

Significant differences found between patients admitted and not admitted during the 12-month time period for age (p = 0.003), Brief Psychiatric Rating Scale (BPRS; p = 0.026), Family Assessment Device - General Functioning (FAD-GF; p = 0.007) and Social Support Questionnaire total satisfaction level (p = 0.042) at baseline. Bivariate analysis showed that those admitted into hospital were younger with a higher BPRS score, less social satisfaction and disturbed family dynamics. FAD-GF (p = 0.006) and age (p = 0.022) were significant independent predictors for admission.

CONCLUSION

This provides further evidence supporting importance of promoting better family functioning through modified family dynamics, integrating and involving family into the care of such patients.

High-Risk Phenotypes of Early Psychiatric Readmission in Bipolar Disorder With Comorbid Medical Illness

BACKGROUND

Individuals with co-existing serious mental illness and non-psychiatric medical illness are at high risk of acute care utilization. Mining of electronic health record data can help identify and categorize predictors of psychiatric hospital readmission in this population.

OBJECTIVE

This study aimed to identify modifiable predictors of psychiatric readmission among individuals with comorbid bipolar disorder and medical illness. This goal was accomplished by applying objective variable selection via machine learning techniques.

METHOD

This was a retrospective analysis of electronic health record data derived from 77,296 episodes of care from 2006 to 2016 within the University of California Health Care System. Data included 1,250 episodes of care involving patients with bipolar disorder and serious comorbid medical illnesses (defined by transfer between medicine and psychiatry services or concomitant primary medical and psychiatric admission diagnoses). Machine learning (classification trees) was used to identify potential predictors of 30-day psychiatric readmission across hospital encounters. Predictors included demographics, medical and psychiatric diagnoses, medication regimen, and disposition. The algorithm was internally validated using 10-fold cross-validation.

RESULTS

The model predicted 30-day readmission with high accuracy (98% unbalanced model, 88% balanced model). Modifiable predictors of readmission were length of stay, transfers between medical and psychiatric services, discharge disposition to home, and all-cause acute health service utilization in the year before the index hospitalization.

CONCLUSION

Among bipolar disorder patients with comorbid medical conditions, characteristics of the index hospitalization (e.g., duration, transfer, and disposition) emerged as more predictive than static properties of the patient (e.g., sociodemographic factors and psychiatric comorbidity burden). Findings identified phenotypes of patients at high risk for rehospitalization and suggest potential ways of modifying the risk of early readmission.

Psychiatric inpatient cost of care before and after admission at a residential subacute step-up/step-down mental health facility

BACKGROUND

Residential step-up/step-down services provide transitional care and reintegration into the community for individuals experiencing episodes of subacute mental illness. This study aims to examine psychiatric inpatient admissions, length of stay, and per capita cost of care following the establishment of a step-up/step-down Prevention And Recovery Care (PARC) facility in regional Australia.

METHODS

This was a pragmatic before and after study set within a participatory action research methodology. The target sample comprised patients at a PARC facility over 15 months. Six-month individual level data prior to study entry, during, and over 6-months from study exit were examined using patient activity records. Costs were expressed in 2015-2016AU$.

RESULTS

An audit included 192 people experiencing 243 episodes of care represented by males (58%), mean age = 39.3 years (SD = 12.7), primarily diagnosed with schizophrenia (48%) or mood disorders (30%). The cost of 1 day in a psychiatric inpatient unit was found to be comparable to an average of 5 treatment days in PARC; the mean cost difference per-bed day (AU$1,167) was associated with fewer and shorter inpatient stays. Reduced use of inpatient facility translated into an opportunity cost of improved patient flow equivalent to AU$12,555 per resident (bootstrapped 95% CI = $5,680-$19,280). More noticeable outcomes were observed among those who stayed in PARC for longer during index admission (r_s = 0.16, p = 0.024), who have had more and lengthy inpatient stays (r_s = 0.52, p < 0.001 and r_s = 0.69, p < 0.001), and those who stepped-down from the hospital (p < 0.001). This information could be proactively used within step-up/step-down services to target care to patients most likely to benefit. Despite early evidence of positive association, the results warrant further investigation using an experimental study design with alongside economic evaluation.

CONCLUSION

Efforts should be directed toward the adoption of cost-effective alternatives to psychiatric inpatient facilities that provide comparable or improved patient outcomes.

Pharmacological risk factors associated with hospital readmission rates in a psychiatric cohort identified using prescriptome data mining

BACKGROUND

Worldwide, over 14% of individuals hospitalized for psychiatric reasons have readmissions to hospitals within 30 days after discharge. Predicting patients at risk and leveraging accelerated interventions can reduce the rates of early readmission, a negative clinical outcome (i.e., a treatment failure) that affects the quality of life of patient. To implement individualized interventions, it is necessary to predict those individuals at highest risk for 30-day readmission. In this study, our aim was to conduct a data-driven investigation to find the pharmacological factors influencing 30-day all-cause, intra- and interdepartmental readmissions after an index psychiatric admission, using the compendium of prescription data (prescriptome) from electronic medical records (EMR).

METHODS

The data scientists in the project received a deidentified database from the Mount Sinai Data Warehouse, which was used to perform all analyses. Data was stored in a secured MySQL database, normalized and indexed using a unique hexadecimal identifier associated with the data for psychiatric illness visits. We used Bayesian logistic regression models to evaluate the association of prescription data with 30-day readmission risk. We constructed individual models and compiled results after adjusting for covariates, including drug exposure, age, and gender. We also performed digital comorbidity survey using EMR data combined with the estimation of shared genetic architecture using genomic annotations to disease phenotypes.

RESULTS

Using an automated, data-driven approach, we identified prescription medications, side effects (primary side effects), and drug-drug interaction-induced side effects (secondary side effects) associated with readmission risk in a cohort of 1275 patients using prescriptome analytics. In our study, we identified 28 drugs associated with risk for readmission among psychiatric patients. Based on prescription data, Pravastatin had the highest risk of readmission (OR = 13.10; 95% CI (2.82, 60.8)). We also identified enrichment of primary side effects (n = 4006) and secondary side effects (n = 36) induced by prescription drugs in the subset of readmitted patients (n = 89) compared to the non-readmitted subgroup (n = 1186). Digital comorbidity analyses and shared genetic analyses further reveals that cardiovascular disease and psychiatric conditions are comorbid and share functional gene modules (cardiomyopathy and anxiety disorder: shared genes (n = 37; P = 1.06815E-06)).

CONCLUSIONS

Large scale prescriptome data is now available from EMRs and accessible for analytics that could improve healthcare outcomes. Such analyses could also drive hypothesis and data-driven research. In this study, we explored the utility of prescriptome data to identify factors driving readmission in a psychiatric cohort. Converging digital health data from EMRs and systems biology investigations reveal a subset of patient populations that have significant comorbidities with cardiovascular diseases are more likely to be readmitted. Further, the genetic architecture of psychiatric illness also suggests overlap with cardiovascular diseases. In summary, assessment of medications, side effects, and drug-drug interactions in a clinical setting as well as genomic information using a data mining approach could help to find factors that could help to lower readmission rates in patients with mental illness.

Socio-demographic characteristics and factors associated with hospitalization in psychiatry of old age patients: an international comparison between Ireland and Turkey

BACKGROUND

Taking predictors of hospitalization characteristics into consideration internationally would broaden our understanding of this population on a local basis.

AIMS

We aimed to examine and compare socio-demographic profiles along with hospitalization characteristics including length of hospital stay (LOS), reasons for admission and diagnoses among older adult inpatients hospitalized in Ireland and Turkey, and to assess factors predicting these features.

METHODS

The admission charts of 356 psychiatric inpatients over 65 years of age who were admitted to two different acute psychiatric hospitals (Sligo/Ireland and Istanbul/Turkey) were analysed by means of descriptive modalities and logistic regression.

RESULTS

There were significant differences in several domains of socio-demographics, reasons of admission and diagnoses. LOS was significantly longer in Ireland. Living alone was the only significant predictor for longer LOS in both countries, whereas in addition to living alone, younger age was also a contributor for longer LOS in Turkey.

DISCUSSION

Given that the only factor predicting LOS both in Turkey and Ireland was living alone, helping to identify more acceptable ways of providing social support for living arrangements constitutes an important service to shorten LOS in old age psychiatric population.

CONCLUSIONS

It is possible to infer that independent from the cultural diversities, living arrangement is a consistent entity to influence length of hospital stay in older adult population.

Evaluating psychiatric readmissions in the emergency department of a large public hospital

INTRODUCTION

Hospital emergency departments (EDs) around the country are being challenged by an ever-increasing volume of patients seeking psychiatric services. This manuscript describes a study performed to identify internal and external factors contributing to repeated psychiatric patient admissions to the hospital main ED.

METHODS

Data from ED visits of patients who were admitted to the Parkland Memorial Hospital ED (the community hospital for Dallas County, TX, USA) with a psychiatric complaint more than once within a 30-day period were evaluated (n=202). A 50-item readmission survey was used to collect information on demographic and clinical factors associated with 30-day readmission, as well as to identify quality improvement opportunities by assessing related moderating factors. An analysis of acute readmission visits (occurring within 3 days of previous discharge) was also performed.

RESULTS

Patients readmitted to the ED commonly present with a combination of acute psychiatric symptoms, substance use (especially in the case of acute readmission), and violent or suicidal behavior. The vast majority of cases reviewed found that readmitted patients had difficulties coordinating care outside the ED. A number of moderating factors were identified and targeted for quality improvement including additional support for filling prescriptions, transportation, communication with family and outside providers, drug and alcohol treatment, intensive case management, and housing.

CONCLUSION

Many of the resources necessary to reduce psychiatric patient visits to hospital EDs are available within the community. There is no formal method of integrating and insuring the continuity of community services that may reduce the demand for psychiatric and related services in the ED. While agreements between community service providers may be challenging and require considerable vigilance to maintain equitable agreements between parties, this route of improving efficiency may be the only available method, given the current and projected patient care needs.

Rapid and frequent psychiatric readmissions: associated factors

OBJECTIVE

This article aims to examine the impact of clinical and demographic factors on both rapid readmission (being readmitted within 30 d) and frequent readmission (experiencing three or more admissions) in a London mental health trust.

METHODS

A four-year study period with a sample of 7648 inpatients were examined with chi-square or Mann-Whitney U tests, and binary logistic regressions to assess the associations and possible predictors of rapid (readmitted within 30 d) and frequent (admitted at least three times) readmission.

RESULTS

Frequent admitters were more likely to be unemployed, have more care-coordinators, be living in accommodation with support, be Black or Black British, and to have certain diagnoses. Binary logistic regression revealed that our variables of interest explained between 36.1 and 60.9% of the variation in number of readmissions (±3 admissions), and between 3.7 and 4.2% of the variation in time to readmission (±30 d).

CONCLUSIONS

Identifying factors that are associated with rehospitalisation and understanding their importance is necessary to reduce the risk of readmission. This study suggests that particular demographic, clinical and treatment factors require consideration to tackle the seemingly wide range of factors that could be affecting readmission to inpatient services.

Overview of post-discharge predictors for psychiatric re-hospitalisations: a systematic review of the literature

BACKGROUND

High levels of hospital readmission (rehospitalisation rates) is widely used as indicator of a poor quality of care. This is sometimes also referred to as recidivism or heavy utilization. Previous studies have examined a number of factors likely to influence readmission, although a systematic review of research on post-discharge factors and readmissions has not been conducted so far. The main objective of this review was to identify frequently reported post-discharge factors and their effects on readmission rates.

METHODS

Studies on the association between post-discharge variables and readmission after an index discharge with a main psychiatric diagnosis were searched in the bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management, OpenGrey and Google Scholar. Relevant articles published between January 1990 and June 2014 were included. A systematic approach was used to extract and organize in categories the information about post-discharge factors associated with readmission rates.

RESULTS

Of the 760 articles identified by the initial search, 80 were selected for this review which included a total number of 59 different predictors of psychiatric readmission. Subsequently these were grouped into four categories: 1) individual vulnerability factors, 2) aftercare related factors, 3) community care and service responsiveness, and 4) contextual factors and social support. Individual factors were addressed in 58 papers and were found to be significant in 37 of these, aftercare factors were significant in 30 out of the 45 papers, community care and social support factors were significant in 21 out of 31 papers addressing these while contextual factors and social support were significant in all seven papers which studied them.

CONCLUSIONS

This review represents a first attempt at providing an overview of post-discharge factors previously studied in association with readmission. Hence, by mapping out the current research in the area, it highlights the gaps in research and it provides guidance future studies in the area.

Factors associated with readmission in South African adolescents discharged from two inpatient psychosocial rehabilitation units

OBJECTIVE

This study aimed to describe the socio-demographic and clinical factors associated with readmission in an adolescent population discharged from two inpatient psychosocial rehabilitation (PSR) units in Cape Town, South Africa.

METHOD

Data were obtained from 97 consecutive patients discharged from two adolescent psychiatric PSR units over a period of one year. Patients were followed up for readmission to hospitals offering specialised psychiatric care in the Western Cape Province over a period of 18 months.

RESULTS

35 patients (36%) were readmitted during the study period. Multivariable analysis showed that previous admission increased readmission rate (Incidence Rate Ratio (IRR): 8.01, p < 0.001). Adolescents who were still schooling (IRR: 0.29, p < 0.001) or had a higher level of education (IRR: 0.45, p = 0.001) were less likely to be readmitted. No association was seen with type of diagnosis and readmission, although 51 adolescents (53%) were diagnosed on the schizophrenia spectrum of disorders.

CONCLUSION

Study findings highlight the need for increased collaboration between the Departments of Health and Education. Furthermore, the study illustrates the need for specific post-discharge community follow-up for adolescents. Prospective research in this particular population group is needed to contribute to the literature on factors associated with readmission in South African adolescent patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Challenges following discharge from acute psychiatric inpatient care in Japan: patients' perspectives

WHAT IS KNOWN ON THE SUBJECT?: A lack of transitional care covering the period from psychiatric hospital discharge to community mental health care can increase the likelihood of illness recurrence or readmission of discharged patients. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The participants expressed the view that discontinuity between inpatient and community life was a post-discharge challenge after being involuntarily admitted to a psychiatric emergency ward. These challenges arose from the dissatisfaction with inpatient treatment, inability to coordinate post-discharge life WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Patients should be able to disclose their feelings about their own experiences in inpatient care settings and the current challenges in community care settings in an open manner. An advocate should be appointed in acute psychiatric inpatient care settings to reflect patients' own feelings and individual needs to transitional care without bias to inpatient and community care providers.

ABSTRACT

Introduction Psychiatric care in Japan usually comprises inpatient care provided during lengthy hospital stays. Recently, policies for shortening psychiatric hospital stays have been aggressively pursued. However, appropriate transitional care is not always provided for acute psychiatric inpatient care. Aim We elucidated patients' challenges immediately after hospital discharge following acute psychiatric inpatient care to clarify how to improve inpatient care and post-discharge follow-ups. Method This study utilized a qualitative descriptive study design and incorporated patient interviews. Participants comprised 18 patients who experienced involuntary admission following a diagnosis of schizophrenia spectrum disorder. Inductive qualitative content analysis was used to create codes and categories from interview transcripts. Findings The core category of post-discharge challenges that emerged was 'separating life as an inpatient from community life'. This comprised two subcategories: 'dissatisfaction with the inpatient care received' and 'lack of abilities to coordinate lifestyle following discharge'. Discussion Patients should be able to disclose their feelings about their experiences in inpatient care settings and the current challenges in community care settings openly. Implications for practice Advocate (e.g. peer staff) should be appointed in acute psychiatric inpatient care settings to reflect patients' feelings and individual needs to transitional care without bias to inpatient and community care providers.

Risk Factors for Psychiatric Hospital Admission for Participants in California's Full-Service Partnership Program

This study investigated the demographic and clinical predictors of psychiatric hospitalization during the first 2 years of treatment for adults participating in the full-service partnership (FSP) program, based on Assertive Community Treatment, in a large county in northern California. Clinical and demographic characteristics, data on prior hospitalizations, length of enrollment, and living situation for 328 FSP participants were collected from the county's internal billing system and the California Department of Health Care Services. In univariate models, the probability of hospitalization varied by diagnosis, age, and hospitalization history. In the multivariate model, younger age and frequent hospitalization prior to enrollment predicted hospitalization during enrollment. Findings support prior research on hospital recidivism and may be beneficial in refining future strategies for meeting the needs of adults with serious mental illness.

When Partial Hospitalization Fails: Risk Factors for Inpatient Hospitalization

Partial hospitalization is an understudied bridge between outpatient and inpatient care. One of its primary functions is to prevent the need for inpatient hospitalization. We examined potential demographic and clinical risk factors for inpatient hospitalization for current partial hospital patients. We conducted separate multiple logistic regression analyses for patients referred from inpatient care and the community. For individuals referred from inpatient care, suicidal ideation and greater psychotic symptoms upon admission to the partial program were associated with acute inpatient re-hospitalization. For individuals referred from the community, suicidal ideation and worse relationship functioning upon partial hospital admission were significant risk factors for inpatient hospitalization. Number of previous inpatient hospitalizations and greater substance abuse were not associated with inpatient hospitalization in either sample. Implications at the provider and program level are discussed.

Social functioning as a predictor of the use of mental health resources in patients with severe mental disorder

Previous studies have tried to determine the factors causing greater use of health resources by patients with mental disorders. These studies have essentially focused on socio-economic variables. Nevertheless, many other variables, such as social functioning, have not yet been explored. This study aims to assess the effect of social functioning on mental health service use in a sample of patients with severe mental disorder (schizophrenia, other psychotic disorders or bipolar affective disorder) in an area of Spain. The Social Functioning Scale (SFS) was administered to 172 family members of patients with a severe mental disorder who were receiving care at a community mental health unit. Analysis of bivariate logistic regression identified specific areas as predictors of the use of mental health resources over a 12-month follow-up period. The overall social functioning score predicted need for hospital admissions. In addition, interpersonal behaviour had a major role in the number of outpatient visits, while social isolation significantly predicted the need for hospitalization. These results point out the necessity for including psychosocial variables, such as social functioning in current mental health resource use models.

Predictors of psychiatric rehospitalization among elderly patients

The population of Hong Kong and the proportion of elderly people have been increasing rapidly. The aim of this retrospective cohort study is to determine predictive factors for psychiatric rehospitalization within 2 years among elderly patients who were discharged from psychiatric wards, in attempt to reduce their rehospitalization rate and to reintegrate them into the community. Patients aged 65 and over, who were discharged from psychiatric wards of Pamela Youde Nethersole Eastern Hospital from 1 March 2010 to 29 February 2012, were identified. Rehospitalization within 2 years after discharge was the primary outcome measure, and the time to rehospitalization was measured as the secondary outcome. Patients were subgrouped into readmitted and non-readmitted groups. Logistic regression and Cox regression analyses were applied to the potential predictive factors with odds ratios and hazard ratios obtained, respectively, for the significant findings. Kaplan-Meier survival curves were plotted for graphical representation of the study results in survival analysis. 368 individuals satisfying the study criteria were identified. The same four factors were shown to be significantly associated with rehospitalization in both multiple logistic regression and Cox regression survival analysis. Referral to other psychiatric disciplines upon discharge (p< 0.001, OR=0.325, HR=0.405) was associated with a lower rehospitalization risk and correlated to a longer time to rehospitalization. History of suicidal behaviors (p< 0.001, OR=4.906, HR=3.161), history of violent behaviors (p< 0.001, OR=5.443, HR=3.935) and greater number of previous psychiatric admissions (p< 0.001, OR=1.250, HR=1.121)  were associated with a higher rehospitalization risk and predicted earlier rehospitalization. The rehospitalization rate of elderly patients was 5.2% at 1 month, 9.5% at 3 months, 15.0% at 6 months, 17.1% at 1 year, 18.8% at 1.5 year and 20.9% at 2 years.

Factors differentially associated with early readmission at a university teaching psychiatric hospital

RATIONALE, AIMS AND OBJECTIVES

The rate of psychiatric readmissions within 30 days of discharge is a well-established behavioural health system performance measure linked to the quality of inpatient hospital care as well as to access to community-based aftercare services. The purpose of this study was to examine the factors differentially associated with earlier readmission among a sample of patients (n = 588) readmitted within 30 days of discharge to a university teaching psychiatric hospital from 2001 to 2010.

METHODS

Quality assurance interviews were conducted with patients readmitted within 30 days of discharge. The interview data were merged with clinical symptom and electronic medical record data. Multinomial logistic regression analysis was used to examine readmission within 7 days and from 8 to 14 days compared with 15-30 days after discharge while controlling for socio-demographic and treatment variables previously associated with psychiatric readmission.

RESULTS

Multiple clinical, treatment and patient-reported factors were differentially associated with earlier readmission. In particular, lack of engagement in post-discharge aftercare services was a strong predictor of earlier readmission.

CONCLUSIONS

Strategies are needed to improve patients' transition from inpatient psychiatric hospitalization to aftercare services. Psychiatric hospitals attempting to reduce very early readmissions should seek to implement innovative transitional care initiatives targeting both patient and treatment factors.

Predictors of frequent recourse to health professionals by people with severe mental disorders

OBJECTIVE

Based on Andersen's behavioural model, our study sought to determine predictors and blocks of factors that could explain why people with severe mental disorders (SMDs) more often seek the services of health professionals.

METHODS

This longitudinal study involved 292 users with SMDs located in Le Sud-Ouest, the southwest borough of Montreal. Data were collected from participants' medical records and through 7 questionnaires. Using Andersen's Behavioral Model of Health Services Use, independent variables were divided into 3 classes-predisposing factors, enabling factors, and need factors-and were introduced in this order in a hierarchical logistic model.

RESULTS

Among 292 users, 110 (37.7%) were frequent users who consulted about one health professional every 3 days. Participants who were more likely to call on health professionals were single and older, depended on welfare as their main source of income, lived in supervised housing, suffered from schizophrenia, schizophrenia spectrum disorders, and adjustment disorders, and, marginally, exhibited multiple mental disorders.

CONCLUSION

Mental health services could promote strategies to overcome the reluctance of younger people to seek professional services. Professionals should pay close attention to subsidiary conditions, such as adjustment disorders, from which people with SMDs may suffer. Interventions to improve the socioeconomic condition of unemployed people with SMDs may help to reduce health care service use among that clientele. Programs such as supported employment should be tailored and enhanced for people receiving welfare to decrease stigmatization and improve job market integration.

Patterns of service utilisation in psychosis: findings of the 2010 Australian national survey of psychosis

OBJECTIVE

This paper reports patterns of health service utilisation in the second Australian national survey of psychosis corresponding with changes in available services of this period.

METHOD

Semi-structured interviews were carried out of an age-stratified random sample of adults who screened positive for psychosis. Multivariate logistic regressions were used to identify predictors of service use for a sample of 1825 individuals.

RESULTS

Use of psychiatric inpatient services was associated with higher symptom levels, suicidal ideation, poor social functioning and younger age. High users of emergency mental health services similarly reported higher symptom levels, poor functioning and younger age, and also reported being married or in a de facto relationship. Recipients of general practitioner services had greater anxiety symptoms and suicidal thoughts, fewer negative symptoms, single marital status and English as their first language. Rehabilitation service use was associated with greater anxiety symptoms, unemployment, younger age of illness onset, living alone and having no dependent children living at home. Last, outpatient/community services were more frequently used by younger people with good premorbid adjustment, hallucinations and a less severe course of illness.

CONCLUSIONS

Service utilisation patterns vary with the clinical and socio-demographic features of those who use them - inpatient and emergency service users being similar in such features and differing from users of other services. Comparison with the first national survey of psychosis revealed a significant decline in acute inpatient service use and a substantial increase in the use of outpatient/community and rehabilitation services over the past 10 years.

Time-dependent effect analysis of antipsychotic treatment in a naturalistic cohort study of patients with schizophrenia

OBJECTIVE

Evidence based treatment of schizophrenia as well as antipsychotic drug utility patterns have changed considerably in recent years and the present study aims to investigate the current level of unplanned hospital readmissions in a cohort of patients with schizophrenia, and to determine the risk-reducing effects of current antipsychotic drug treatment.

METHOD

An open cohort study included all consecutively discharged patients with schizophrenia in a 3-year period (n=277). The treatment-dependent variables were entered in a multivariate Cox survival analyses with time to unplanned readmission as the dependent variable.

RESULTS

11.2% of patients were readmitted within 30 days of discharge, and 44.8% were readmitted within 12 months. Antipsychotic monotherapy reduced the risk of readmission by 74.9%. Treatment in CMHC also had a risk-reducing effect. The prescription rate of clozapine in this sample was 10.1%.

DISCUSSION

The over-all level of unplanned readmissions was in correspondence with the findings of others. Current antipsychotic drug treatment independently offers strong protection against unplanned readmissions. There may be a potential for further optimalizing antipsychotic drug treatment according to treatment guidelines.

CONCLUSIONS

Unplanned readmissions are very common for patients with schizophrenia but antipsychotic drug treatment is associated with a strong risk-reducing effect in this regard.

Transitional interventions to reduce early psychiatric readmissions in adults: systematic review

BACKGROUND

Up to 13% of psychiatric patients are readmitted shortly after discharge. Interventions that ensure successful transitions to community care may play a key role in preventing early readmission.

AIMS

To describe and evaluate interventions applied during the transition from in-patient to out-patient care in preventing early psychiatric readmission.

METHOD

Systematic review of transitional interventions among adults admitted to hospital with mental illness where the study outcome was psychiatric readmission.

RESULTS

The review included 15 studies with 15 non-overlapping intervention components. Absolute risk reductions of 13.6 to 37.0% were observed in statistically significant studies. Effective intervention components were: pre- and post-discharge patient psychoeducation, structured needs assessments, medication reconciliation/education, transition managers and in-patient/out-patient provider communication. Key limitations were small sample size and risk of bias.

CONCLUSIONS

Many effective transitional intervention components are feasible and likely to be cost-effective. Future research can provide direction about the specific components necessary and/or sufficient for preventing early psychiatric readmission.

Factors associated with frequent psychiatric admissions in a general hospital in Spain

OBJECTIVES

To identify demographic or clinical factors associated with frequent admissions in a sample of patients admitted to an acute psychiatric hospitalization unit, controlling for potentially confounding factors.

METHODS

Socio-demographic variables, diagnosis, and the legal status, date and length of admission were collected for 1,722 consecutively admitted psychiatric patients during a period of up to eight years (1998-2005). Frequently admitted patients were defined as undergoing one or more admissions per year on average.

RESULTS

After controlling for potential confounding factors, logistic regression showed that being a frequently admitted patient was significantly associated with diagnoses of schizoaffective disorder, personality disorder or schizophrenia; an involuntary commitment at first admission; and younger age.

CONCLUSIONS

Factors associated with frequently admitted patients should be identified in order to establish more effective strategies for preventing relapse.

Predictors of re-hospitalization over a two-year follow-up period among patients with schizophrenia enrolled in a community management program in Chengdu, China

BACKGROUND

China has recently introduced a community-based service network for managing individuals with schizophrenia but there has been relatively little formal evaluation of the effectiveness of this approach.

OBJECTIVE

Assess the retention rate and the two-year re-hospitalization rate of patients who are enrolled in the community management network in Chengdu, China.

METHODS

Patients with a confirmed diagnosis of schizophrenia who had at least one prior hospitalization and who were enrolled in the service network at the community health clinics in 14 communities in the Jinniu District of Chengdu and 10 communities in the Qingyang District of Chengdu participated in the two-year prospective follow-up assessment. Detailed demographic and clinical information was obtained at the time of intake into the follow-up program and their hospitalization status was recorded during monthly evaluations over the subsequent two years.

RESULTS

Of the 1 027 participating patients, 963 (93.8%) remained in the program for the entire two-year period. Patients with a lower level of education and those who did not live with family members were more likely to drop-out of the network. Among the 963 patients who completed the follow-up 174 (18.1%) were re-hospitalized over the two-year period. Multivariate logistic regression identified factors related to re-hospitalization: not married or not living with family members, having more prominent positive and negative symptoms at the time of intake, and using medication less in the six months prior to intake.

CONCLUSION

The 94% two-year retention of patients in this urban community management network for individuals with schizophrenia was excellent and the two-year re-hospitalization rate of 18% is better than that reported in most similar programs in other countries. Patients not living with family members were at higher risk for dropping out of the network and for re-hospitalization so this is a high-risk group that deserves special attention. Standardization of the community interventions and longer follow-up studies with control communities that consider the full range of factors relevant to the well-being of patients with schizophrenia (i.e., social integration, quality of life and re-hospitalization) are needed to definitively demonstrate the effectiveness of this community service network.

Hospitalisation for schizophrenia in acute psychiatric wards of the Lazio region: a 4-year follow-up study

Aim – To determine the rates of psychiatric hospitalisation and to evaluate the predictors of readmissions in a cohort of 887 schizophrenic patients at their “first” psychiatric admission. Methods – Data were collected using the hospital dis-charge database of the Lazio region, Italy. The cohort included patients admitted to a psychiatric ward in 1999, with a main diagnosis of schizophrenia and no prior psychiatric hospitalisation during the 5 years preceding the index admission. Psychiatric read-missions were considered up to year 2004. Kaplan-Meier survival curves and logistic procedures were performed to estimate the cumulative readmission incidence and ORs of readmissions for potential confounders. Results – During the 4-year follow-up, 44.3% of the patients were readmitted at least once. An active treatment among community psychiatric facilities at the time of index admission predicted a higher readmission risk. However, for those who experienced their first admission in a private ward read-mission risk was consistently higher, whether or not having had such a treatment. Conclusions – Risk of readmission in a psychiatric ward appears to be related to the level of integration with mental health community facilities, while length of stay is strongly affected by service system variables. Possible uses of medical information systems in this field are described.

Declaration of Interest: none.

An examination of risk factors for readmission to acute adult mental health services within 28 days of discharge in the Australian setting

OBJECTIVE

The aim of this paper was to identify risk factors associated with readmission within 28 days of discharge from eight Australian adult acute mental health inpatient services.

METHOD

A detailed file audit was conducted comparing 222 patients readmitted within 28 days of discharge with 253 patients not readmitted during the same period.

RESULTS

There was an association between early readmission and having had contact with the service in the previous 12 months (51% vs 21%), having been admitted in the previous 12 months (65% vs 36%), and having been diagnosed with an emotionally unstable personality disorder (14% vs 4%). Those who were not readmitted had a significantly higher score in the Health of the Nation Outcome Scales on index admission than those who were readmitted. Those who had community team contact on the day of discharge and those who received follow up by the mental health team within 7 days of discharge were more likely to be readmitted (55% vs 45% and 29% vs 19% respectively).

CONCLUSIONS

Significant determinants of early readmission identified were a history of recent previous admissions and a diagnosis of unstable personality disorder. The usefulness of this performance measure to Area Mental Health Services and clinicians is discussed.

Typology of adults diagnosed with mental disorders based on socio-demographics and clinical and service use characteristics

BACKGROUND

Mental disorder is a leading cause of morbidity worldwide. Its cost and negative impact on productivity are substantial. Consequently, improving mental health-care system efficiency - especially service utilisation - is a priority. Few studies have explored the use of services by specific subgroups of persons with mental disorder; a better understanding of these individuals is key to improving service planning. This study develops a typology of individuals, diagnosed with mental disorder in a 12-month period, based on their individual characteristics and use of services within a Canadian urban catchment area of 258,000 persons served by a psychiatric hospital.

METHODS

From among the 2,443 people who took part in the survey, 406 (17%) experienced at least one episode of mental disorder (as per the Composite International Diagnostic Interview (CIDI)) in the 12 months pre-interview. These individuals were selected for cluster analysis.

RESULTS

Analysis yielded four user clusters: people who experienced mainly anxiety disorder; depressive disorder; alcohol and/or drug disorder; and multiple mental and dependence disorder. Two clusters were more closely associated with females and anxiety or depressive disorders. In the two other clusters, males were over-represented compared with the sample as a whole, namely, substance abuses with or without concomitant mental disorder. Clusters with the greatest number of mental disorders per subject used a greater number of mental health-care services. Conversely, clusters associated exclusively with dependence disorders used few services.

CONCLUSION

The study found considerable heterogeneity among socio-demographic characteristics, number of disorders, and number of health-care services used by individuals with mental or dependence disorders. Cluster analysis revealed important differences in service use with regard to gender and age. It reinforces the relevance of developing targeted programs for subgroups of individuals with mental and/or dependence disorders. Strategies aimed at changing low service users' attitude (youths and males) or instituting specialised programs for that particular clientele should be promoted. Finally, as concomitant disorders are frequent among individuals with mental disorder, psychological services and/or addiction programs must be prioritised as components of integrated services when planning treatment.

Predictors of psychiatric readmissions in the short- and long-term: a population-based study in Taiwan

OBJECTIVES

To explore the risks and rates of readmission and their predictors 14 days, one year, and five years after discharge for the psychiatric population in Taiwan.

METHODS

This was a prospective study based on claims from 44,237 first-time hospitalized psychiatric patients discharged in 2000, who were followed for up to five years after discharge. The cumulative incidence and incidence density of readmission were calculated for various follow-up periods after discharge, and Cox proportional hazard models were generated to identify the significant predictors for psychiatric readmission.

RESULTS

The less than 14-day, one-year, and five-year cumulative incidences were estimated at 6.1%, 22.3%, and 37.8%, respectively. The corresponding figures for incidence density were 4.58, 1.04, and 0.69 per 1,000 person-days, respectively. Certain factors were significantly associated with increased risk of readmission irrespective of the length of follow-up, including male gender, length of hospital stay >15 days, economic poverty, a leading discharge diagnosis of schizophrenia/affective disorders, and residence in less-urbanized regions. Compared to children/adolescents, young adults (20-39 years) were significantly associated with increased risks of

CONCLUSIONS

This study found that the significant predictors for psychiatric readmission 14 days to five years after discharge were essentially the same except for patient's age and hospital accreditation level. This study also highlighted the importance of socioeconomic factors in the prediction of readmission.

Collapse

Key Words

• Affective disorder
• Health services research
• Readmission
• Schizophrenia
• Social factor

Collapse

MESH Headings

• Adult
• Age Factors
• Aged
• Epidemiologic Methods
• Female
• Hospitals, Psychiatric/statistics & numerical data
• Humans
• Male
• Middle Aged
• Patient Discharge/statistics & numerical data
• Patient Readmission/statistics & numerical data
• Schizophrenia/rehabilitation
• Socioeconomic Factors
• Taiwan
• Time Factors
• Young Adult

Collapse

Grants Collapse

Affiliation(s)

Chuan-Hsiung Lin Department of Health Care Administration, Central Taiwan University of Science and Technology - Taichung, Taiwan
Wen-Ling Chen Department of Health Care Management, National Taipei College of Nursing - Taipei, Taiwan
Chih-Ming Lin Department of Healthcare Information and Management, Ming Chuan University - Taoyuan County, Taiwan
Ming-Der Lee Graduate Institute of Long-Term Care, National Taipei College of Nursing, - Taipei, Taiwan
Ming-Chung Ko Department of Surgery, Taipei City Hospital - Taipei, Taiwan.,
Chung-Yi Li Department of Health Care Management, National Taipei College of Nursing - Taipei, Taiwan

Collapse

Readmission to an acute psychiatric unit within 28 days of discharge: identifying those at risk

Objective.To examine factors that could help identify those most at risk of readmission to an acute psychiatric in-patient unit within 28 days of a discharge. Method.A detailed file audit was conducted comparing 54 consecutive patients who had been readmitted within 28 days of discharge with 61 patients, chosen at random, who had not been readmitted during the same period. Results.Readmission within 28-days of discharge was associated with having been admitted in the previous year (P = 0.004), receiving the Disability Support Pension (P = 0.015), not having a discharge plan sent to the patient’s GP on discharge from the index admission (P = 0.05), receiving follow-up by the mental health team within 7 days of discharge (P = 0.007) and being unemployed (P = 0.015). Conclusions.Targeting those with previous admissions for focussed discharge planning may help organisations reduce the numbers of unnecessary early readmissions. What is known about the topic?Readmission within 28-days of discharge is being increasingly used by service funders and organisations as an indicator of the effectiveness of community care and of the organisation’s ability to provide continuous care across programs. Previous studies, mainly conducted in the US in the mid-90s, often reach contradictory conclusions and their relevance to the Australian setting is limited. What does this paper add?This paper uses data from an Australia mental health service. It identifies patient and service characteristics associated with rapid re-admission and provides a baseline to evaluate strategies to reduce the readmission rate. What are the implications for practitioners?This paper highlights the importance of careful discharge planning and communication with general practitioners particularly in relation to patients who have had previous admissions.

A descriptive interview with 64 patients discharged from an acute-psychiatric-inpatient service

BACKGROUND

Acute-mental-health services receive hundreds of admissions every year. Some of these patients will continue to be case-managed by community mental-health teams on discharge from the acute unit while others will not remain in contact with the mental-health service. This study compares the findings of comprehensive interviews conducted with current and past patients of the community mental-health service 3 or more years following case closure from the community ambulatory service.

METHODS

Between 1 July 1999 and 30 June 2001, there were 2245 closed cases identified at Barwon Health. Letters of invitation to participate in a research project were sent to people who had suffered from psychotic illnesses, and had been case-closed by community mental-health services between the above dates and had not been in contact with the Community and Mental Health Service for at least 6 months. A second group of participants was recruited from people who had also been case-closed by community mental-health teams in Barwon Health during the 1999-2001 2-year-time window but whose cases had been re-opened and who were in case management with Barwon Health at the time of the study. All participants were interviewed using the Diagnostic Interview for Psychosis.

RESULTS

Letter responses were received from 17 men and 18 women, aged 40.7 +/- 12.0 (mean +/- SD), who were interviewed. A second group of 17 men and 12 women, aged 40.9 +/- 9.6 (mean +/- SD) of currently case-managed patients was interviewed. All interviewees reported a detailed history of mental illness. Persistent social dysfunction and impaired quality of life were reported in both groups.

CONCLUSION

Patients suffering from psychotic disorders who had been case-closed by community mental-health teams and had been discharged to the care of their general practitioners or elsewhere continued to show evidence of significant impairment due to mental illness 3 years after being case-closed.

Adverse incidents in acute psychiatric inpatient units: rates, correlates and pressures

OBJECTIVE

This paper reports findings from a multicentre service evaluation project conducted in acute psychiatric inpatient units in NSW, Australia. Overall rates of aggression, absconding and early readmission are reported, as well as length-of-stay profiles and associations between these outcomes and selected sociodemographic and clinical characteristics routinely collected by health services.

METHOD

Data from the 11 participating units were collected for a 12month period from multiple sources, including electronic medical records, routine clinical modules, incident forms, and shift based project-specific logs. For the current analyses, two admission-level datasets were used, comprising aggregated patient-level events (n=3242 admissions) and basic sociodemographic, clinical, admission and discharge information (n=5546 admissions by 3877 patients).

RESULTS

The participating units were under considerable strain: 23.3% of admissions were high acuity; 60.4% had previous hospital stays; 47.6% were involuntary; 25-30% involved adverse incidents; bed occupancy averaged 88.4%; median length of stay was 8 days (mean=14.59 days); and 17.4% had a subsequent early readmission. Reportable aggressive incidents (11.2% of admissions) were intermittent (averaging 0.55 incidents per month per occupied bed) and associated with younger age, personality disorder, less serious aggression, longer periods of hospitalization, and subsequent early readmission. Less serious aggressive incidents (15.0% of admissions) were maximal in the first 24h (averaging 3.73 incidents per month per occupied bed) and associated with younger age, involuntary status, bipolar and personality disorders, the absence of depression, and longer hospital stays. Absconding (15.7% of admissions) peaked in the second week following admission and was associated with drug and alcohol disorder, younger age, and longer periods of hospitalization.

CONCLUSIONS

By examining relationships between a core set of risk factors and multiple short-term outcomes, we were able to identify several important patterns, which were suggestive of the need for a multi-level approach to intervention, shifting from a risk management focus during the early phase of hospitalization to a more targeted, therapeutic approach during the later phase. But the latter approach may not be achievable under current circumstances with existing resources.

Patterns of mental health service utilization in a general hospital and outpatient mental health facilities: analysis of 365,262 psychiatric consultations

PURPOSE

Mental health is one of the priorities of the European Commission. Studies of the use and cost of mental health facilities are needed in order to improve the planning and efficiey of mental health resources. We analyze the patterns of mental health service use in multiple clinical settings to identify factors associated with high cost.

SUBJECTS AND METHODS

22,859 patients received psychiatric care in the catchment area of a Spanish hospital (2000-2004). They had 365,262 psychiatric consultations in multiple settings. Two groups were selected that generated 80% of total costs: the medium cost group (N = 4,212; 50% of costs), and the high cost group (N = 236; 30% of costs). Statistical analyses were performed using univariate and multivariate techniques. Significant variables in univariate analyses were introduced as independent variables in a logistic regression analysis using "high cost" (>7,263$) as dependent variable.

RESULTS

Costs were not evenly distributed throughout the sample. 19.4% of patients generated 80% of costs. The variables associated with high cost were: age group 1 (0-14 years) at the first evaluation, permanent disability, and ICD-10 diagnoses: Organic, including symptomatic, mental disorders; Mental and behavioural disorders due to psychoactive substance use; Schizophrenia, schizotypal and delusional disorders; Behavioural syndromes associated with physiological disturbances and physical factors; External causes of morbidity and mortality; and Factors influencing health status and contact with health services.

DISCUSSION

Mental healthcare costs were not evenly distributed throughout the patient population. The highest costs are associated with early onset of the mental disorder, permanent disability, organic mental disorders, substance-related disorders, psychotic disorders, and external factors that influence the health status and contact with health services or cause morbidity and mortality.

CONCLUSION

Variables related to psychiatric diagnoses and sociodemographic factors have influence on the cost of mental healthcare.

Socio-demographic and clinical predictors of occupational status in schizophrenic psychoses--follow-up within the Northern Finland 1966 Birth Cohort

We studied occupational status of persons with schizophrenic psychoses by age 34 in a longitudinal population-based cohort and predicted which demographic and illness-related factors could support the patients to maintain their occupational capacity. Subjects of the Northern Finland 1966 Birth Cohort with the diagnosis of DSM-III-R schizophrenic psychoses (n=113) by the year 1997 were followed until the end of year 2000. Various illness and socio-demographic factors at the time of onset of illness were used as predictors. At the end of the follow-up time 50 (44%) of patients were not pensioned and 22 (20%) were also working at least half of the time during year 2000. After adjusting for gender, being unemployed at onset, educational level and proportion of time spent in psychiatric hospitals, those who were married or cohabiting at the time of onset of illness were less often on pension than those who were single (OR 6.51; 95% CI 1.83-23.12). Thus, nearly half of the patients with schizophrenic psychoses were not pensioned after an average 10 years follow-up. Based on our findings, those who were single at time of their onset of illness probably need most support to retain their contacts to work life.

Comparison of self-report and clinician-rated measures of psychiatric symptoms and functioning in predicting 1-year hospital readmission

This study compared the self-report Behavior and Symptom Identification Scale (BASIS-32) and clinician-rated Global Assessment of Functioning (GAF) in their ability to predict a measure of psychiatric outcome, 1-year psychiatric hospital readmission. BASIS-32 and GAF were completed at admission for 1034 patients in an inpatient psychiatric facility. Multiple informants analysis was used to determine the difference between the two in predicting readmission within 1 year. We also examined sensitivity, specificity, and predictive value positive of the two measures, and whether self-report added information above clinician rating in predicting outcome. While the odds of 1-year readmission decreased with increasing BASIS-32 score, there was no association between change in GAF score and 1-year readmission. Although neither measure used alone demonstrated high predictive value, using both scores improved predictive ability over using clinician rating alone. In this setting, self-report was better than clinician rating in predicting psychiatric outcome. Differences between the two in relation to other outcomes need to be examined.

Heavy use of acute in-patient psychiatric services: the challenge to translate a utilization pattern into service provision

OBJECTIVE

There is an inequality in resource utilization among acute psychiatric in-patients. About 20-30% of them absorb 60-80% of the total resources allocated to this form of treatment. This study intends to summarize findings related to heavy in-patient service use and to illustrate them by means of utilization data for acute psychiatric wards.

METHOD

Longitudinal assessment of consecutive acute in-patients hospitalized for the first time. Analysis of individual utilization patterns by using latent class cluster analysis.

RESULTS

Four groups with different utilization patterns were found all including heavy service users. In most cases heavy service use was temporary and could only be poorly predicted.

CONCLUSION

Specific preventive interventions to contain heavy service use seem to be out of reach for the majority of high utilizing patients. However, services that have proven effective in reducing admissions to in-patient treatment and length of stay may nevertheless help to reduce heavy service use.

Patterns of psychiatric hospitalizations in schizophrenic psychoses within the Northern Finland 1966 Birth Cohort

We report patterns of hospitalization in schizophrenic psychoses by age 34 in a longitudinal population-based cohort. We test the predictive ability of various demographic and illness-related variables on patterns of hospitalization, with a special focus on the length of the first psychiatric hospitalization. All living subjects of the Northern Finland 1966 Birth Cohort with DSM-III-R schizophrenia (n=88) and other schizophrenia spectrum cases (n=27) by the year 1997 in the Finnish Hospital Discharge Register were followed for an average of 10.5 years. Measures of psychiatric hospitalization included time to re-hospitalization (as continuous and as re-hospitalization within 2 years) and the number of hospital episodes. Length of the first hospitalization, other illness-related and various socio-demographic predictors were used to predict hospitalization patterns. After adjusting for gender, age at first admission and number of hospital days a short (1-14 days) first hospitalization (reference >30 days; adjusted odds ratio 6.39; 95% CI 2.00-20.41) and familial risk of psychosis (OR 3.36; 1.09-10.39) predicted re-hospitalization within 2 years. A short first hospitalization also predicted frequent psychiatric admissions defined as the first three admissions within 3 years (OR 13.77; 3.92-48.36). A short first hospitalization was linked to increased risk of re-hospitalizations. Although short hospitalization is recommended by several guidelines, there may be a group of patients with schizophrenic psychoses in which too short a hospitalization may lead to inadequate treatment response.

Operating conditions of psychiatric hospitals and early readmission--effects of high patient turnover

OBJECTIVE

To study the association between hospitals' operating conditions and the risk of early readmission. The hypothesis was that high patient turnover might lead to a rise in the risk of readmission soon after discharge (within 30 days).

METHOD

A multivariate model including hospital and patient variables was tested using Cox's regression analysis, adjusting for clustering effects. The material included data from 20 hospitals, with 5,520 patients in the final model.

RESULTS

High patient turnover (annual discharges per bed) was significantly associated with an increased risk of readmission (hazard ratio (HR)= 3.37 (95% CI = 2.39-4.75)). In addition, being discharged from a ward with relatively low access to therapists increased the hazard further.

CONCLUSION

High patient turnover at the discharging ward was found to increase the patients' hazard of early readmission. This observation supports the hypothesis of a link between the operation conditions of the hospitals and patient outcome on a short time-scale.