Impact of Physician Follow-Up Care on Psychiatric Readmission Rates in a Population-Based Sample of Patients With Schizophrenia

Predictors of Physician Follow-Up Care Among Patients Affected by an Incident Mental Disorder Episode in Quebec (Canada)

OBJECTIVES

This study identified predictors of prompt (1+ outpatient physician consultations/within 30 days), adequate (3+/90 days) and continuous (5+/365 days) follow-up care from general practitioners (GPs) or psychiatrists among patients with an incident mental disorder (MD) episode.

METHODS

Study data were extracted from the Quebec Integrated Chronic Disease Surveillance System (QICDSS), which covers 98% of the population eligible for health-care services under the Quebec (Canada) Health Insurance Plan. This observational epidemiological study investigating the QICDSS from 1 April 1997 to 31 March 2020, is based on a 23-year patient cohort including 12+ years old patients with an incident MD episode (n = 2,670,133). Risk ratios were calculated using Robust Poisson regressions to measure patient sociodemographic and clinical characteristics, and prior service use, which predicted patients being more or less likely to receive prompt, adequate, or continuous follow-up care after their last incident MD episode, controlling for previous MD episodes, co-occurring disorders, and years of entry into the cohort.

RESULTS

A minority of patients, and fewer over time, received physician follow-up care after an incident MD episode. Women; patients aged 18-64; with depressive or bipolar disorders, co-occurring MDs-substance-related disorders (SRDs) or physical illnesses; those receiving previous GP follow-up care, especially in family medicine groups; patients with higher prior continuity of GP care; and previous high users of emergency departments were more likely to receive follow-up care. Patients living outside the Montreal metropolitan area; those without prior MDs; patients with anxiety, attention deficit hyperactivity, personality, schizophrenia and other psychotic disorders, or SRDs were less likely to receive follow-up care.

CONCLUSION

This study shows that vulnerable patients with complex clinical characteristics and those with better previous GP care were more likely to receive prompt, adequate or continuous follow-up care after an incident MD episode. Overall, physician follow-up care should be greatly improved.

Ensuring Continuity of Care: Effective Strategies for the Post-hospitalization Transition of Psychiatric Patients in a Family Medicine Outpatient Clinic

In healthcare, continuity of care is a crucial element, especially for patients in the field of psychiatry who have recently been discharged from a hospital. The shift from inpatient to outpatient care poses challenges for patients and healthcare providers, including openness to treatment, competing priorities, financial insecurity, concerns and dilemmas faced by patients regarding their post-hospitalization life after improvements in symptoms, lack of social support, poor patient-doctor relationships, lack of insight, and stigma associated with mental illness. Therefore, it is vital to employ effective strategies to ensure patients receive the required care and support during this transition. This review delves into the significance of continuity of care for psychiatric patients post-hospitalization, effective strategies for the transition, and the challenges and barriers to implementation from the perspective of a family medicine practice. To analyze physicians' role in managing psychiatric patients post-hospitalization, we developed a comprehensive search strategy. This involved extracting relevant data, updates, guidelines, and recommendations. Our search spanned various online repositories, such as PubMed and Google Scholar, specifically focusing on US-based guidelines aligned with our objectives. The search was conducted using medical subject headings (MeSH) and combinations of "OR," "AND," and "WITH." We crafted keywords to optimize our search strategy, including psychiatric illness, post-hospitalization, follow-up, follow-up care, primary care follow-up, and guidelines. Exploring online repositories yielded 132 articles, and we identified some guidelines that addressed our objectives. We established inclusion and exclusion criteria for our review and reviewed 21 papers. Post-hospitalization follow-up is a critical facet of psychiatric care, aligning with guidelines from the American Psychiatric Association and other relevant sources. Emphasizing continuity of care ensures a smooth transition from inpatient to outpatient settings, sustaining therapeutic momentum and minimizing the risk of relapse. This comprehensive approach involves careful medication management, regular mental health assessments, education on condition-specific coping strategies, and coordinated care between healthcare providers. It includes conducting risk assessments, safety planning, building social support and community integration, prompt post-hospitalization follow-up, and tailored treatment plans. Together, these measures enhance overall wellness for recently discharged patients. This holistic strategy tackles pressing short-term needs while facilitating long-term stability, promoting resilience and successful community reintegration, reducing readmission likelihood, and ultimately supporting sustained recovery.

Reduction of Mental Health-Related Emergency Department Admissions for Youth and Young Adults Following a Remote Intensive Outpatient Program: Quality Improvement Analysis

BACKGROUND

Pediatric mental health emergency department (ED) visits are increasing at 6% to 10% per year, at substantial cost, while 13% of youth with psychiatric hospitalizations are readmitted in the following weeks. Hospitals do not have the resources to meet escalating youth's mental health needs. Intensive outpatient (IOP) programs, which provide multiple hours of care each week, have the power to reduce the number of patients in need of hospitalized care and provide a step-down option for patients discharging from ED's in order to prevent readmissions.

OBJECTIVE

The purpose of this program evaluation was to assess (1) whether youth and young adult ED admission rates decreased following participation in a remote IOP program and (2) whether there were differences in readmission rates between youth and young adults by gender identity, sexual orientation, race, or ethnicity.

METHODS

Data were collected from intake and 3-month postdischarge surveys for 735 clients who attended at least 6 sessions of a remote IOP program for youth and young adults. Patients reported if they had been admitted to an ED within the previous 30 days and the admission reason. Over half (407/707, 57.6%) of clients were adolescents and the rest were young adults (300/707, 42.4%; mean age 18.25, SD 4.94 years). The sample was diverse in gender identity (329/687, 47.9% female; 196/687, 28.5% male; and 65/669, 9.7% nonbinary) and sexual orientation (248/635, 39.1% heterosexual; 137/635, 21.6% bisexual; 80/635, 10.9% pansexual; and 170/635, 26.8% other sexual orientation) and represented several racial (9/481, 1.9% Asian; 48/481, 10% Black; 9/481, 1.9% Indigenous; 380/481, 79% White; and 35/481, 7.2% other) and ethnic identities (112/455, 24.6% Hispanic and 28/455, 6.2% other ethnic identity).

RESULTS

Mental health-related ED admissions significantly decreased between intake and 3 months after discharge, such that 94% (65/69) of clients with a recent history of mental health-related ED admissions at IOP intake reported no mental health-related ED admissions at 3 months after discharge from treatment (χ21=38.8, P<.001). There were no differences in ED admissions at intake or in improvement at 3 months after discharge by age, gender, sexuality, race, or ethnicity.

CONCLUSIONS

This study documents a decrease in ED admissions between intake and 3 months after discharge among both youth and young adults who engage in IOP care following ED visits. The similar outcomes across demographic groups indicate that youth and young adults experience similar decreases after the current tracks of programming. Future research could conduct a full return-on-investment analysis for intensive mental health services for youth and young adults.

Profiles of patients with substance-related disorders who dropped out or not from addiction treatment

This longitudinal study identified profiles of patients with substance-related disorders (SRD) who did or did not drop out of specialized addiction treatment, integrating various patterns of outpatient service use. Medical administrative databases of Quebec (Canada) were used to investigate a cohort of 16,179 patients with SRD who received specialized addiction treatment. Latent class analysis identified patient profiles, based on multi-year outpatient service use. Four patient profiles related to treatment dropout were identified: patients who did not drop out and were low service users (Profile 1); patients who did not drop out and were high service users (Profile 2); patients who dropped out and were low service users (Profile 3); patients who dropped out and were high service users (Profile 4). Profile 1 had the best health and social conditions, while Profile 4 had the worst. The risks of being frequent emergency department users, being hospitalized or dying were highest in Profile 4, followed by Profiles 3, 2 and 1. Assertive treatment programs may be suited to Profile 4 and intensive case management programs to Profile 3. Collaborative care with higher psychosocial interventions and regularity of care may be extended to Profile 2 and interventions integrating motivational treatment to Profile 1.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The role of geography and distance on physician follow-up after a first hospitalization with a diagnosis of a schizophrenia spectrum disorder: A retrospective population-based cohort study in Ontario, Canada

BACKGROUND

Timely follow-up after hospitalization for a schizophrenia spectrum disorder (SSD) is an important quality indicator. We examined the proportion of individuals who received physician follow-up within 7 and 30 days post-discharge by health region and estimated the effect of distance between a person's residence and discharging hospital on follow-up.

METHODS

We created a retrospective population-based cohort of incident hospitalizations with a discharge diagnosis of a SSD between 01/01/2012 and 30/03/2019. The proportion of follow-up with a psychiatrist and family physician within 7 and 30 days were calculated for each region. The effect of distance between a person's residence and discharging hospital on follow-up was estimated using adjusted multilevel logistic regression models.

RESULTS

We identified 6,382 incident hospitalizations for a SSD. Only 14.2% and 49.2% of people received follow-up care with a psychiatrist within 7 and 30 days of discharge, respectively, and these proportions varied between regions. Although distance from hospital was not associated with follow-up within 7 days of discharge, increasing distance was associated with lower odds of follow-up with a psychiatrist within 30 days.

CONCLUSION

Post-discharge follow-up is poor across the province. Geospatial factors may impact post-discharge care and should be considered in further evaluation of quality of care.

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

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

The Impact of 90-day Physician Follow-up Care on the Risk of Readmission Following a Psychiatric Hospitalization

AIMS

This study measures the impact of 90-day physician follow-up care after psychiatric hospitalization among 3,311 adults and youth, with risk of subsequent readmission within six months.

METHODS

A 5-year investigation was conducted based on Quebec (Canada) medical administrative databases. Cox proportional-hazards regression was performed, with 90-day follow-up care as the main independent variable, controlling for various sociodemographic, clinical, and other service use variables.

RESULTS

Within the 90-day follow-up period after patient discharge, or in the first 30 days, receiving at least one consultation per month as opposed to no consultation was associated with a reduced risk of psychiatric readmission. Women showed an increased readmission risk compared to men, while those living in less materially deprived areas a decreased risk as opposed to more deprived areas. Patients hospitalized for suicide attempt or schizophrenia spectrum and other psychotic disorders, and those with co-occurring mental and substance-related disorders or chronic physical illnesses, especially illnesses high on the severity index, also presented a heightened risk of hospitalization. Patients hospitalized for personality disorders or receiving a high continuity of physician care showed a reduced risk of readmission.

CONCLUSION

This study demonstrates that follow-up care, if provided within the first 30 days of discharge or monthly during the 90-day follow-up period, decreased the risk of readmission, as did having a high continuity of physician care prior to and within the 90-day follow-up period. However, few patients in this study had received such high-quality care, indicating that the Quebec system needs to considerably improve its discharge planning processes.

Primary care for individuals with serious mental illness (PriSMI): protocol for a convergent mixed methods study

INTRODUCTION

People with serious mental illness (SMI) have poor health outcomes, in part because of inequitable access to quality health services. Primary care is well suited to coordinate and manage care for this population; however, providers may feel ill-equipped to do so and patients may not have the support and resources required to coordinate their care. We lack a strong understanding of prevention and management of chronic disease in primary care among people with SMI as well as the context-specific barriers that exist at the patient, provider and system levels. This mixed methods study will answer three research questions: (1) How do primary care services received by people living with SMI differ from those received by the general population? (2) What are the experiences of people with SMI in accessing and receiving chronic disease prevention and management in primary care? (3) What are the experiences of primary care providers in caring for individuals with SMI?

METHODS AND ANALYSIS

We will conduct a concurrent mixed methods study in Ontario and British Columbia, Canada, including quantitative analyses of linked administrative data and in-depth qualitative interviews with people living with SMI and primary care providers. By comparing across two provinces, each with varying degrees of mental health service investment and different primary care models, results will shed light on individual and system-level factors that facilitate or impede quality preventive and chronic disease care for people with SMI in the primary care setting.

ETHICS AND DISSEMINATION

This study was approved by the University of Ottawa Research Ethics Board and partner institutions. An integrated knowledge translation approach brings together researchers, providers, policymakers, decision-makers, patient and caregiver partners and knowledge users. Working with this team, we will develop policy-relevant recommendations for improvements to primary care systems that will better support providers and reduce health inequities.

Readmissions, costs, and duration to subsequent outpatient visit after hospital discharge among Medicaid beneficiaries utilizing oral versus long-acting injectable antipsychotics in bipolar disorder or schizophrenia

BACKGROUND

Long-acting injectable antipsychotics (LAIs) may reduce hospitalizations versus oral formulations (OAP) in bipolar disorder (BP) and schizophrenia/schizoaffective disorder (SCZ), but the impact on time to outpatient follow-up is less understood.

OBJECTIVES

To assess hospital readmissions and medical costs among Medicaid beneficiaries with BP or SCZ utilizing OAP or LAI SGAs.

METHODS

Cross-sectional and longitudinal analyses utilized comprehensive administrative claims of Oklahoma Medicaid beneficiaries (≥18 years) with BP or SCZ between 1 January 2013 and 31 December 2017. Readmissions, total direct medical costs, and psychiatry-related outpatient visits were assessed via generalized linear models and generalized estimating equations, controlling for demographic and clinical covariates.

RESULTS

Among 2523 included members, LAI utilization was associated with 1.50 and 1.73 times higher odds of any hospitalization and any readmission, respectively (p < .05). Cases involving both BP and SCZ were associated with a 2.40 times higher odds of any readmission, 2.26 times higher number of readmissions, and 24.5% higher costs (p < .001). Of the 468 members with a subsequent psychiatry-related outpatient visit, LAIs were associated with a 23.9% shorter duration to outpatient visit and 16.4% lower costs (p < .05).

CONCLUSION

In contrast to prior studies, this real-world investigation noted higher hospitalizations and readmissions among LAIs relative to OAP medications, but among members with a hospitalization or ED visit, LAIs were associated with shorter durations to outpatient visits and lower costs. Those with diagnoses of both BP with SCZ had higher odds of any readmission, number of readmissions, and costs relative to those with bipolar disorder alone and may be a key target for interventions.

Characterization of multilevel influences of mental health care transitions: a comparative case study analysis

Purpose

Mental health care transitions are increasingly prioritized given their potential to optimize care delivery and patient outcomes, especially those focused on the transition from inpatient to outpatient mental health care. However, limited efforts to date characterize such mental health transition practices, especially those spanning multiple service setting contexts. Examination of key influences of inpatient to outpatient mental health care transitions across care contexts is needed to inform ongoing and future efforts to improve mental health care transitions. The current work aims to characterize multilevel influences of mental health care transitions across three United States-based mental health system contexts.

Methods

A comparative multiple case study design was used to characterize transition practices within the literature examining children’s, non-VA adult, and VA adult service contexts. Andersen’s (1995) Behavioral Health Service Use Model was applied to identify and characterize relevant distinct and common domains of focus in care transitions across systems.

Results

Several key influences to mental health care transitions were identified spanning the environmental, individual, and health behavior domains, including: community capacity or availability, cross-system or agency collaboration, provider training and experience related to mental health care transitions, client care experience and expectations, and client clinical characteristics or complexity.

Conclusions

Synthesis illustrated several common factors across system contexts as well as unique factors for further consideration. Our findings inform key considerations and recommendations for ongoing and future efforts aiming to plan, expand, and better support mental health care transitions. These include timely information sharing, enhanced care coordination and cross setting and provider communication, continued provider/client education, and appropriate tailoring of services to improve mental health care transitions.

Personality predictors of 6-month readmission in adult psychiatric inpatients

Readmission of psychiatric inpatients is highly prevalent and places a significant financial burden on the healthcare system. Rehospitalisation is often used as a metric of quality of care in psychiatric settings, but little is known about how specific personality traits impact readmission in adult psychiatric inpatients. A convenience sample of 94 adults (mean age = 36.8 years; female = 54.3%; European American = 76.6%) at an inpatient psychiatric hospital completed the Personality Inventory for DSM-5-Brief Form (PID-5-BF; American Psychiatric Association, 2013); demographic and medical information and readmission data were extracted via chart review. Poisson regression was used to predict number of readmissions at 6 months after discharge from PID-5-BF domain scores of Negative Affectivity, Detachment, Antagonism, Disinhibition and Psychoticism. Twenty-three patients (24.5%) were readmitted at least once by 6-month follow-up. Higher PID-5-BF Negative Affectivity domain scores predicted greater number of readmissions at 6 months (incidence rate ratio (IRR) = 1.14, robust standard error (RSE) = 0.05, p < .01, 95% confidence interval [1.04, 1.25]). The other PID-5-BF domain scores were not significantly related to number of readmissions. Thus, greater negative affect, indicative of higher trait neuroticism, heightened experience of negative emotions and poor self-concept, was a significant personality predictor of readmission in the study. These results suggest that assessing this trait domain might help to identify psychiatric inpatients at greater risk for readmission and determine those most in need of enhanced services to reduce rehospitalisation.

The Incidence of Psychotic Disorders and Area-level Marginalization in Ontario, Canada: A Population-based Retrospective Cohort Study

BACKGROUND

There is limited Canadian evidence on the impact of socio-environmental factors on psychosis risk. We sought to examine the relationship between area-level indicators of marginalization and the incidence of psychotic disorders in Ontario.

METHODS

We conducted a retrospective cohort study of all people aged 14 to 40 years living in Ontario in 1999 using health administrative data and identified incident cases of psychotic disorders over a 10-year follow-up period. Age-standardized incidence rates were estimated for census metropolitan areas (CMAs). Poisson regression models adjusting for age and sex were used to calculate incidence rate ratios (IRRs) based on CMA and area-level marginalization indices.

RESULTS

There is variation in the incidence of psychotic disorders across the CMAs. Our findings suggest a higher rate of psychotic disorders in areas with the highest levels of residential instability (IRR = 1.26, 95% confidence interval [CI], 1.18 to 1.35), material deprivation (IRR = 1.30, 95% CI, 1.16 to 1.45), ethnic concentration (IRR = 1.61, 95% CI, 1.38 to 1.89), and dependency (IRR = 1.35, 95% CI, 1.18 to 1.54) when compared to areas with the lowest levels of marginalization. Marginalization attenuates the risk in some CMAs.

CONCLUSIONS

There is geographic variation in the incidence of psychotic disorders across the province of Ontario. Areas with greater levels of marginalization have a higher incidence of psychotic disorders, and marginalization attenuates the differences in risk across geographic location. With further study, replication, and the use of the most up-to-date data, a case may be made to consider social policy interventions as preventative measures and to direct services to areas with the highest risk. Future research should examine how marginalization may interact with other social factors including ethnicity and immigration.

The Effectiveness of Discharge Planning for Psychiatric Inpatients With Varying Levels of Preadmission Engagement in Care

OBJECTIVE

This study examined the extent to which prehospital treatment engagement is related to posthospital follow-up treatment among psychiatric inpatients and whether the effects of inpatient discharge planning on posthospital follow-up treatment vary by level of pretreatment engagement in care.

METHODS

New York State Medicaid and other administrative databases were used to examine service use by 18,793 adult patients discharged to the community after inpatient psychiatric care in 2012-2013. Outcomes included attending an outpatient mental health service within 7 days and within 30 days after discharge. The sample was stratified by whether patients had high, partial, low, or no engagement in outpatient psychiatric services in the 6 months before admission.

RESULTS

Scheduling an outpatient appointment as part of the patient's discharge plan was significantly associated with attending outpatient psychiatric appointments, regardless of the patient's level of engagement in care before admission. The differences were most pronounced for patients who had not received any outpatient care in the 6 months before admission. When an appointment was scheduled, these patients were three times more likely to follow up with care within 7 days and more than twice as likely to follow up within 30 days than were patients without a scheduled appointment.

CONCLUSIONS

The likelihood of psychiatric inpatients following up with outpatient psychiatric care was directly related to their level of outpatient care engagement before hospital admission. Even among those who had not been engaged in outpatient care, inpatient discharge planning was associated with a greater likelihood of receiving follow-up outpatient care.

Utility of the READMIT Index to Identify Community Hospital 30-Day Psychiatric Readmissions

This case-controlled study determined the utility of the READMIT index to identify the risk for 30-day readmission of patients discharged from an urban community hospital psychiatric inpatient unit. Data was collected from 118 matched patient pairs from 2017 to 2018. Findings demonstrated the READMIT index did not effectively discriminate those patients who were likely to readmit within 30 days. However, the following factors were associated with likelihood of 30-day readmission: the inability to care for self, number of lifetime readmissions, the comorbidity of liver disease, as well as a history of substance abuse.

Measurement of unnecessary psychiatric readmissions in the context of care transition interventions: a scoping review

OBJECTIVE

The objective of this study was to examine how published studies of inpatient to outpatient mental healthcare transition processes have approached measuring unnecessary psychiatric readmissions.

DESIGN

Scoping review using Levac et al's enhancement to Arksey and O'Malley's framework for conducting scoping reviews.

DATA SOURCES

Medline (Ovid), Embase (Ovid), PsycINFO, CINAHL, Cochrane and ISI Web of Science article databases were searched from 1 January 2009 through 28 February 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included studies that (1) are about care transition processes associated with unnecessary psychiatric readmissions and (2) specify use of at least one readmission time interval (ie, the time period since previous discharge from inpatient care, within which a hospitalisation can be considered a readmission).

DATA EXTRACTION AND SYNTHESIS

We assessed review findings through tabular and content analyses of the data extracted from included articles.

RESULTS

Our database search yielded 3478 unique articles, 67 of which were included in our scoping review. The included articles varied widely in their reported readmission time intervals used. They provided limited details regarding which readmissions they considered unnecessary and which risks they accounted for in their measurement. There were no perceptible trends in associations between the variation in these findings and the included studies' characteristics (eg, target population, type of care transition intervention).

CONCLUSIONS

The limited specification with which studies report their approach to unnecessary psychiatric readmissions measurement is a noteworthy gap identified by this scoping review, and one that can hinder both the replicability of conducted studies and adaptations of study methods by future investigations. Recommendations stemming from this review include (1) establishing a framework for reporting the measurement approach, (2) devising enhanced guidelines regarding which approaches to use in which circumstances and (3) examining how sensitive research findings are to the choice of the approach.

Characteristics of patients with mental illness and persistent high-cost status: a population-based analysis

BACKGROUND

Most of the literature on high-cost users of health care has evaluated this population as a whole, but few studies have focused on high-cost patients with mental illness and whether they persist in the high-cost state. We sought to analyze this patient population in depth and determine predictors of persistency in the high-cost state.

METHODS

We used 8 years of longitudinal patient-level population data (2010-2017) from Ontario to follow high-cost patients (those in and above the 90th percentile of the cost distribution) with mental illness. We classified high-cost status, based on the proportion of the study period that patients spent in the high-cost state, as persistent (6-8 yr), sporadic (1-2 yr) or moderate (3-5 yr). We compared characteristics between groups and determined predictors of being a patient with mental illness and persistent high-cost status.

RESULTS

Among 52 638 patients with mental illness and high-cost status, 18 149 (34.5%) were considered persistent high cost. These patients had higher mean annual costs of care ($44 714, 95% confidence interval [CI] $43 724-$45 703) than patients with sporadic ($23 205, 95% CI $22 741-$23 668) and moderate ($31 055, 95% CI $30 359-31 751) status, largely owing to psychiatric hospital admissions. Patients with mental illness and persistent high-cost status were more likely to be female, older, long-term residents of Ontario (information ascertained from the Immigrants, Refugees and Citizenship Canada Database), living in low-income or urban areas, or to have comorbidities. The strongest predictors of persistent (v. sporadic) high-cost status were HIV (relative risk ratio [RRR] 4.32, 95% CI 3.08-6.06), psychosis (RRR 3.41, 95% CI 3.25-3.58) and dementia (RRR 3.21, 95% CI 2.81-3.68).

INTERPRETATION

Among patients with mental illness and high-cost status, persistence in the high-cost state was determined mainly by psychosis and other comorbidities. Quality-of-care interventions directed at managing psychosis and multimorbidity, as well as preventive interventions to target patients with mental illness before they enter the persistent high-cost state, are needed.

The Impact of the North Carolina Statewide Telepsychiatry Program (NC-STeP) on Patients' Dispositions From Emergency Departments

OBJECTIVE

The number of patients seeking treatment in emergency departments (EDs) for mental health reasons is rising, and these patients are often kept in the ED until they can be treated or discharged, leading to overcrowding. Telepsychiatry may alleviate overcrowding by increasing the rate of discharges home.

METHODS

ED discharge records for 86,931 patients with psychiatric symptoms were examined to compare patient disposition and length of stay (LOS) between times when the North Carolina Statewide Telepsychiatry Program (NC-STeP) program was available or unavailable.

RESULTS

For patients with a LOS of >2 days (N=3,144) and when NC-STeP was available, 62% (N=1,941) were discharged home, and 29% (N=922) were transferred to a psychiatric facility. When NC-STeP was unavailable (N=2,662), 43% (N=1,139) of these patients were discharged home, and 46% (N=1,230) were transferred to a psychiatric facility. For patients with a LOS of 1-2 days and when NC-STeP was available (N=41,713), 77.0% (N=32,131) were discharged home, and 15.4% (N=6,441) were transferred to a psychiatric facility, compared with 74.2% (N=29,237) discharged home and 13.9% (N=5,495) transferred to a psychiatric facility when NC-STeP was unavailable (N=39,412). The increases in discharges home and decreases in referrals to psychiatric facilities when NC-STeP was available were statistically significant for patients in both groups (p<0.001).

CONCLUSIONS

Results suggest that telepsychiatry programs such as NC-STeP increase the number of discharges home and decrease transfers to psychiatric facilities, likely promoting patient satisfaction and improving ED efficiency.

Relationship Between Continuity of Care and Discharge Planning After Hospital Psychiatric Admission

OBJECTIVE

This study examined whether communication between inpatient and outpatient mental health providers during patients' inpatient stays was associated with whether patients attended postdischarge appointments.

METHODS

Psychiatric inpatient medical records of 189 Medicaid recipients at two hospitals were reviewed to document whether inpatient staff had communicated with current or prior outpatient providers. Medicaid claims provided demographic, clinical, and outpatient attendance data. Associations between provider communications and follow-up care for patients who had or had not received outpatient mental health care within the 30 days prior to admission were evaluated.

RESULTS

Inpatient staff communicated with outpatient providers for 118 (62%) patients. For patients who had not received outpatient care within 30 days of admission, compared with those who had, communication was associated with increased odds of attending timely outpatient appointments (odds ratio=2.73, 95% confidence interval=1.09-6.84).

CONCLUSIONS

Communication with outpatient providers may be especially important for patients who were not engaged in outpatient care prior to admission.

Closed for Business? Using a Mixture Model to Explore the Supply of Psychiatric Care for New Patients

OBJECTIVE

To investigate the degree to which psychiatrists are accessible to new outpatients and the factors that predict whether psychiatrists will see new outpatients.

METHODS

We used administrative health data on all practicing full-time psychiatrists in Ontario, Canada, over a 5-year period (2009-2010 to 2013-2014). We used a regression model to estimate the number of new outpatients seen, accounting for case mix, outpatient volume, and psychiatrist practice characteristics.

RESULTS

Approximately 10% of full-time psychiatrists are seeing 1 or fewer new outpatients per month, and another 10% are seeing between 1 and 2 new outpatients per month. Our model identified psychiatrists in 3 distinct practice styles. One practice style (representing 29% of psychiatrists), on average, saw fewer than 2 new outpatients per month and 69 unique outpatients annually. Relative to other practice styles, they tended to see fewer patients with a previous psychiatric hospitalization and fewer patients who lived in lower income neighbourhoods.

CONCLUSIONS

Nearly 1 in 3 full-time psychiatrists in Ontario see very few new outpatients. This has implications for access to care, particularly for outpatients with newly diagnosed mental illness. It also highlights the continued need to address access issues by assessing the role of psychiatrists within the Canadian health care system.

Measurement of unnecessary psychiatric readmissions: a scoping review protocol

INTRODUCTION

Care transition for patients being discharged from inpatient mental healthcare to outpatient settings is a growing focus for healthcare delivery systems. Many studies of this inpatient to outpatient transition use the rate of postdischarge readmissions as a patient-level outcome measure to assess the quality of transition. However, it is unclear how studies define the measure, and whether there is a shared understanding by the field regarding which definition is appropriate for which circumstances. This scoping review thus aims to examine how published studies have approached measuring unnecessary psychiatric readmissions.

METHODS AND ANALYSIS

The scoping review will be structured according to Levac et al's enhancement to Arksey and O'Malley's framework for conducting scoping reviews. The protocol is registered through the Open Science Framework (https://osf.io/5nxuc/). We will search literature databases for studies that (1) are about care transition processes associated with unnecessary psychiatric readmissions and (2) specify use of at least one readmission time interval (ie, time period since previous discharge from inpatient care, within which a hospitalisation can be considered a readmission). Screening and review of articles will be carried out by two reviewers, first independently then involving a third reviewer as needed for consensus. We will assess review findings through both tabular and thematic analyses, noting prevalent trends in study characteristics and emergent themes across our reviewed studies.

ETHICS AND DISSEMINATION

This work comes at a time of heightened interest by many mental healthcare systems in high-quality practices that structure their care processes towards effective inpatient to outpatient transitions. Findings will support the systems' careful examination of alternative potential transitional interventions, helping to ensure that their often limited quality enhancement resources are put to optimal use. We will focus on disseminating our findings to the healthcare community through strong communication infrastructures and connections with health system stakeholders that our multidisciplinary study consultants will foster throughout this study.

Predictors of Cost and Incidence of 30-Day Readmissions Following Hospitalizations for Schizophrenia and Psychotic Disorders: A Nationwide Analysis

BACKGROUND

Schizophrenia and psychotic disorders (SPDs)-related hospitalizations are the second leading cause of 30-day readmission. This study assessed the effect of patient and hospital-level factors on readmission costs following index hospital discharges for SPDs.

METHODS

2014 Nationwide Readmissions Database was used to identify SPD-related discharges between January 1, 2014, and November 30, 2014. Multivariable logistic regression was used to estimate patient and hospital-level predictors for readmissions. A two part model was used to estimate the predictors of readmission and associated cost for index hospital discharges with SPDs.

RESULTS

A total of 77 625 of 343 579 (22%) index hospital discharges for SPDs resulted in readmissions. The average index and readmission costs were $9285 and $8593, respectively. Being 25 to 44 years old (odds ratio: 1.14), with nonmental comorbidities (odds ratio: 1.52), and admitted in private hospitals (odds ratio: 1.24) had significantly higher odds of readmission rates. Being males ($105), 25 to 44 years of age ($99), urban residents ($312), Medicare enrollees ($713 over privately insured), high-income area residents ($393), having multiple comorbidities ($923), and those admitted in large metropolitan ($680) and government-owned hospitals ($417) had higher costs of readmission.

CONCLUSION

The high SPD-related readmission rates can be reduced by providing integrated behavioral health services for this high-risk cohort.

Timely follow-up visits after psychiatric hospitalization and readmission in schizophrenia and bipolar disorder in Japan

The study objective was to investigate the association between timely follow-up visits after psychiatric hospitalization and the risk of readmission in patients with schizophrenia or bipolar disorder. A retrospective cohort study was conducted using a nationwide claims database in Japan. Between April 2014 and March 2015, all psychiatric hospitalization data were obtained and patients with a principal diagnosis of schizophrenia or bipolar disorder were followed up from 180 days before admission to 210 days after discharge. The primary outcome of this study was psychiatric readmission during the 180-day period (between 31 and 210 days) after the index discharge. A total of 48,579 eligible patients were identified. After psychiatric hospitalization, 15% of patients received no follow-up visits to a psychiatrist within 30 days. Patients who received follow-up visits had lower readmission rates during the subsequent 180 days (21.7% vs. 37.5%; adjusted risk ratio, 0.54 [95% confidence interval, 0.52-0.57]) than those who did not. Timely follow-up visits after discharge could be helpful for reducing the readmission risk in patients.

Exploring Geographic Variation of Mental Health Risk and Service Utilization of Doctors and Hospitals in Toronto: A Shared Component Spatial Modeling Approach

Mental Health has been known to vary geographically. Different rates of utilization of mental health services in local areas reflect geographic variation of mental health and complexity of health care. Variations and inequalities in how the health care system addresses risks are two critical issues for addressing population mental health. This study examines these issues by analyzing the utilization of mental health services in Toronto at the neighbourhood level. We adopted a shared component spatial modeling approach that allows simultaneous analysis of two main health service utilizations: doctor visits and hospitalizations related to mental health conditions. Our results reflect a geographic variation of both types of mental health service utilization across neighbourhoods in Toronto. We identified hot and cold spots of mental health risks that are common to both or specific to only one type of health service utilization. Based on the evidence found, we discuss intervention strategies, focusing on the hotspots and provision of health services about doctors and hospitals, to improve mental health for the neighbourhoods. Limitations of the study and further research directions are also discussed.