Variations in the performance of hip fracture procedures

OBJECTIVE: To determine the cause and frequency of unplanned readmissions to a coronary care unit (CCU) after initial transfer to a general cardiac unit, but before hospital discharge. DESIGN: Analysis of 1776 admissions to a CCU during a 16-month period. SETTING: The CCU of a major teaching hospital in South Australia. PARTICIPANTS: All patients admitted to the CCU during the 16-month period. OUTCOME MEASURES: CCU readmissions before hospital discharge were categorized as either "planned" or "unplanned." The latter were investigated for determination of casualty and variations in patient characteristics (including age, sex, initial diagnosis, pharmacotherapy, and duration of stay in the CCU). RESULTS: Of the 1776 CCU admissions examined, 44 (2.5% of total) were unplanned readmissions before hospital discharge. Most of these (39 of 44) were related to "reactivation" of acute myocardial ischemia. Patients whose initial diagnosis was acute myocardial infarction or unstable angina pectoris were more likely to require a further unplanned CCU admission (p < 0.05); those with unstable angina pectoris had a second stay in CCU significantly longer than their first (p < 0.05). Six patients were readmitted within 6 hours of cessation of a heparin infusion (4 of the 6 without aspirin administration), and 11 patients had not received antiplatelet therapy after their initial CCU stay. Overall, a disproportionate number of men were readmitted to CCU (p < 0.05). CONCLUSIONS: In the current study, unplanned readmissions to the CCU: (1) were relatively infrequent, (2) were more protracted than initial stays in CCU, (3) may have been prevented in 15 of the 44 cases with more appropriate pharmacotherapy, and (4) involved a disproportionate number of male patients.     

Better at home: a continuous health care program for patients with advanced chronic respiratory disease

The objective of this study was to analyze the effect of continuous health care on the frequency of readmissions of patients with advanced chronic respiratory disease. The study was prospective, enrolling 26 patients (16 with COPD, 7 with bronchiectasis and 3 with pachypleuritis) who had been admitted at least 3 times within the past year. The patients were assigned to 3 groups: group A was the ambulatory monitoring group, with 8 patients who were able to travel to the hospital for monthly outpatient checkups; group B was the ambulatory pulmonary rehabilitation group, with 10 patients who were able to travel to the hospital and who needed rebreathing training (one weekly group session); and group C was the home care group, with 8 patients who were unable to travel to the hospital and who received weekly or biweekly house calls. All patients had telephone contact with the program team. Mean lung function values for the whole population were FVC 40 (11)%, FEV1 23 (7)% of reference, PaO2 55 (7) and PaCO2 55 (10) mmHg. A significant decrease in number of admissions (79 versus 18, p < 0.0001) was observed in both the first and second halves of the year in all three treatment groups: A, 25 to 2; B, 28 to 8; and C, 26 to 8 (p < 0.001). The reduction in health care costs over the previous year's expenditure was calculated to be 22,751,402 pesetas. We conclude that specialized health care that is continuous and personalized reduces the number of hospital readmissions of patients with advanced chronic respiratory disease. Moreover, the overall cost of care, without the need to make house calls to all patients.     

Prognostic relevance of transforming growth factor alpha (TGF-alpha) and tumor necrosis factor alpha (TNF-alpha) detected in breast cancer tissues by immunohistochemistry

BACKGROUND: Reducing inappropriate hospital admissions could lead to lower total health care costs without compromising the quality of care. Research suggests that a sizeable portion of hospital admissions are inappropriate. Other studies indicate that family physicians use health care resources, including hospitalizations, less often than other primary care physicians. To gain additional insight into family physicians' decisions to admit patients, we performed an exploratory study using the Appropriateness Evaluation Protocol, a validated, clinically based utilization review instrument. METHODS: We assessed admissions by community-based and residency-based family physicians to a single university-affiliated hospital during calendar year 1988. A total of 905 patients were admitted to the hospital by family physicians during the study period. Of these, 889 records had complete data. Each was reviewed for appropriateness of admission. We calculated percentages of inappropriate admissions and used logistic regression to ascertain variables that were significant predictors of inappropriateness. RESULTS: Overall, 5.4 percent of admissions were categorized as inappropriate. Omitting obstetric cases, the rate was 10.5 percent. Inappropriate admissions did not cluster around a small number of diagnoses or diagnosis-related groups. Using logistic regression, we found that urgency of admission, patient insurance status, and residency-based physician admission versus community-based physician admission were significant predictors of inappropriate hospital use. Of the inappropriate admissions, 70 percent were so rated because diagnostic procedures or treatments could have been performed on an outpatient basis. CONCLUSIONS: In contrast with other studies for which physician specialty was not controlled, family physicians less frequently admitted patients inappropriately. Predictors of inappropriateness differed from those found in other studies. Changes in hospital systems, in addition to educational efforts directed toward individual physicians, hold promise as a strategy for reducing inappropriate hospital use.     

Cost-effectiveness of providing insurance benefits for posthospital psychiatric halfway house stays.

A model insurance benefit package for posthospitalization psychiatric halfway house care was developed and administered to 32 hospitalized mentally ill persons. The therapeutic and cost effectiveness of providing a 120-day benefit package was examined over a 14-mo posthospitalization period. This was compared with the effectiveness of hospitalization benefits alone for the same patients over the 42 mo prior to halfway house admission. In terms of therapeutic efficacy, there was no significant deterioration after hospitalization release in either the symptom or behavioral coping scales, except for an increase in somatization. Yearly hospital recidivism rates fell from 79% to 29%, and the average yearly length of hospital stay per patient fell from 83 days to 18 days. In terms of cost-effectiveness, halfway house benefits saved the insurers 59% of their hospitalization costs. The implications of these findings are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Staphylococcus aureus bacteremia and endocarditis. New diagnostic and therapeutic concepts

The Health Care Financing Administration (HCFA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) conducted a demonstration between 1982 and 1985 to test the feasibility of providing payments for alcoholism treatment services to Medicare and Medicaid recipients in specially selected freestanding facilities. This study of the Medicare part of the demonstration answers two questions: do freestanding facilities save money for Medicare and do their patients have lower health care utilization following initiation of treatment than patients treated in hospital-based facilities? The statistical methodology is a logit and cluster approach. The analysis begins with a logistic regression model to predict the probability of patients seeking alcoholism treatment in either the demonstration (freestanding facility) or hospital-based cohort. The statistically significant variables from logit analysis are then used to form clusters. The health expenditures of freestanding and hospital patients are compared within homogeneous clusters. This study shows that the number of admissions, the average length of stay, and the average monthly health expenditures following the start of treatment are lower for the group treated in the freestanding facilities. The conclusion is that for some persons with alcohol problems, treatment in freestanding facilities is less costly and leads to lower subsequent health care utilization than treatment in hospitals.     

Admission to hospitals with on-site cardiac catheterization facilities :impact on long-term costs and outcomes

BACKGROUND: Admission to a hospital with a capability for cardiac procedures is associated with a higher likelihood of referral for a cardiac procedure but not with a better short-term clinical outcome. Whether there are differences in long-term mortality and resource consumption is not clear. We sought to determine whether elderly Medicare patients with acute myocardial infarction admitted to hospitals with on-site cardiac catheterization facilities have lower long-term hospital costs and better outcomes than patients admitted to hospitals without such facilities. METHODS AND RESULTS: As part of the Cooperative Cardiovascular Project pilot in Connecticut, we conducted a retrospective cohort study using data from medical charts and administrative files. The study sample included 2521 patients with acute myocardial infarction covered by Medicare from 1992 to 1993. The cardiac catheterization rate was higher in the hospitals with facilities (38.6% versus 26.9%; P<0.001), but the revascularization rate was similar (20.5% versus 19.5%) during the initial episode of care and at 3 years (29.7% versus 29.7%). Mortality rates were similar for patients admitted to the 2 types of hospitals at 30 days (OR, 1.08; 95% CI, 0.83 to 1.42) and at 3 years (OR, 1.02; 95% CI, 0.83 to 1.26). The adjusted readmission rates were significantly lower among patients admitted to hospitals with cardiac catheterization facilities (OR, 0.76; 95% CI, 0.61 to 0.94). However, the overall mean days in the hospital for the 3 years after admission was 25.9 for patients admitted to hospitals with facilities and 24.6 for the other patients (P=0.234). Adjusting for baseline patient characteristics, there was no significant difference in the 3-year costs between patients admitted to the 2 types of hospitals. CONCLUSIONS: With higher rates of cardiac catheterization and lower readmission rates, patients admitted to hospitals with on-site cardiac catheterization facilities did not have significantly different hospital costs compared with patients admitted to hospitals without these facilities. There was also no significant difference in short- or long-term mortality rates.     

Closed degloving injury of the fifth toe

The overcrowding of emergency departments (EDs) with inpatients results in an increased average inpatient length of stay; therefore, overcrowded hospitals have increased costs per patient. All admissions through the ED to our institution for 1988, 1989, and 1990 were reviewed. These admissions were analyzed based on whether they had spent less than 1 day or more than 1 day in the ED, after they had been admitted to the hospital and were waiting for a bed assignment. Analyses were performed for the five medical diagnosis-related groups, with the highest volumes of admissions via the ED. All categories were reviewed on the basis of whether or not the payor was Medicare. This was a retrospective data analysis of 3 years worth of hospital and ED length of stay. There was no intervention. The total number of patients admitted via the ED for 1988, 1989, and 1990 was 26,020. In 1988, 19% of admissions via the ED spent more than 1 day in the ED. The total hospital length of stay for this 19% was 11% longer than for the group who reached an inpatient bed on the first hospital day. In 1989, 32% of admissions via the ED remained in the ED for more than 1 day and had a 13% increase in total hospital length of stay. In 1990, 25% of admissions via the ED spent more than 1 day in the ED and had a 10% increase in total hospital length of stay. Inpatients who remained in the ED after admission had a greater average length of stay than those who were promptly transferred to inpatient units.(ABSTRACT TRUNCATED AT 250 WORDS)     

Psychiatric hospital admission rates: Facts and artifacts.

Examined types of patient admissions in the 1st yr of a new psychiatric hospital opening to address issues raised by I. Silverman and D. Saunders (see record 1982-01855-001). It was found that, for all patients residing in the county where the new facility was located, 39%, 48%, and 13% were transfer admissions, readmissions, and 1st admissions, respectively. By using a more valid definition of the same criterion variable (admission rates), these results question Silverman and Saunders's interpretation of the same data. (French abstract) (3 ref) (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

What changes drug metabolism in critically ill patients--III? Effect of pre-existing disease on the metabolism of midazolam

OBJECTIVE: To determine the number and duration of hospital admissions due to diabetes in children aged 0-19 years between 1980-1991. RESEARCH DESIGN AND METHODS: Secondary analysis of data collected by the SIG Health Care Information was based on the 9th revision of the International Classification of Diseases. The subjects were all children in The Netherlands, aged 0-19 years. The main outcome measures were number and duration of hospital admissions due to type I diabetes (ICD 9 code 250.0-250.9). RESULTS: The hospital admission rate due to diabetes decreased > 30%. This decrease was statistically significant in all age subgroups. The total number of days in hospital due to diabetes decreased dramatically: from 24,961 in 1980 to 11,305 in 1991. The average duration of hospital stay length due to diabetes decreased as well from 14.5 days in 1980 to 11.9 days in 1991. CONCLUSIONS: The hospital admission rate and the length of hospital stay for diabetes in children aged 0-19 years have decreased, in spite of an increasing incidence. The hospital admission rate may decrease still further if more children with newly diagnosed diabetes can be adequately managed by team management at home in the initial phase.     

Prolonged beneficial effects of a home-based intervention on unplanned readmissions and mortality among patients with congestive heart failure

BACKGROUND: A single home-based intervention (HBI) applied immediately after hospital discharge in a cohort of "high-risk" patients with congestive heart failure has been shown to decrease numbers of unplanned readmissions plus out-of-hospital deaths during a period of 6 months. The duration of this beneficial effect remains uncertain. METHODS: Hospitalized patients with congestive heart failure who had been randomly assigned to receive either usual care (n=48) or HBI 1 week after discharge (n=49) were subject to an extended follow-up of 18 months. The primary end point of the study was frequency of unplanned readmissions plus out-of-hospital deaths. Secondary end points included total hospital stay, frequency of multiple readmissions, cost of hospital-based care, and total mortality. RESULTS: During 18-month follow-up, HBI patients had fewer unplanned readmissions (64 vs 125; P=.02) and out-of-hospital deaths (2 vs 9; P=.02), representing 1.4+/-1.3 vs 2.7+/-2.8 events per HBI and usual-care patient, respectively (P=.03). The HBI patients also had fewer days of hospitalization (2.5+/-2.7 vs 4.5+/-4.8 per patient; P=.004) and, once readmitted, were less likely to experience 4 or more readmissions (3/31 vs 12/38; P=.03). Hospital-based costs were significantly lower among HBI patients (Aust $5100 vs Aust $10600 per patient; P=.02). Unplanned readmission was positively correlated with 14 days or more of unplanned readmission in the 6 months before study entry (odds ratio [OR], 5.4; P=.006). Positive correlates of death were (1) non-English speaking (OR, 4.9; P=.008), (2) 14 days or more of unplanned readmission in the 6 months before study entry (OR, 4.9; P=.008), and (3) left ventricular ejection fraction of 40% or less (OR, 3.0; P=.03); conversely, assignment to HBI was a negative correlate (OR, 0.3; P=.02). CONCLUSIONS: In this controlled study, among a cohort of high-risk patients with congestive heart failure, beneficial effects of a postdischarge HBI were sustained for at least 18 months, with a significant reduction in unplanned readmissions, total hospital stay, hospital-based costs, and mortality.     

Impact of a clinical pathway for elective infrarenal aortic reconstructions

OBJECTIVE: To determine the impact of a clinical pathway for elective infrarenal aortic reconstruction on outcome, resource utilization, and cost in a university medical center. SUMMARY BACKGROUND DATA: Clinical pathways have been reported to control costs, reduce resource utilization, and maintain or improve the quality of patient care, although their use during elective aortic reconstructions remains unresolved. METHODS: A clinical pathway was developed for elective infrarenal aortic reconstructions by a multidisciplinary group comprised of representatives from each involved service. The prepathway practice and costs were analyzed and an efficient, cost-effective practice with specific outcome measures was defined. The impact of the pathway was determined by retrospective comparison of outcome, resource utilization, and cost (total and direct variable) between the pathway patients (PATH, n = 45) and a prepathway control group (PRE, n = 20). RESULTS: There were no significant differences in the patient demographics, comorbid conditions, operative indications, or type of reconstruction between the groups. There were no operative deaths and the overall complication rate (PRE, 35% vs. PATH, 34%) was similar. The pathway resulted in significant decreases in the total length of stay and preoperative length of stay and a trend toward a significant decrease (p = 0.08) in the intensive care length of stay for the admission during which the operation was performed. The pathway also resulted in significant decreases in both direct variable and total hospital costs for this admission, as well as a significant decrease in the overall direct variable and total hospital costs for the operative admission and the preoperative evaluation (< or =30 days before operative admission). Despite these reductions, the discharge disposition, 30-day readmissions, and number of postoperative clinic visits within 90 days of discharge were not different. CONCLUSIONS: Implementation of a clinical pathway for elective infrarenal aortic reconstructions dramatically decreased resource utilization and hospital costs without affecting the quality of patient care and did not appear to shift the costs to another setting.     

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.     

Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective, randomized, controlled trial

BACKGROUND: Economics has caused the trend of early tracheal extubation after cardiac surgery, yet no prospective randomized study has directly validated that early tracheal extubation anesthetic management decreases costs when compared with late extubation after cardiac surgery. METHODS: This prospective, randomized, controlled clinical trial was designed to evaluate the cost savings of early (1-6 h) versus late tracheal extubation (12-22 h) in patients after coronary artery bypass graft (CABG) surgery. The total cost for the services provided for each patient was determined for both the early and late groups from hospital admission to discharge home. All costs applicable to each of the services were classified into direct variables, direct fixed costs, and overhead (an indirect cost). Physician fees and heart catheterization costs were included. The total service cost was the sum of unit workload and overhead costs. RESULTS: One hundred patients having elective CABG who were younger than 75 yr were studied. Including all complications, early extubation (n = 50) significantly reduced cardiovascular intensive care unit (CVICU) costs by 53% (P < 0.026) and the total CABG surgery cost by 25% (P < 0.019) when compared with late extubation (n = 50). Forty-one patients (82%) in each group were tracheally extubated within the defined period. In the early extubation group, the actual departmental cost savings in CVICU nursing and supplies was 23% (P < 0.005), in ward nursing and supplies was 11% (P < 0.05), and in respiratory therapy was 12% (P < 0.05). The total cost savings per patient having CABG was 9% (P < 0.001). Further cost savings using discharge criteria were 51% for CVICU nursing and supplies (P < 0.001), 9% for ward nursing and supplies (P < 0.05), and 29% for respiratory therapy (P < 0.001), for a total cost savings per patient of 13% (P < 0.001). Early extubation also reduced elective case cancellations (P < 0.002) without any increase in the number of postoperative complications and readmissions. CONCLUSIONS: Early tracheal extubation anesthetic management reduces total costs per CABG surgery by 25%, predominantly in nursing and in CVICU costs. Early extubation reduces CVICU and hospital length of stay but does not increase the rate or costs of complications when compared with patients in the late extubation group. It shifts the high CVICU costs to the lower ward costs. Early extubation also improves resource use after cardiac surgery when compared with late extubation.     

Relationship of provider characteristics to outcomes, process, and costs of care for community-acquired pneumonia

OBJECTIVES: The authors describe the relation of provider characteristics to processes, costs, and outcomes of medical care for elderly patients hospitalized for community-acquired pneumonia. METHODS: Using Medicare claims data, Medicare beneficiaries discharged from Pennsylvania hospitals during 1990 with community-acquired pneumonia were identified. Claims data were used to ascertain mortality, readmissions, use of procedures and physician consultations, and the costs of care. The relationship of these measures to provider characteristics was analyzed using regression techniques to adjust for patient characteristics, including comorbidity and microbial etiology. RESULTS: Among 22,294 pneumonia episodes studied, 30-day mortality was 17.0%. After adjusting for patient characteristics, 30-day mortality and readmission rates were unrelated to hospital teaching status or urban location or to physician specialty. Use of procedures and physician consultations was more common and costs were 11% higher among patients discharged from teaching hospitals compared with nonteaching hospitals. Similarly, costs were 15% higher at urban hospitals compared with rural hospitals. General internists and medical subspecialists used more procedures and had higher costs than family practitioners. CONCLUSIONS: Processes and costs of care for community-acquired pneumonia varied by provider characteristics, but neither mortality nor readmission rates did. These differences cannot be explained by clinical variables in the database. Further studies should determine whether less costly patterns of care for pneumonia, and perhaps other conditions, could replace more costly ones without compromising patient outcomes.     

Anthropometric nutritional assessment of critically ill hospitalized children

In a prospective study, the nutritional status was evaluated in 46 consecutive admissions to a Pediatric Intensive Care Unit, using anthropometric parameters. About 65% of the patients presented malnutrition on admission, with predominance of the chronic form. The mortality rate was greater in the malnourished (20 versus 12.5%) and chronic malnutrition was associated with a higher incidence of infection (42%). There was a fall in channel of percentile for weight-for-height in 36% of the patients evaluated at the final follow up. These results suggest that a significant number of patients are at nutritional risk at the time of hospital admission, and there is an association between nutritional status and hospital course. The anthropometric nutritional evaluation is a simple an reproducible method, and a valuable parameter for an objective nutritional assessment of the critically ill child. Therefore, it should be performed on admission and follow up of hospitalized children.     

The effect of Medicare's payment system for rehabilitation hospitals on length of stay, charges, and total payments

BACKGROUND: Medicare's system for the payment of rehabilitation hospitals is based on limits derived from a hospital's average allowable charges per patient discharged during a base year. Thereafter, payments are capped but hospitals receive incentive payments if charges per patient are reduced in succeeding years. We hypothesized that per-patient charges would increase during the base year and then decrease in subsequent years. Hospitals would thus have higher reimbursement limits and receive incentive payments for reducing their charges. METHODS: We analyzed Medicare claims data for 190,921 discharges from 69 rehabilitation hospitals from 1987 through 1994. We compared total charges, length of stay, and interim payments before, during, and after each hospital's base year. RESULTS: After we controlled for inflation and temporal and seasonal trends, mean charges per patient discharged increased from $25,131 for patients discharged before the base year to $32,167 for patients discharged in the base year (a 28 percent increase, P<0.001) and the mean length of stay increased from 22.1 to 26.7 days (a 21 percent increase, P<0.001). After the base year, mean charges decreased to $29,307 (a 9 percent decrease) and the mean length of stay decreased to 24.0 days (a 10 percent decrease) (P<0.001 for both comparisons). Analysis of data on patients according to diagnosis -- for example, spinal cord injury, brain injury, stroke, amputations and deformities, hip fracture, and arthritis and joint disorders -- showed similar findings for each, with increases in charges and length of stay in the base year, followed by smaller reductions thereafter. For-profit hospitals had greater increases than nonprofit hospitals in their per-patient charges (mean increase, $7,434 vs. $2,929; P<0.001) and length of stay (mean increase, 4.6 vs. 2.3 days, P<0.001) during the base year. CONCLUSIONS: Although Medicare's reimbursement system for rehabilitation hospitals put an upper limit on total payments, its design was associated with substantial extra costs, including significantly increased payments to hospitals and doctors and increased numbers of hospital days for the average patient.     

The primary care network--a new type of HMO for private practice physicians

A new type of health maintenance organization has been developed to encourage primary care physicians in private practice to become coordinators and financial managers for all medical care. Each patient chooses one internist, family or general physician, or pediatrician and must be referred by that physician for all hospital admissions and care by specialists. The primary care physician authorizes all payments from his own account for care provided to his patients. He shares any deficit or surplus remaining at the end of the year. Hospital admission rates and length of stay are lower than those of Blue Cross, with only one of three dollars paid to hospitals. The plan is providing care to 38,000 persons with 750 participating physicians in Northern California, Washington and Utah. This plan represents an attempt by physicians to control costs without government regulation.     

Predictors of return to a psychiatric hospital

Examined social factors as measured by a community adjustment scale and other known variables associated with recidivism for their ability to predict rehospitalization of 108 former psychiatric inpatients. One-third of this sample were readmitted to a psychiatric hospital during the 6-mo period. Multiple linear regression analyses indicated that 2 of the subscales of the Self-Assessment Guide, the number of previous hospital admissions, and whether the individual had been in the hospital during the year prior to admission accounted for a sizable portion of variance. Results suggest that social factors are important determinants of recidivism. (PsycINFO Database Record (c) 2010 APA, all rights reserved)