Diagnosis-related groups: implications for psychiatry

Payment by results and mental health services

Payment by results is likely to be applicable to mental health services, with the exception of specialist services, next year. Its introduction will completely change the way mental health services are funded. It has three main components: national tariffs for treatments, codings or currencies for treatments according to resource use, and diagnosis and activity-based funding. This article describes payment by results, how ‘currencies’ are being developed for mental health, and outlines some of the problems and advantages of introducing this new system.

Information-based management of mental health services: a two-stage model for improving funding mechanisms and clinical governance

The government and commissioners have a responsibility to distribute resources for healthcare services to ensure equity across the country. They should also be concerned about quality, cost-effectiveness and safety. However, at present these tasks are seriously hampered by a lack of good-quality information about what is happening within services. Internal trust management is also poorly informed.

Casemix in psychiatry

Just as the management of individual patients requires specific and timely information upon which clinical decisions can be based, so managers and clinicians, responsible for service planning, require appropriate information on the activity levels and functions of their services. This is true at all levels, from individual clinicians and teams who wish to audit their activities, through clinical directors and managers of departments and units, to those who plan for Districts and Regions. Casemix is an attempt to facilitate this process by developing a meaningful language, to describe and measure clinical activity.

Does psychopathology at admission predict the length of inpatient stay in psychiatry? Implications for financing psychiatric services

BACKGROUND

The debate on appropriate financing systems in inpatient psychiatry is ongoing. In this context, it is important to control resource use in terms of length of stay (LOS), which is the most costly factor in inpatient care and the one that can be influenced most easily. Previous studies have shown that psychiatric diagnoses provide only limited justification for explaining variation in LOS, and it has been suggested that measures such as psychopathology might be more appropriate to predict resource use. Therefore, we investigated the relationship between LOS and psychopathological syndromes or symptoms at admission as well as other characteristics such as sociodemographic and clinical variables.

METHODS

We considered routine medical data of patients admitted to the Psychiatric University Hospital Zurich in the years 2008 and 2009. Complete data on psychopathology at hospital admission were available in 3,220 inpatient episodes. A subsample of 2,939 inpatient episodes was considered in final statistical models, including psychopathology as well as complete datasets of further measures (e.g. sociodemographic, clinical, treatment-related and psychosocial variables). We used multivariate linear as well as logistic regression analysis with forward selection procedure to determine the predictors of LOS.

RESULTS

All but two syndrome scores (mania, hostility) were positively related to the length of stay. Final statistical models showed that syndromes or symptoms explained about 5% of the variation in length of stay. The inclusion of syndromes or symptoms as well as basic treatment variables and other factors led to an explained variation of up to 25%.

CONCLUSIONS

Psychopathological syndromes and symptoms at admission and further characteristics only explained a small proportion of the length of inpatient stay. Thus, according to our sample, psychopathology might not be suitable as a primary indicator for estimating LOS and contingent costs. This might be considered in the development of future costing systems in psychiatry.

Developing community mental health services: an evaluation of Glasgow's mental health resource centres

Greater Glasgow Health Board's strategy for the development of community mental health services includes the establishment, over a 7-year period, of multi-disciplinary community mental health resource centres throughout Glasgow. An evaluation of the first phase of the development was carried out in three resource centres. This focused on three key themes: the establishment of multi-disciplinary teams, targeting of those with the most severe illnesses and the participation of users in the care process. The evaluation exercise comprised five substantive elements: analysis of the clinical database; interviews with staff within each of those centres, interviews with representatives of key external agencies associated with each centre; a survey of general practitioners; and a survey of the views of clients, their carers, their key workers, and their general practitioners (GPs). Clients were generally very satisfied with the services and felt that the resource centres met all their mental health needs. Although the majority of current centre cases had severe mental illnesses and those with the more severe conditions had the highest contact rates there was evidence that in the absence of a clear framework for referral the centres were also providing services for those with less severe illnesses. Despite a wish by centre staff to move towards modes of working less dominated by health professionals and more inclusive of other resources and especially of clients themselves, these goals remained to be achieved: there was a lack of clarity in the definition of the appropriate target groups for the centres; access to crisis support was regarded as problematic; the concept of multi-disciplinary team working had yet to be fully realized with evidence suggesting that some psychiatrists working in the resource centres had not embraced many aspects of the new approach to service delivery including a focus on the severely ill; and progress towards the ideal of active client involvement had been slow.

Diagnosis and length of psychiatric in-patient stay

This paper examines the link between diagnosis and length of psychiatric in-patient stay. Up to now the main method of predicting the use of in-patient services has been to use diagnosis-related groups (DRGs), primarily in the USA. Previous findings have revealed that DRGs generally predict less than 10% of variation in hospital stay. Psychiatric DRGs are considered to lack homogeneity and are too broad. Nevertheless, diagnosis, as an indicator of resource utilization, is now on the agenda in the UK and a study which examines the link between service use and diagnosis per se is called for. Altogether 5482 patients were allocated to 43 diagnostic categories (DCs). These DCs covered mental disorders, drug and alcohol-related problems, diseases of the nervous system and sense organs, and other related illnesses. Age was used in an attempt to refine the model further. Coefficients of variation were calculated for the DCs, and multivariate regression analysis was performed to gauge predictiveness. The results reveal that DCs contain extremely limited homogeneity and only predict 3% of variation in length of stay. When age group is included the results are only marginally improved, although the numbers contained in some DCs are low. Diagnosis, even when clearly defined, is a poor indicator of resource utilization.