Day hospital/crisis respite care versus inpatient care, Part II: Service utilization and costs

OBJECTIVE: The authors compared service utilization and costs for acutely ill psychiatric patients treated in a day hospital/crisis respite program or in a hospital inpatient program. METHOD: The patients (N = 197) were randomly assigned to one of the two programs and followed for 10 months after discharge. Both programs were provided by a community mental health center (CMHC) in a poor urban community. Data were collected for developing service utilization profiles and estimates of per-unit costs of the inpatient, day hospital, and outpatient services provided by the CMHC. RESULTS: On average, the day hospital/crisis respite program cost less than inpatient hospitalization. The average saving per patient was +7,100, or roughly 20% of the total direct costs. There were no significant differences between programs in service utilization or costs during the follow-up phase. Cost savings accrued in the index episode because per-unit costs were lower for day hospital/crisis respite and the average stay was shorter. Significant differences in cost were found among patient groups with psychosis, affective disorders, and dual diagnoses; psychotic patients had the highest costs in both programs. The two programs had roughly equal direct service staff and capital costs but significantly different operating costs (day hospital/crisis respite operating costs were 51% of inpatient hospital costs). CONCLUSIONS: The programs were equally effective, but day hospital/crisis respite treatment was less expensive for some patients. Potential cost savings are higher for nonpsychotic patients. Cost differences between the programs are driven by the hospital's relatively higher overhead costs. The roughly equal expenditures for direct service staff costs in the two programs may be an important clue for understanding why these programs provided equally effective acute care.     

Detection of serum transforming growth factor-alpha in patients of primary epithelial ovarian cancers by enzyme immunoassay

OBJECTIVE: To survey the social outcome of patients with schizophrenia attending State mental health facilities in southern Tasmania. METHOD: Using the Statewide Mental Health Register, patients using inpatient and outpatient facilities who received a diagnosis of schizophrenia between 1981 and 1988 were identified (n = 771), and demographic and illness measures, and admissions and length of inpatient stay were compiled. The Life Skills Profile (LSP) was completed by mental health personnel for the 247 who were regular attenders or inpatients in 1991. RESULTS: Social morbidity as indexed by the LSP was highest in psychiatric hospital inpatients and patients in long-term rehabilitation programs, and lower in patients attending community centres. The majority of patients in suburban settings and attending community centres lived with their families, whereas patients in the inner city or in the rehabilitation service were mainly in hostel accommodation or living alone. Patients with schizophrenia attending State services were of a similar age range but had a longer duration of illness and more admissions, and had spent more days in hospital than patients who were not in regular contact with the service. CONCLUSIONS: The distribution of social morbidity in schizophrenia confirms that the public health system is supporting a group with high social morbidity. Patients with the highest morbidity are receiving the highest levels of care and intervention.     

Perception of natural fluctuations in peak flow in asthma: clinical severity and psychological correlates

OBJECTIVE: This review focused on empirical research that addressed the effectiveness of service models for the care of patients with personality disorders. METHOD: Services discussed included those delivering acute care, such as crisis and emergency services and acute psychiatric hospitalization; continuing care, such as outpatient services, day hospital treatment, and assertive community treatment programs; and other community programming, such as integrated treatment for comorbid substance abuse and psychoeducational interventions for families of patients with personality disorders. The review focused on studies that included patients with personality disorders, and it measured outcomes relevant to patients with personality disorders. Evidence from randomized controlled trials was highlighted. RESULTS: Few systematic studies of acute services were available. Community programming can decrease the risk of suicide attempts and reliance on inpatient admissions. Services must develop methods of ensuring compliance with treatment. Assertive community treatment for Axis II patients should be developed, implemented, and tested. Comprehensive programming for patients with personality disorders must include integrated treatment for substance abuse and family psychoeducational programs. CONCLUSION: Promising new models of care for patients with personality disorders are ready for testing and wider application.     

A controlled comparison of psychiatric day treatment and inpatient hospitalization.

59 seriously ill, female, 16-72 yr old psychiatric patients were randomly assigned, after 2-6 wks of inpatient evaluation, to an inpatient or day service where they were evaluated, along with a control group of 34 "usual" day hospital patients, for up to 24 mo. Data from the Psychiatric Status Schedule, Psychiatric Evaluation Form, Dynamic Assessment Scale, and other similar measures indicate that for the range of patients studied, day treatment is, on the whole, superior to inpatient treatment in 5 distinct areas: subjective distress, community functioning, family burden, total hospital cost, and days of attachment to the hospital program. The findings of other controlled studies are confirmed and extended to include previously unreported outcome dimensions and a broader socioeconomic population. (25 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is day care equivalent to inpatient care for active rheumatoid arthritis? Randomised controlled clinical and economic evaluation

OBJECTIVE: To test the clinical equivalence and resource consequences of day care with inpatient care for active rheumatoid arthritis. DESIGN: Randomised controlled clinical trial with integrated cost minimisation economic evaluation. SETTING: Rheumatic diseases unit at a teaching hospital between 1994 and 1996. SUBJECTS: 118 consecutive patients with active rheumatoid arthritis randomised to receive either day care or inpatient care. MAIN OUTCOME MEASURES: Clinical assessments recorded on admission, discharge, and follow up at 12 months comprised: the health assessment questionnaire, Ritchie articular index, erythrocyte sedimentation rate, hospital anxiety and depression scale, and Steinbrocker functional class. Resource estimates were of the direct and indirect costs relating to treatment for rheumatoid arthritis. Secondary outcome measures (health utility) were ascertained by time trade off and with the quality of well being scale. RESULTS: Both groups had improvement in scores on the health assessment questionnaire and Ritchie index and erythrocyte sedimentation rate after hospital treatment (P < 0.0001) but clinical outcome did not differ significantly between the groups either at discharge or follow up. The mean hospital cost per patient for day care, 798 Pounds (95% confidence interval 705 Pounds to 888 Pounds), was lower than for inpatient care, 1253 Pounds (1155 Pounds to 1370 Pounds), but this difference was offset by higher community, travel, and readmission costs. The difference in total cost per patient between day care and inpatient care was small (1789 Pounds (1539 Pounds to 2027 Pounds) v 2021 Pounds (1834 Pounds to 2230 Pounds)). Quantile regression analysis showed a cost difference in favour of day care up to the 50th centile (374 Pounds; 639 Pounds to 109 Pounds). CONCLUSIONS: Day care and inpatient care for patients with uncomplicated active rheumatoid arthritis have equivalent clinical outcome with a small difference in overall resource cost in favour of day care. The choice of management strategy may depend increasingly on convenience, satisfaction, or more comprehensive health measures reflecting the preferences of patients, providers, and service commissioners.     

Prevalence and predictors of the prone sleep position among inner-city infants

Total and lifestyle-related medical care costs for employees of a major corporation participating in a worksite health promotion (WHP) program over a three-year period were compared with the costs for non-participants in a cross-sectional study. The study population consisted of 8,334 active employees based in the Cincinnati headquarters of The Procter & Gamble Company. Adjusting for age and gender, participants (n = 3,993) had significantly lower health care costs (29% lower total and 36% lower lifestyle-related costs) when compared with non-participants (n = 4,341) in the third year of the program. Similarly, in the third year of the program, participants had significantly lower inpatient costs, fewer hospital admissions, and fewer hospital days of care when compared with non-participants. No significant differences in costs were found between participants and non-participants during the first two years of the WHP program. Conclusions drawn from this study are that long-term participation in a WHP that includes high-risk screening and intensive one-on-one counseling results in lower total and lifestyle-related health care costs, as well as lower utilization of hospital services.     

Predicting Outpatient Mental Health Program Withdrawal Among Recently Discharged Inpatients With Schizophrenia.

Recently discharged inpatients with schizophrenia are vulnerable for hospital readmission when they prematurely self-terminate outpatient interventions (J. S. Brekke, M. Ansel, J. Long, E. Slade, & M. Weinstein, 1999). This study explored risk factors for community care nonadherence and the effectiveness of various inpatient practices in maintaining continuous post-discharge service use among 264 individuals with schizophrenia or schizoaffective disorder. In addition to previously established risk factors for outpatient care nonadherence, such as service dissatisfaction and medication noncompliance, results suggest that at-risk individuals are also more likely to have an arrest history and that inpatient substance abuse treatment can help prevent community mental health program withdrawal. Policy, practice, and research implications are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sustained local delivery of heparin to the rabbit arterial wall with an electroporation catheter

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

Comparative effectiveness of day hospital and inpatient psychiatric treatment.

Employed a pre–posttreatment control group design to compare the treatment effects of partial hospitalization to those of full-time hospitalization. Ratings of home and community adjustment were obtained from community informants (relatives or close friends) for 2 groups of Ss: (a) 24 day-hospital clients (partial hospitalization condition) matched on age (average age 32 yrs), education, and intelligence with (b) 24 inpatient clients (full-time hospitalization condition), and from an unmatched sample of 79 consecutive inpatient admissions. Treatment outcome was measured by clients' pre- and postscores on the Personal Adjustment and Role Skills scale. Results show that all groups evidenced improvement 2 mo after treatment started, particularly on measures of symptom reduction. Although patterns of improvement were comparable for both settings in univariate data analyses, multiple discriminant function analysis indicated that the day hospital sample evidenced greater gains in attentiveness and in employment. Gains favoring the day hospital sample were more striking for the unmatched 3-group comparison than for the matched 2-group comparison. Findings indicate that partial hospitalization is an attractive alternative to inpatient psychiatric hospitalization. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluation and treatment of the infected foot in a community teaching hospital

More inpatient hospital days are used for the care of diabetic foot infection than for any other diabetic sequela. Both the number of lower extremity amputations and the overall treatment cost of treating diabetic infections may be reduced by using a team approach in the care of the infected diabetic pedal wound. The authors propose an evaluation and treatment protocol of infected pedal ulcerations in an urban, community teaching institution when admitted to an established, multidisciplinary diabetic foot care team. The hospital course of 111 patients admitted with a primary diagnosis of infected pedal ulceration are retrospectively reviewed. Results revealed an average-length hospital stay of 7.4 days with a 96% limb-salvage rate. The authors suggest that in the treatment of the infected pedal wound, a diabetic foot care team with a well developed treatment protocol may yield a consistently favorable outcome and a cost-effective hospital course.     

The impact of methadone on consumption of inpatient care and mortality, with special reference to HIV status

This study investigates the impact of methadone treatment on inpatient care admissions and mortality among 331 methadone-maintained patients compared with 1,483 similar untreated opiate misusers. The methadone patients manifested a lower mortality during treatment than the comparison group and those patients who had left their treatment. The annual incidence rate decreased from 1.4 inpatient care admissions per year for those who had stayed 0-1 year, less than 1 for those who stayed more than 2 years, and 0.3 for those who had stayed longer (>4 years) in methadone treatment. A similar decrease occurred in both sexes. The incidence rate decreased more among the HIV-negative than the HIV-positive patients. The low incidence of inpatient care during treatment may be due to treatment but may also be partly due to selection factors.     

Focal damage to cochlear microcirculation measured using a non-contact laser blood flowmeter in guinea pigs

OBJECTIVE: The purpose of this study was to investigate the perceptions of community staff regarding service process and quality, while a public mental health service integrated acute inpatient and continuing care components. METHODS: The study employed a naturalistic successive measures design in which community mental health staff completed a questionnaire on three occasions during the integration process. RESULTS: Staff perceived overall service quality to improve during the integration process with continuity of care being the area subject to greatest improvement. CONCLUSIONS: The integration of acute inpatient and continuing care services resulted in changes to service process and outcome, which were judged by staff to be beneficial, especially with respect to continuity of patient care.     

Characteristic difference in gastrointestinal excretion of clarithromycin and roxithromycin

BACKGROUND: This paper describes trends in hospital activity, hospital admissions, and treatments for colorectal cancer on residents of the South Thames regions (population 8 million) between 1989-1993 against the background of the Calman Report on the future of cancer services in England and Wales. METHODS: The analyses are derived from UK hospital data, which are collected as finished consultant episodes (FCEs). These are defined as episodes "where a patient has completed a period of care under a consultant and is either transferred to another consultant or is discharged." Probability matching was used to derive patient-based records, matching FCEs to admissions. A total of 18,542 South Thames residents aged 40-99 were admitted for colorectal cancer between 1 January 1989 and 31 December 1993. Time trends were analysed for procedures, FCEs, admissions, and patient numbers by admission type (ordinary admissions and day case admissions). RESULTS: Between 1989 and 1993 inclusive colorectal cancer admissions doubled (98% increase p (trend) < 0.0001). These admissions were a result of a 6.4-fold increase in day case admissions and a 41% increase in ordinary admissions. The proportion of patients having a day case admission rose from 9% in 1989 to 18% in 1993 (p < 0.0001). Overall, 2894 (16%) patients had a day case admission; 1894 of these (65%) were also admitted as ordinary admissions. The number of FCEs and admissions per patient rose from 1.37 and 1.28 respectively in 1989 to 2.09 and 1.99 respectively in 1993. FCEs were between 5% and 8% higher than admissions over the five years. The number of ordinary (that is, overnight) inpatient admissions per patient rose from 1.23 to 1.41 over the five year period and day case inpatient admissions from 1.25 to 3.45. Chemotherapy accounted for 50% of the rise in day case admissions; colonoscopy and sigmoidoscopy were associated with a further 18%. Fourteen per cent of the increase in ordinary admissions was also because of chemotherapy. CONCLUSION: The monitoring of site specific trends in admission, treatments, and procedures on a population basis should be a core requirement of health authorities to inform needs assessment, resource allocation, and service planning. The rise in admissions and chemotherapy treatments have implications for drug costs, laboratory and inpatient services, monitoring, and clinical audit.     

Follow-up studies of psychotic patients receiving inpatient treatment or alternative forms of psychiatric care

An analysis of populations treated in the III Department of Psychiatry indicates that 12 years since the transformation of the organizational model of care for patients from sub-regionalized catchment area, inpatient treatment continues to be of major importance, as it was provided to over half of all referrals. Intermediate forms of care, replacing a half of the former number of psychiatric beds, were offered mainly to schizophrenic patients, with the exclusion of those with a marked agitation, psychomotor retardation, or aggressive, presenting imminent danger to self or others. At one-year follow-up J.E. Overall's scale was used to examine 39 schizophrenic patients treated at the inpatient ward, day hospital, or by a community treatment team. Patients treated at the day hospital providing an intense therapeutic program manifested a significantly more marked improvement in respect of 6 symptoms: autism, affective bluntness, guilt feelings, tension, suspiciousness, and bizarre thoughts. No significant differences were found between the compared forms of care as regards the degree of other symptoms amelioration. Thus, the day hospital turned out to be a more effective form of care in case of schizophrenic patients manifesting the cluster of symptoms listed above.     

The effectiveness of inpatient case management. Fact or fiction?

Production processes and service delivery in acute care hospitals can be fragmented. Inpatient case management has the potential to improve both processes and outcomes of hospital care. The author reports on 18 research studies that used inpatient case management as the treatment variable. These outcome studies, using case management, did not provide the evidence needed to address deficiencies in inpatient settings. However, these studies do provide clear direction for nurse administrators and nurse researchers to take concerning the next steps needed to address this critical issue.     

Acceptance of moderate drinking by alcoholism treatment services in Canada

OBJECTIVE: The present study was conducted to provide a nationwide survey of acceptance of nonabstinence goals and related alcoholism treatment practices by Canadian alcoholism treatment services. METHOD: A random sample of 335 Canadian alcoholism treatment service agencies were mailed a 4-page questionnaire designed to assess acceptance of moderate drinking as a drinking goal and related alcoholism treatment practices. RESULTS: Acceptance varied by type of service, with considerably more acceptance by outpatient programs (62%) and mixed inpatient/outpatient programs (43%) than inpatient/detoxification/ correctional facilities (27%) and halfway houses (16%). Two-thirds of the respondents who reported moderate drinking as unacceptable in their own agencies categorically rejected moderation for all alcoholism clients. CONCLUSIONS: Individuals seeking services in Canadian alcoholism treatment agencies are more likely to have a choice of drinking goals if they present to an outpatient program than a residential institution, and Canadian agencies appear more accepting of moderation goals than American programs, but less accepting than British and Norwegian service agencies.     

Factors associated with multiple admissions to a public psychiatric hospital

The purpose of this study was to identify the psychiatric and social factors associated with multiple admissions, especially for psychotic patients. Demographic and diagnostic information (based on the DSM-III-R) was collected on a computerized database for all patients admitted to the only psychiatric hospital in Geneva, Switzerland. Patients who had had at least three admissions over a period of 1 year were compared with a control group drawn from the total clinic population. In 1994, a total of 1575 patients were hospitalized, and 18% of these patients were readmitted for the third or more time. The principal diagnoses were psychotic disorders (25%), affective disorders (35%) and substance-related disorders (24%). The predictors of multiple admissions for psychotic patients were a comorbidity of substance-related disorder, longer duration of illness, female sex, younger age and poorer psychosocial adjustment during the past year. These results highlight the usefulness of a computerized psychiatric database. Indeed, early identification of the types of psychiatric patient who are likely to be readmitted is necessary to enable the planning and implementation of specific programmes of ambulatory care to prevent rehospitalization.     

The cost of treatment of psychiatric emergencies: a comparison of hospital and community services

This study aimed to compare the costs of treatment by community-based and hospital-based psychiatric services. The design entailed random allocation of patients presenting with psychiatric emergencies over a subsequent 3-month period to one of two services, followed by retrospective quantification of service use and its cost for each group. One hundred patients with emergency presentations to the psychiatric service via the Accident and Emergency Department, liaison psychiatrist and approved social worker were included in the study. Their use of a range of terms of service was recorded and disaggregated costings of these items of service was calculated. The use of non-psychiatric services was similar for both groups, but the use of psychiatric services differed, with the hospital group making greater use of in-patient beds and the community group employing more frequent home-based interventions. The total cost of treatment for the community group (pound 56,000) was much lower than for the hospital group (pound 130,000), although the median patient cost was 50% higher in the community group (pound 938 v. pound 610), and a greater proportion of the community service expenditure (10% v. 2%) was due to failed contacts. Taken together with clinical outcome, which showed no advantages for the hospital-based service over the community-based service, our findings suggest that this form of community psychiatric service is a cost-efficient alternative to hospital-based care for this group of patients.     

Use of inpatient hospital services by people aged 90-99 years

OBJECTIVE: To examine the use of inpatient hospital services by people aged 90-99 years. DESIGN: Retrospective case note review. SETTING: Flinders Medical Centre, a 516-bed university teaching hospital in Adelaide, South Australia. PATIENTS: All patients aged 90-99 years on the separation register for 1995. MAIN OUTCOME MEASURES: Patient demographic characteristics, principal diagnosis, length of hospital stay and outcome, including destination at discharge. RESULTS: In 1995, 317 separations involved 214 patients aged 90-99 years; 148 patients (69%) were admitted to hospital once, 43 (20%) twice and 23 (11%) three times or more. In 54% of separations, patients came from the community, and these were less likely to be emergency admissions (72%) than were admissions from hostels (87%) and nursing homes (93%). Patients had a wide range of acute medical and surgical problems and a median of five documented comorbidities. Patients survived to leave hospital in 290 separations (91%) and returned directly to their previous living circumstances in 212 (67%). Median hospital stay was 5.0 days, and in 25% of separations stay was one day or less. Patients admitted under the care of geriatricians had more emergency admissions (98%) and longer mean hospital stays (8.9 days) than those admitted under surgeons (69%; 5.9 days) or other physicians (66%; 5.0 days). CONCLUSION: Despite the acute nature of their illnesses and their multiple medical problems, most hospitalised nonagenarians in this study returned directly to their previous living circumstances after short hospital stays.