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.     

Suicide following an inpatient hospitalization for a suicide attempt: a Canadian follow-up study

This study contributes a Canadian perspective to a growing body of international studies examining suicide among cohorts of suicide attempters, and a much more limited literature on the epidemiology of suicide in Canada. We evaluated the 13-year mortality experience of a regional cohort of 876 first-ever inpatient hospital admissions for a suicide attempt admitted between 1979 and 1981. Compared to the general population, study subjects were 4 times more likely to die of any cause, but 25 times more likely to commit suicide and 15 times more likely to die of accidental or adverse causes. Ten years after then first hospitalization for attempted suicide, 5.9% of study subjects had committed suicide. Baseline age appeared to be a risk factor for women, but not for men. Women under 60 years had the best 10-year survival (3.6% had committed suicide) and women over 60 years had the poorest (17.5%). A total of 8.7% of men under 60 years and 10% of those over 60 years committed suicide within 10 years. The remainder of the analysis focused on those under 60 years of age at the time of their index inpatient hospitalization. Three factors were prognostic for suicide: being male, which had a relative risk (RR) of 5.0, living in a lower income area (RR = 3.2), and having used a violent method during the index attempt (RR = 2.5). The periods of greatest risk for suicide were within the 1st and 4th years following first-ever inpatient hospitalization, with the 4th year representing the time of highest risk. The identification of time periods subsequent to first-ever hospitalization when patients are at greatest risk of suicide can be used to guide the timing and duration of clinical interventions and aftercare to ensure that patients are appropriately supported during periods of highest risk.     

Psychiatric hospitalization of persons with dual diagnoses: estimates from two national surveys

Individuals with both mental illness and alcohol or drug use disorders present distinctive treatment and human service problems, including increased risk for psychiatric hospitalization in community hospitals. Using national hospital discharge abstract data for 1990 and 1994, this study compared differences in psychiatric hospitalization in community hospitals of patients with mental illness only and those with mental disorders and substance use disorders. Individuals with dual diagnoses were younger, and a greater proportion were men. Medicaid was the primary payer for a larger percentage of those with dual diagnoses. Nationally, the number of community hospitalizations for dually diagnosed patients increased 15 percent from 1990 to 1994, and total hospital charges increased from $1.9 to $2.2 billion.     

Discharge of psychiatric patients into the community: how many more must die?

Since the advent of community care, mental health services are increasingly coming under scrutiny, particularly the management of people with mental health problems in the community. Several murders committed by psychiatric patients in the community have fuelled public debate. This article reports on a study examining the recommendations of the Department of Health regarding the discharge of psychiatric patients from hospital to community care. It describes the background to events such as the Clunis report and guidance from the Department of Health on the management of mental health services. Semi-structured interviews, questionnaires and document analysis were used to ascertain the views of community psychiatric nurses and managers regarding the discharge of patients into the community. The findings identify areas of good practice and the need for nurses to improve their knowledge of the care-programming approach, risk assessment and inter-agency collaboration.     

Situations associated with admission to an acute care inpatient psychiatric unit.

This study examined whether stressful events occurred during the week preceding admission to an inpatient psychiatric unit in a sample of 97 adults with serious mental illness. The study also examined whether patients who had been readmitted within 30 days reported different stressful events than patients who had lived in the community for at least 6 months prior to admission. A structured interview was developed to obtain information about depressive and psychotic symptoms, stressful events, substance use, and aggressive and disruptive behaviors. Suicide risk was the most common reason for hospitalization (65%). Between 25% and 38% of patients reported interpersonal problems with family members or people outside their family, and about 50% reported financial problems immediately before hospitalization. Comparison of patients who had been readmitted within 30 days with patients who had been living in the community for at least 6 months since their last hospitalization found few differences between these groups. Results indicate that most patients were admitted to an inpatient psychiatric unit because of suicide risk, and interpersonal events seemed to precipitate hospital admission for these patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Race differences in psychopathology and disparities in treatment seeking: Community and jail-based treatment-seeking patterns.

Whites in community samples use mental health services at a much higher rate than African Americans (Kessler et al., 2005). Is this also the case among those in jails? In this study of jail inmates (229 African American, 185 White), there were no race differences in the overall need for mental health treatment (63% of participants had significant symptoms on the Personality Assessment Inventory), but race differences in the level and types of symptoms were evident. In addition, although Whites were more likely to report preincarceration treatment, there were no differences in treatment seeking or access to mental health programs while in jail, implying that if barriers to treatment in the community were removed (cost/insurance, location/transportation, time), racial disparities in treatment utilization may be reduced. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mental health service utilization among African American and Caucasian mothers and fathers.

Mental health services have been routinely underutilized. This study investigated the influence of parents' gender, race, and psychopathology on perceived barriers and attitudes toward mental health utilization for themselves and for their children. A unique contribution of this study is the examination of father, mother, and child factors influencing service utilization from the parents' perspective. A total of 194 African American and Caucasian parents were recruited from the community to participate. Parents completed measures on barriers and attitudes toward treatment for themselves and for their children, history of mental health service utilization for themselves and for their children, and their own current psychological symptoms. Results indicated that 36.3% and 19.4% of parents and children, respectively, had used mental health services during their lifetime. Parents perceived fewer barriers and had more positive attitudes toward seeking services for their children than for themselves. Race and gender differences were found in parents' perceptions of barriers and attitudes toward treatment. Furthermore, barriers, attitudes, and psychopathology predicted parents' plans for future utilization of mental health services. The clinical implications of this study and directions for future research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Use of health services for anxiety disorders: a multisite study in Quebec

OBJECTIVE: We investigated patient characteristics and use of services for anxiety disorders among patients seeking care from participating clinicians at 7 anxiety clinics in Quebec: 3 general hospital clinics, 3 psychologist-run clinics, and one psychiatric hospital clinic. METHODS: Persons eligible for the study were those who were visiting the clinics for the first time, had a current diagnosis of an anxiety disorder, and could communicate in French or English. Subjects recruited through advertisements were excluded. Data, collected by a self-administered questionnaire, included demographics, treatment history, use of services for anxiety, and the Beck Anxiety Inventory (BAI). RESULTS: The sample comprised 235 subjects: 146 seen at 3 general hospital clinics, 54 at 3 psychologist-run clinics, and 35 at a psychiatric hospital clinic. There were statistically significant differences by clinic type in the prevalence of specific anxiety diagnoses, BAI score, referral source, antidepressant use, and use of services. High-intensity use (10 or more consultations during the previous year) was reported by 23.4% of the sample for medical services and 19.6% for mental health services. Multiple logistic regression identified variables associated with high-intensity use of medical services (higher BAI score, 1 to 4 years since first sought treatment, and less than 12 years of education) and high-intensity use of mental health services (clinic type, obsessive-compulsive disorder [OCD], and 5 or more years since first sought treatment). CONCLUSIONS: The patient populations seen at different types of anxiety clinics differ in several respects, including referral source, previous treatment, and severity of symptoms. Regardless of type of clinic, patients with a longer time since they first sought treatment use more services, particularly mental health services. Those with less education use more medical services than those with greater education.     

Evaluation of a stroke family care worker: results of a randomised controlled trial

OBJECTIVE: To examine the effect of contact with a stroke family care worker on the physical, social, and psychological status of stroke patients and their carers. DESIGN: Randomised controlled trial with broad entry criteria and blinded outcome assessment six months after randomisation. SETTING: A well organised stroke service in an Edinburgh teaching hospital. SUBJECTS: 417 patients with an acute stroke in the previous 30 days randomly allocated to be contacted by a stroke family care worker (210) or to receive standard care (207). The patients represented 67% of all stroke patients assessed at the hospital during the study period. MAIN OUTCOME MEASURES: Patient completed Barthel index, Frenchay activities index, general health questionnaire, hospital anxiety and depression scale, social adjustment scale, mental adjustment to stroke scale, and patient satisfaction questionnaire; carer completed Frenchay activities index, general health questionnaire, hospital anxiety and depression scale, social adjustment scale, caregiving bassles scale, and carer satisfaction questionnaire. RESULTS: The groups were balanced for all important baseline variables. There were no significant differences in physical outcomes in patients or carers, though patients in the treatment group were possibly more helpless less well adjusted socially, and more depressed, whereas carers in the treatment group were possibly less hassled and anxious. However, both patients and carers in the group contacted by the stroke family care worker expressed significantly greater satisfaction with certain aspects of their care, in particular those related to communication and support. CONCLUSIONS: The introduction of a stroke family care worker improved patients' and their carers' satisfaction with services and may have had some effect on psychological and social outcomes but did not improve measures of patients' physical wellbeing.     

The treatment of common mental disorders by a community team based in primary care: a cost-effectiveness study

Thirty patients suffering from new episodes of depression or anxiety disorders seen by a hospital-based psychiatric service were matched for severity of illness with 30 patients seen by a community mental health team based upon primary care. These patients were drawn from a total of 108 such patients seen in the community and 57 seen by the hospital service. Clinical and social outcomes were similar in both groups, and neither was clearly superior in terms of quality of clinical information recorded. However, patients treated in the community were seen more quickly, had more continuity of care and were more satisfied with the service. Health services costs were less for those patients treated in the community, because patients were less likely to be admitted. With one atypical patient excluded, treatment by the community team is more cost effective. The greater number of patients seen by the primary-care-based service means that there is no overall cost saving to the NHS.     

Morbidity in hospital admission for stroke

INTRODUCTION: In spite of advances in the prevention and treatment of ischemic vascular disease, this continues to be one of the main causes of disablement and prolonged hospitalization in developed countries. Also, hospitalization itself leads to complications which have a negative effect on the morbi-mortality of these patients during the time spent in hospital. OBJECTIVE: We decided to study the effect of systemic complications during the period of hospital stay, on the functional recovery of patients which ictusl. MATERIAL AND METHODS: A prospective study was made of 47 patients admitted to our unit for neurological deficit of more than 24 hours evolution and of cerebrovascular aetiology. Functional recovery was evaluated by means of the index of Barthel on discharge and after a period of 3 months with respect to the degree of neurological involvement (Canadian scale on admission), glycemia on admission, time spent in hospital and the occurrence of systemic complications in hospital. RESULTS: These were no differences between the groups of patients with and without systemic complications regarding age, glycemia and Canadian scale on admission. Nor wes there any difference between the groups regarding the number of patients with significant deterioration of their neurological condition (decrease > 20% in the EC). Functional recovery on hospital discharge was worse in the group with systemic complications (IB: 43.05 +/- 34.1: as compared with IB: 72.8 +/- 22.7 in the group without complications). This difference persisted after 3 months. CONCLUSIONS: Systemic complications related to hospitalization have a negative effect on the functional recovery of patient with ictus and also prolong the time spent in hospital.     

The impact of an information pack on patients with stroke and their carers: a randomized controlled trial

OBJECTIVES: To assess the impact of information packs on patients with stroke and their carers, and to pilot some of the methodology for a trial of a Family Support Organiser (FSO). SUBJECTS: Seventy-one patients admitted to Oxford hospitals with acute stroke during February-July 1995, and 49 informal carers of these patients. DESIGN: Randomized controlled trial. Intervention group received an Information pack containing various Stroke Association publications one month after their stroke, or at discharge from hospital, whichever was sooner. Control group received nothing. Follow-up was by interview at the place of residence of the patients six months after their stroke. MEASURES: Outcome measures assessed knowledge about stroke; satisfaction with information received; patient behaviour in terms of access to community services and benefits; and health status and quality of life. RESULTS: Patients and carers in the intervention group tended to know more about stroke, but these differences were not significant once adjusted for age. Patients in the intervention group (but not carers) tended to be more satisfied with the information that they had received, but the differences were not significant. There were no differences with regard to any aspects of quality of life in patients in the intervention group, though carers in the intervention group were found to have significantly better mental health (p = 0.04). CONCLUSIONS: While the study was too small to generate firm conclusions, information leaflets may lead to improved knowledge about stroke several months after they have been distributed. This finding is worth following up with larger studies. The stroke knowledge questionnaire that was piloted in this trial seems to be able to detect differences between groups.     

Family characteristics of subjects with panic attacks

OBJECTIVE: Patients with panic symptoms are heavy users of the health care system, although many do not seek care specifically for those symptoms. This study documents utilization of various sources of health care of subjects with panic symptoms, including those who met criteria for panic disorder and those with infrequent panic, distinguishing between use specifically for panic symptoms and use for reasons not related to panic. METHODS: This community-based sample, predominantly Mexican American and female, included 97 subjects with panic symptoms and 97 matched control subjects with no panic symptoms. Data were collected on two-month utilization of various sources of health care both within and outside the mainstream health care system, barriers to access to care, and levels of medical insurance coverage. RESULTS: Subjects with panic symptoms had higher utilization rates for the services of psychiatrists and psychologists and for ambulance services than control subjects. Subjects who met criteria for panic disorder and who sought care specifically for panic symptoms generally accounted for the differences between the group with panic symptoms and the control group. The two groups differed little in barriers to access, but the control group reported that their medical insurance covered more types of services. CONCLUSIONS: Compared with control subjects, subjects with panic symptoms reported higher rates of health care utilization despite having less insurance coverage and experiencing similar barriers to access. The higher rate was due to increased utilization of health care by subjects who met criteria for panic disorder and to help seeking specifically for symptoms of panic.     

Effect of a stroke protocol on hospital costs of stroke patients

OBJECTIVE: To determine the impact of a protocol on hospitalization costs for patients admitted with stroke. DESIGN AND SETTING: Nonrandomized control trial in an urban community hospital with 376 beds. PATIENTS: All patients admitted with a diagnosis-related group code of 014 (cerebrovascular disease) were included (N = 390). Patients with subdural hematoma (N = 2) or subarachnoid hemorrhage (N = 2) were excluded. INTERVENTION: A protocol for treatment of acute stroke was developed that included a critical path for nursing care, an algorithm for emergency department care, and suggested admission orders for physicians. MAIN OUTCOME MEASURES: The hospital information system computer database was searched for hospitalization charges, length of stay, tests performed, and treatments provided. RESULTS: Patients treated with the protocol had lower charges compared with historical (p = 0.026) and concurrent (p = 0.02) control groups. Lower charges were accounted for by a decreased length of stay in the protocol group compared with historical (p = 0.001) and concurrent (p = 0.13) controls. Tests and treatments provided were similar except that carotid Doppler studies and deep venous thrombosis prophylaxis were more frequently done in those treated with the protocol (p = 0.001 for carotid Doppler and p = 0.026 for deep venous thrombosis prophylaxis). There were no differences in outcome measures such as death or discharge disposition. Medical complications were similar in all groups. CONCLUSIONS: There were significant savings in hospitalization cost for patients with acute stroke after introduction of a treatment protocol. These savings were almost entirely related to decreased length of stay. The protocol led to modest differences in tests ordered and treatments provided.     

Does a hostel's managing agency determine the access to psychiatric services of its residents?

This study examines the effect of managing agency (local authority, private or voluntary) on the use of other health and social care services by residents in mental health hostels and group homes with different levels of staffing in England and Wales. The sample comprised 1323 residents in 275 facilities in eight districts. The measures of service use were number of days in hospital and number of other service contacts. There were highly significant differences between facilities with similar levels of staffing managed by different agencies. Residents in the voluntary sector used fewer community services overall; residents in low-staffed local authority facilities used more services than those in similar facilities managed by other agencies. These differences were not easily explained by differences in the social or clinical characteristics of residents. This suggests that there may be organisational factors, e.g. hostel staff, knowledge of services, which influence access to and use of community services.     

Public mental health service and diagnostic trends regarding individuals who are deaf or hard of hearing.

From a pool of 84,437 public mental health case records in Rochester, NY, 544 pertained to deaf or hard of hearing (DHH) patients. Proportional comparisons of demographic, service, and diagnostic patterns revealed significant differences between DHH and comparison samples. Women, children, and non-Caucasians were underrepresented in the DHH sample; male and elderly DHH patients were overrepresented. DHH patients were overrepresented in 4 small but communicatively accessible programs that provided a limited range of services. When served by community services, DHH patients received fewer clinical services and more continuing treatment and case management services. Axis II diagnoses of mental retardation were more frequent in the DHH sample, and clinicians were less able to rule out Axis II pathology. It is suggested that observed differences reflect service accessibility and clinician expertise problems rather than clinical distinctions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Emerging trends in mental health policy and practice

The continuing deinstitutionalization of patients in public mental hospitals and the growth of managed care are fundamentally altering mental health practice. Managed care provides opportunities for achieving parity of insurance coverage between mental and physical illness, but serious problems persist in integrating mental health, substance abuse, and general medical care and assuring an appropriate range of services and programs for persons with serious mental illness residing in community settings. Hospital and community care are poorly coordinated, and hospital care needs to be integrated into a more balanced system of services. Important new roles are emerging for purchasers, patient advocates, and mental health authorities.     

Utilization of ambulatory psychotherapy by patients with endogenous depression after inpatient psychiatric treatment

The long-term course of major depressive disorder is often accompanied by relapses or chronicity. Since psychosocial factors have been shown to be important predictors for the long-term outcome, psychotherapy along with drug therapy belongs to the standard methods of treatment. In spite of the effectiveness of psychotherapy, only some of the inpatients are treated with outpatient psychotherapy after hospital discharge. Within the framework of the Heidelberg depression study the authors examined what kind of, how many and for how long endogenously depressed patients sought out-patient psychotherapy after an inpatient treatment in a two-year follow-up. During the follow-up one half of patients were treated with outpatient psychotherapy. They were found to be younger, had suffered from more previous episodes, and their personality was more disturbed than those who had not undergone psychotherapy. The Expressed Emotion index did not make any further difference, whereas certain aspects of partnership quality did. The distinction between the two groups of patients is discussed regarding possible selection processes by treatment indication. It is pointed out that research on synergistic cooperation between members of the mental health services is highly desirable.     

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.     

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.