The care of patients with chronic schizophrenia: a comparison between two services

BACKGROUND: There has been a widespread development of community multi-disciplinary teams aimed to deliver coordinated comprehensive mental health care, yet there is little published evidence on the quality of care and economics of providing such care for people with severe mental illness. METHOD: This is a clustered randomized controlled economic comparison of the quality of care for patients with chronic schizophrenia by a multi-disciplinary community team with close links with primary care, and a traditional psychiatric service in a district general hospital psychiatric unit. RESULTS: Two years after it was established, patients with access to the community team had more of their needs met; they had fewer unmet needs; and they were more satisfied with the care they had received. They had more service contacts and received more interventions. The community team resulted in savings in the use of some hospital resources but these were not sufficient to offset the cost of the new service. The community team successfully directed care to patients with more needs, whereas no such relationship was evident for the traditional hospital-based service. Four years after the team was established, it met a greater proportion of needs for underactivity, daily living skills, use of public amenities and managing finances. CONCLUSIONS: Better quality care was provided at 2 and 4 years after its establishment by the multi-disciplinary community service than the traditional hospital-based service. Resources were targeted more efficiently by the community service.     

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.     

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.     

VESAS: a solution to seasonal fluctuations in emergency department census

STUDY OBJECTIVE: To design and implement a plan for emergency department staffing and additional space to reduce waiting time and the rate of patients leaving without being seen during the viral epidemic season. METHODS: The study was conducted in the ED of a tertiary care children's hospital. We compared 24,657 children who presented for care between November 1996 and March 1997 (VESAS plan enacted) with 24,012 children who presented for care during the same period in the preceding year. VESAS (Viral Epidemic Supplemental Attending and Staff), an additional team of personnel, was on call for the viral epidemic season and was called to work if the hourly ED census that day was 25% or more of the past year's average hourly patient volume. Extra examination rooms were made available in space contiguous to the ED. Interval data, "left without being seen" rates, and ED census were monitored and compared with the previous year's data. RESULTS: The VESAS team was used for 32% of the days during the 4-month intervention period. The left-without-being-seen rate was reduced by 37% (95% confidence interval, 33% to 41%). The average time from arrival to consultation with a physician was decreased by 15 minutes (95% confidence interval, -10 to -20) for all patients. Waiting times were most markedly reduced for less acutely ill or injured patients, although a modest decrease was also observed in patients with more severe illnesses or injuries (-10 minutes). The percentage of lesser-severity patients seen in an urgent care area was increased from 35% to 51%. CONCLUSION: VESAS, a plan for providing space and personnel to handle an increased volume of patients that can be activated on the basis of hourly census data, was successful as judged by waiting times and percentage of patients who left without being seen.     

Closed rupture of the posterior tibial artery secondary to a soccer injury

OBJECTIVE: To evaluate activities of a nurse led minor injuries unit based in a community hospital situated eight miles away from its sister district hospital in Crawley to demonstrate whether nurses can provide an alternative service. DESIGN: "Walk in" service provided by emergency nurse practitioners (ENPs) working within protocols and parameters with supervision from the accident and emergency consultant during the period of May 1995 to April 1996. RESULTS: Within the 12 month period, ENPs treated 6944 new patients. Altogether 234 patients were transferred to Crawley Hospital for further treatment. The ENPs reviewed 1611 patients and the consultant 1342; 1945 patients required radiographs and 793 were given medication; 553 patients were referred to other health care professionals. Almost all patients were happy to see a nurse and all were satisfied with the treatment they received. CONCLUSION: With careful planning, adequate supervision, and support from multidisciplinary teams nurses can provide a worthwhile and effective service for a local community.     

Stable chronic disease: a behavioral model

A three-year study was undertaken in the general medical clinic of a private community hospital, to assess the health behavior, health status, and profile of function of stable chronic disease was developed and tested. It was shown that these patients used a disproportionate amount of health care services. Half of the group was treated by a nurse practitioner/physician team and half by a house officer/preceptor team. Patients in both groups behaved similarly. These patients: 1) made frequent demands for outpatient services but did not need more than average hospital care; 2) tended to have problems of socio-economic indigency; 3) were likely to have hypertension, obesity, arthritis, and functional disease; 4) were chiefly women; 5) required special visits 9 percent of the time, usually for exacerbations of illness or intercurrent health problems; 6) made greater demands if they had functional complaints as a primary or secondary health problem; and 7) viewed their health more positively and functioned at a higher level if they were over 65 years of age. It was also found that the nurse practitioner, working in consultation with a physician, was able to provide high-quality health care.     

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.     

Establishing a high-school-based training room clinic

Being a team physician can be a time-consuming commitment. The team physician is responsible for all aspects of the athlete's care and has the final say in all medical matters related to athletic participation. Primary care physicians are well suited to be team physicians. The training room is an outstanding way to increase physician availability to adolescents and underserved population. Setting up a training room must be planned in advance, including funding, supplies and liability. Most legal problems can be avoided with a contract and proper documentation. The school-based training room provides the physician with an excellent opportunity for community service and can be a very rewarding experience.     

Ovarian vein syndrome

SETTING: A voluntary community health worker programme, in the Western Cape, South Africa, utilizing volunteers to administer directly observed therapy to tuberculosis (TB) patients. OBJECTIVE: This study describes the perceptions of health team members regarding the voluntary community health worker project. DESIGN: A qualitative, participatory research study utilizing focus groups. RESULTS: TB was perceived by the health team to be a stigmatized disease causing some patients to be reluctant to be associated with the TB control programme. Despite the project's dedicated approach to case-holding, volunteers expressed the need to develop skills in providing more comprehensive care. The volunteers appear to administer a more personalized service to TB patients and can bridge the gap between TB patients and the health agency. CONCLUSION: Sustained evaluation and support seem to be a vital tool in integrating a volunteer project into a health team approach. Its effectiveness appears to depend to a large degree on the people involved.     

Attaching community psychiatric nurses to general practice

A scheme for attachment of psychiatric nurses from hospital to group practice in Oxford is described. One community psychiatric nurse can work satisfactorily with eight general practitioners covering a population of about 18,000. From analysis of a working year, it is concluded that this arrangement improves the care of patients in the community by providing psychiatric help at times when it was previously unavailable or unacceptable.The implications of such a scheme for the workings of the primary health care team and the hospital psychiatric service are considered, and a case is made for a further study involving a comparison between practices with and without the attachment of a community psychiatric nurse.     

Cost effectiveness of community leg ulcer clinics: randomised controlled trial

OBJECTIVES: To establish the relative cost effectiveness of community leg ulcer clinics that use four layer compression bandaging versus usual care provided by district nurses. DESIGN: Randomised controlled trial with 1 year of follow up. SETTING: Eight community based research clinics in four trusts in Trent. SUBJECTS: 233 patients with venous leg ulcers allocated at random to intervention (120) or control (113) group. INTERVENTIONS: Weekly treatment with four layer bandaging in a leg ulcer clinic (clinic group) or usual care at home by the district nursing service (control group). MAIN OUTCOME MEASURES: Time to complete ulcer healing, patient health status, and recurrence of ulcers. Satisfaction with care, use of services, and personal costs were also monitored. RESULTS: The ulcers of patients in the clinic group tended to heal sooner than those in the control group over the whole 12 month follow up (log rank P=0.03). At 12 weeks, 34% of patients in the clinic group were healed compared with 24% in the control. The crude initial healing rate of ulcers in intervention compared with control patients was 1.45 (95% confidence interval 1.04 to 2. 03). No significant differences were found between the groups in health status. Mean total NHS costs were 878.06 pounds per year for the clinic group and 859.34 pounds for the control (P=0.89). CONCLUSIONS: Community based leg ulcer clinics with trained nurses using four layer bandaging is more effective than traditional home based treatment. This benefit is achieved at a small additional cost and could be delivered at reduced cost if certain service configurations were used.     

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.     

C.A.T. scans

With the rapidly mounting cost of medical care in hospitals, physicians must seek alternative forms of therapy for illnesses that could conceivably be treated by less confining methods. One appraoch to this problem is the Psoriasis Day Care Center, where psoriasis patients with extensive disease are treated during the day and allowed to return home at night. The advantages include reduced cost, accessibility for more patients, and superior therapeutic results. This day care center concept could be equally applicable to other diseases now routinely treated by complete hospitalization.     

Mutations in human TBX3 alter limb, apocrine and genital development in ulnar-mammary syndrome

The aim of this study was to determine the effect cognitive impairment has on direct and indirect costs to elderly people, their carers and the community over one year, by following prospectively a cohort of elderly people referred to an aged care assessment team. The 78 subjects were drawn from a random sample of people referred to the NorthWest Hospital team, and validated tools were used to assess their cognitive state. Outcome measures included total costs of community services, residential care, hospital bed use, carer burden and psychological morbidity. A comparison of outcome measures was made between those with cognitive impairment and those without. Use of community services and hospital beds was high overall. Those with cognitive impairment were substantially greater users of residential care, accounting for the higher expenditure in this group. Psychological morbidity and burden remain high in carers of those with cognitive impairment despite a high rate of institutionalisation in this group. The total costs for those referred to aged care assessment teams with cognitive impairment are double those seen for those with normal cognition.     

Effects of establishment of community psychiatry in Aalborg]

The aim of the present study was to illustrate the effects of community-based psychiatry. The catchment area was divided into three homogeneous districts, East, North and West. Teams were established on 1.9. 1990, 1.10.91 and 1.5.1992, respectively. Social, diagnostic and treatment related data were gathered from two cross-sectional investigations (I: February 1992 and II: February 1993) and from in-patients and out-patients files. In cross-section I a majority of long-term ward patients and hospital-based employment offers was found in the district where the community district team had not yet been established. In the district where the first community district team was established most primary target patients were treated. In cross-section II the hospital-based psychiatric service were more homogeneously distributed between the districts. The establishment of community-based psychiatric teams resulted in new referrals, and increasing numbers of patients becoming attached to the psychiatric teams, but crowding and use of compulsory measures in hospital also increased.     

Cost analysis of early discharge after hip fracture

OBJECTIVE: To ascertain the economic impact of an early discharge scheme for hip fracture patients. DESIGN: Population based study comparing costs of care for patients who had "hospital at home" as an option for rehabilitation and those who had no early discharge service available in their area of residence. SETTING: District hospital orthopaedic and rehabilitation wards and community hospital at home scheme. PATIENTS: 1104 consecutively admitted patients with fractured neck of femur. 24 patients from outside the district were excluded. MAIN OUTCOME MEASURES: Cost per patient episode and number of bed days spent in hospital. RESULTS: Patients with the hospital at home option spent significantly less time as inpatients (mean of 32.5 v 41.7 days; p < 0.001). Those patients who were discharged early spent a mean of 11.5 days under hospital at home care. The total direct cost to the health service was significantly less for those patients with access to early discharge than those with no early discharge option (4884 pounds v 5606 pounds; p = 0.048). CONCLUSIONS: About 40% of patients with fractured neck of femur are suitable for early discharge to a scheme such as hospital at home. The availability of such a scheme leads to lower direct costs of rehabilitative care despite higher readmission costs. These savings accrue largely from shorter stays in orthopaedic and geriatric wards.     

Evaluation of a nurse-led continence service in the south-west of Glasgow, Scotland

This paper reports the results of a pilot study of a nurse-led continence promotion service in both the community and a local nursing home. Telephone and written referrals were made to the service from 28 primary care teams in Glasgow, Scotland. In the nursing home all patients were assessed and an appropriate management plan implemented. A full assessment was carried out in all community patients, including an appraisal of contributory factors, urinalysis and diaries of food and drink intake. A management plan suited to the patient was then implemented. Patients' levels of incontinence in both arms of the study were assessed objectively using the Lagro-Janssen method. The cost incurred in both arms of the study were measured. There was a 69% improvement in the level of incontinence in the community group compared with 30% in the residents wing and 13% in the hospital wing. The savings in the nursing home amounted to Pounds 4152 in the residents' wing and Pounds 1959 in the hospital wing. In summary, a nurse dedicated to urinary incontinence in the community allows improved management, a greater level of awareness and results in resource savings, whilst increasing patient accessibility to a service.     

Utilization of carbon from dietary polyunsaturates for brain cholesterol synthesis during early postnatal development in the rat: a 13C NMR study

This article describes the total cost of care, including both informal caregiving and formal services for a cohort of disabled elderly living in the community. The cost of informal caregiving hours was calculated using a market value approach. The total annual cost of caring was estimated to be $9,600. Increased disability was associated with increased costs. High-cost elders were more likely to be severely disabled, live with their caregiver, and become institutionalized. For most elders, even the cost of a complete substitution of informal care for formal services, plus living expenses, was less costly than nursing home care.     

Evaluation of a palliative care service: problems and pitfalls

OBJECTIVE: To evaluate a palliative care home support team based on an inpatient unit. DESIGN: Randomised controlled trial with waiting list. Patients in the study group received the service immediately, those in the control group received it after one month. Main comparison point was at one month. SETTING: A city of 300,000 people with a publicly funded home care service and about 200 general practitioners, most of whom provide home care. MAIN OUTCOME MEASURES: Pain and nausea levels were measured at entry to trial and at one month, as were quality of life for patients and care givers' health. RESULTS: Because of early deaths, problems with recruitment, and a low compliance rate for completion of questionnaires, the required sample size was not attained. CONCLUSION: In designing evaluations of palliative care services, investigators should be prepared to deal with the following issues: attrition due to early death, opposition to randomisation by patients and referral sources, ethical problems raised by randomisation of dying patients, the appropriate timing of comparison points, and difficulties of collecting data from sick or exhausted patients and care givers. Investigators may choose to evaluate a service from various perspectives using different methods: controlled trials, qualitative studies, surveys, and audits. Randomised trials may prove to be impracticable for evaluation of palliative care.