Health service aspects of psychosomatic inpatient treatment in a general hospital

The study objective is to outline basic aspects of medical care service structure in the fields of psychosomatic medicine in a clinical acute-care setting. A total of 216 inpatients in a psychosomatic ward of a general hospital were investigated during a 32 months period using a retrospective study design. Referring physicians and clinics along with referral procedures, the waiting period, teamwork with other clinics, as well as patient and therapy characteristics are described. According to provisions of outpatient psychosocial care, general practitioners refer the majority of the inpatients (55 %), followed by other clinics (25 %) and psychosomatic and psychiatric outpatient specialists (20 %). An outpatient department along with a psychosomatic C-L service are key elements for a psychosomatic department to ensure coordination of the referral procedure. The average waiting period lasts 21 days, the average length of stay is 48 days. 60 % of the inpatients show somatic and psychiatric co morbidity. A psychopharmacological treatment has to be taken into consideration along with multi-modal psychotherapy in a third of all patients.     

Length of stay,referral to aftercare,and rehospitalization among psychiatric inpatients

OBJECTIVE: This retrospective study explored the interrelationship among aftercare, length of hospital stay, and rehospitalization within six months of discharge in a sample of psychiatric inpatients. METHODS: Data were analyzed for 1,481 patients who had received inpatient care at a state psychiatric hospital from November 1991 to July 1994. Logistic regression models were estimated to predict the likelihood of referral to aftercare and of readmission to a hospital within six months of the index discharge. Variables controlled for were patients' characteristics; psychiatric status at the time of discharge, including length of stay; and the availability of informal support. RESULTS: Sixteen percent of the patients received a referral to aftercare, and about 13 percent of the patients were readmitted within six months of discharge. White patients were twice as likely as African Americans to receive a referral to aftercare. Length of hospitalization and having a diagnosis of schizophrenia were also predictors of referral to aftercare. Referral to aftercare was not shown to mediate the relationship between length of stay and rehospitalization. However, having a schizoaffective disorder, a poor discharge prognosis, and a high number of previous admissions were associated with an increased risk of readmission. No other demographic characteristics were related to readmission within six months of discharge, but referral to aftercare significantly increased the risk of readmission. CONCLUSIONS: The study suggested the possibility of racial disparities in referral to aftercare and a complex relationship between referral and rehospitalization. Both these findings warrant further investigation that gives particular attention to individual-level indicators of need and system-level barriers to and facilitators of psychiatric care.     

The consequences of non-cognitive symptoms of dementia in medical hospital departments

OBJECTIVE: To our knowledge, there are no studies investigating the non-cognitive symptoms of patients with dementia such as depression, agitation, or delusions among general hospital inpatients. The aim of this study was to investigate the frequency of such non-cognitive symptoms among medical inpatients and to analyze their impact on the length of hospital stay and on admission to nursing homes. METHOD: The sample consisted of 372 elderly inpatients admitted to four internal medical departments (i.e., not including psychiatric wards) in Austria. Patients were investigated by research psychiatrists using the Clinical Interview Schedule. For the analyses of the non-cognitive symptomatology, only marked and severe symptoms were included. To identify predictors for the length of hospital stay and for nursing home placement, multivariate regression procedures were used. RESULTS: Of all inpatients, 27.4% met criteria for dementia according to DSM-III-R. Of those with dementia, 27.8% had marked or severe non-cognitive symptoms. A diagnosis of dementia markedly increased the risk for nursing home referral and prolonged the duration of inpatient treatment. Among the demented, both, cognitive and non-cognitive symptoms turned out to be significant predictors for nursing home placement and for prolonged duration of acute hospital stay, even when controlling for other independent variables. CONCLUSIONS: Non-cognitive symptoms occur frequently among medical inpatients with dementia and considerably increase both the duration of inpatient treatment and the risk of nursing home placement. Since such non-cognitive symptoms are treatable, they should receive attention from the hospital staff.     

Effects on processes and costs of care associated with the addition of an internist to an inpatient psychiatry team

OBJECTIVE: This study examined the effects of collaboration between an internist and psychiatrists on the processes and cost of care among psychiatric inpatients. METHODS: A randomized controlled study was performed on the psychiatric inpatient units of an academic medical center. All inpatients who were admitted to the units between March 2001 and January 2002 were asked to participate in the study. Patients in the intervention group met with an internist who participated in their care by communicating with the patients' primary care physicians, assessing needs, updating appropriate health maintenance services, managing chronic and acute medical problems, and attending hospital work rounds. Patients in the usual-care group received usual care. The processes of care were measured by examining 17 categories that involved assessment of needs, coordination of care, and completion of health maintenance services. Resource use was measured by examining hospital charges and length of stay. RESULTS: A total of 139 adults participated in the study: 55 were in the intervention group and 84 were in the usual-care group. Patients in the intervention group showed significant improvement in 12 of the 17 categories of the processes of care. Overall, no differences were found in hospital charges or length of stay. CONCLUSIONS: Adding an internist to an inpatient psychiatric team is an effective way of improving care for this traditionally underserved population without increasing cost.     

Is a dedicated specialist social worker working exclusively with psychogeriatric inpatients and an associated dedicated domiciliary care package cost-effective?

BACKGROUND: The length of stay and bed usage on acute psychogeriatric admission wards are influenced by several factors. The impact of a dedicated specialist social worker working exclusively with acutely ill psychogeriatric inpatients and with a dedicated budget for domiciliary care packages on the length of stay, bed usage, and costs was evaluated in an opportunistic "before and after" cohort study. METHOD: The length of stay and bed usage for a 7-month period when a dedicated social worker and a dedicated budget for domiciliary care packages were implemented were compared with an identical 7-month period the year before. Costs incurred for extracontractual referral admissions (ECRs) were also calculated for the same periods. RESULTS: The implementation of a dedicated specialist social worker with a dedicated budget for domiciliary care packages did not demonstrate a statistically significant reduction in length of stay, but bed usage was reduced in both the local National Health Service hospital and the ECR units. The costs incurred for ECR admissions were also reduced; this reduction in costs was similar to the cost of employing a dedicated specialist social worker with the domiciliary care package. CONCLUSIONS: A dedicated specialist social worker working exclusively with psychogeriatric inpatients with a dedicated budget for domiciliary care packages was demonstrated to be cost-effective in this study. Ideally, a multicenter, randomized, and controlled study of such an intervention should be undertaken to confirm these findings.     

Identifying risk factors and key strategies in linkage to outpatient psychiatric care

OBJECTIVE: The substantial failure of psychiatric patients to engage in outpatient specialty mental health care after an acute hospitalization at a time when managed care companies and others increasingly hold hospitals accountable for outcomes underscores the importance of identifying patients at high risk for not completing referrals. This study explored patient risk factors for not completing referrals and examined the success of several interventions targeted to achieving linkage with outpatient care. METHOD: A clinically detailed, structured form was used in abstracting information from the medical records of 229 inpatients with a primary psychiatric diagnosis. Clinicians and staff at outpatient programs were contacted to determine whether patients completed their referrals. RESULTS: Approximately two-thirds (65%) of the patients failed to attend scheduled or rescheduled initial outpatient mental health appointments after a hospital discharge. At high risk for unsuccessful linkage to outpatient care were patients with a persistent mental illness and those who had no prior public psychiatric hospitalization, were admitted involuntarily, and had longer lengths of stay. Controlling for risk factors, three clinical interventions used during the hospital stay more than tripled the odds of successful linkage to outpatient care: communication about patients' discharge plans between inpatient staff and outpatient clinicians, patients' starting outpatient programs before discharge, and family involvement during the hospital stay. CONCLUSIONS: Effective clinical bridging strategies can be used to avoid unnecessary gaps in the delivery of psychiatric services. Incorporating these strategies into routine care would enhance continuity of care, especially for some high-risk patients.     

Mental disorders among internal medical inpatients: prevalence, detection, and treatment status

OBJECTIVE: To determine the prevalence of ICD-10 mental disorders among internal medical inpatients, the relation between mental disorder, age, and gender, and the recognition and referral of the disordered patients. METHOD: 294 consecutive medical inpatients were examined with a two-phase design using the SCAN (Schedules for Clinical Assessment in Neuropsychiatry) for ICD-10 psychiatric diagnoses. Information from questionnaires and interviews with patients, doctors, nurses, and from medical records. RESULTS: The prevalence of current mental disorders was 38.7%, being heavily increased in young patients. Main diagnoses were somatoform disorders (17.6%), phobias (12.9%), substance use disorders (10.9%), and depression (8.3%). Psychiatric consultations were very few. About 38-56% of the cases were recognized by medical doctors and nurses, and only about 20% were in mental health treatment. CONCLUSION: The prevalence of mental disorders among internal medical inpatients is high and increased in young patients and women. Detection and referral are low, and few are treated.     

Differences between long-stay and short-stay inpatients and estimation of length of stay

Summary To find possible differences between new long-stay inpatients and patients with shorter lengths of stay, a prospective study of 340 inpatients in the 4th week of hospitalization was carried out. The new long-stay patients differed from the others in diagnoses, symptoms, duration of prior hospitalizations, and socio-demographic data. On the basis of the data assessed in the 4th week of hospitalization, we tried not only to predict future new long-stay patients, but also to estimate the length of stay for all 340 patients. A time-function model was employed with length of stay as a continuous variable, and this resulted in correct allocation to the quartiles in 38–48% of the cases. Six variables proved to be important for estimating length of stay: emotional withdrawal, blunted affect, mannerisms, duration of previous hospitalizations, living conditions (prior to admission), and marital status.     

Discharge dynamics and related factors of newly-admitted patients in psychiatric hospitals

The focus of psychiatric services in Japan is being shifted from hospitalization to community care, and the Ministry of Health, Labour and Welfare aims for the prompt discharge of newly-admitted patients. Correspondingly, it set a goal to lower the "mean residual rate (MRR)", which indicates the discharge dynamics of newly-admitted patients, to 24%. As a measure to achieve this goal, the present situation should be investigated in each homogeneous patient group. In this study, we conducted a survey of newly-admitted patients to investigate discharge dynamics and related factors by the diagnosis and type of hospitalization. Out of 1,459 psychiatric hospitals to which we sent questionnaires, 183 (12.5%) replied. Each hospital completed questionnaires regarding a maximum of 5 patients for each type of hospitalization (voluntary hospitalization [VH], hospitalization for medical care and protection [HMCP], and involuntary hospitalization ordered by the prefectural governor [IHOPG]) between October 2005 and January 2006. We weighted the obtained patient data in proportion to the estimated total number of patients, and analyzed valid data on 1,784 patients. The MRR for the whole sample was 29.4%. By diagnosis, dementia showed the highest MRR (45.6%), followed by schizophrenia (34.9%); depression, bipolar disorder, and alcoholism showed the lowest MRRs (20-21%). We calculated MRRs by the type of hospitalization for dementia and the other diagnoses separately, considering confounding effect between the diagnosis and type of hospitalization (markedly high proportion of HMCP observed in dementia). In dementia, HMCP showed a higher MRR (46.8%) than VH (43.7%). In the other diagnoses, IHOPG showed the highest MRR (43.7%), followed by HMCP (34.5%) and VH (25.6%). Dementia differed from the other diagnoses in the distribution of residential settings before admission, with a higher proportion of residential care facilities (25.5%) and hospitalization in other departments (19.3%). In dementia, the residential setting after discharge showed a similar distribution, and death was also frequent (6.6%). Multivariate analyses revealed that a long stay (one year or longer) was significantly associated with a residential setting before admission, the type of ward at admission, a founder (a private hospital or public/university hospital), and symptom severity at admission in schizophrenia; and with the type of ward at admission and hospital founder in dementia. In schizophrenia, the risk of a long stay was higher on hospitalization in other psychiatric hospitals (odds ratio [OR] : 28) and other departments (OR: 18), and living alone (OR: 2.1) than in living with the family by residential setting. The risk was also higher in psychiatric long-term care wards than in general psychiatric wards by the type of ward (OR: 3.0), and in private hospitals than in public/university hospitals by hospital founder (OR: 3.0). Additionally, the higher risk was associated with higher symptom severity assessed using a 6-point scale (OR: 1.3 per point). In dementia, the risk was higher in senile dementia wards than in general psychiatric wards by the type of ward (OR: 2.9), and in private hospitals than in public/university hospitals by hospital founder (OR: 6.8). The most frequently reported direct causes of a long stay were problems regarding a family's acceptance (51.5%), poor improvement of symptoms (48.8%), and poor recovery of daily living abilities (44.0%). In dementia, physical diseases (20.8%) and undecidedness of residence after discharge (29.2%) were also frequent. Considering the elapsed time after survey, the low response rate, and the data analyses with sampling bias adjustment, the results should be interpreted carefully. Nevertheless, the discharge dynamics and related factors in newly-admitted patients varied with the diagnosis and type of hospitalization. Particularly, schizophrenia and dementia, as well as IHOPG and HMCP, showed high MRRs and frequent long stays. Additionally, a long stay was related to patients' demographic and social characteristics. Adopting measures suiting patients' characteristics and arranging treatment and casework for patients at high risk of a long stay are important to facilitate community care.     

Intensive outpatient treatment of persons with mental retardation and psychiatric disorder: a preliminary study

The impact of intensive outpatient mental health interventions (in a dual diagnosis clinic) on the hospitalization rate and length of stay was examined for 28 adults with mental retardation and severe psychiatric disorder. They were selected on the basis of frequent use of mental, medical, and social services. Charts were reviewed for the 12-month periods before and after referral to the program to compare service utilization. A single group pretest-posttest design with no control group was employed. Correlated t tests comparing the pre- and post-program number of hospitalizations and lengths of stay indicated significant decreases in both hospitalizations and lengths of stay after program entry, which may result in significant reductions in hospital costs.     

Medical and surgical inpatients who referred themselves for psychiatric consultation

Medical and surgical inpatients who referred themselves for psychiatric consultation are characterized. The 25 "self-referred" compared to 787 "others" referred to the Consultation-Liaison Psychiatry Division were more likely to state depression (52%/25%) and anxiety (36%/11%) as reasons for referral. "Self-referrals" were less likely to be referred by physicians for behavior management (8%/23%), general diagnosis (4%/22%) or suicide evaluation (4%/25%). The "self-referral" represents a challenge to the current medical model referral mechanism in which the physician controls access to consultants. The data indicate that there should be a mechanism for the patient's contribution to the referral process and that increased sensitivity to psychologic difficulties in coping with medical illness would improve the use of psychiatric consultation in the medical setting.     

Arbeitsfelder eines biopsychosozial ausgerichteten psychiatrischen Konsiliardienstes: Ergebnisse einer prospektiven 2-Jahres-Erhebung

Background

Since the establishment of the European Association of Consultation-Liaison Psychiatry and Psychosomatics in 1992, C/L psychiatry in European countries has been increasingly recognized as a subspecialty of clinical psychiatry and psychosomatic medicine. The study explored the areas of work of the biopsychosocial oriented psychiatric consultation – liaison (C/L) service at the university hospital LKH Graz (Austria).

Methods

We conducted two prospective 1-year surveys over two years of observation. Survey I comprised 1,505 consecutive new consultations, and the more recent Survey II extended over 1,478 consecutive new referrals to our C/L service. Psychiatric referrals were analyzed with regard to demographic characteristics, referring departments, principal reasons for referral, diagnostic characteristics, and intervention patterns.

Results

In both surveys, the most common patient to be referred was a middle-aged woman. Internal medicine consistently accounted for almost one third of all referrals, followed by neurology. The most prominent reasons for biopsychosocial referral were any signs of abnormal mood, behaviour, psychotic symptoms or cognitive impairments. The most common mental disorders according to ICD-10 were adjustment disorders, depressive disorders, and delirium. Psychopharmacotherapy and combined psycho- and pharmacotherapy were the most frequent actions in both surveys, followed by biopsychosocial evaluation pretransplant.

Conclusions

To ameliorate the provision of biopsychosocial care for general hospital patients, the need for specially planned biopsychosocial C/L services with equal involvement of specialists in medical psychology, C/L psychiatry, and clinical psychology should be underscored.     

Depression and internal medicine

Although the Fathers of Internal Medicine described melancholia and wrote extensively about the affective disorders, internists continue to have difficulties diagnosing their medical patients' depressions. Consequently, it often falls to the psychiatric consultant to make the diagnosis amongst the medical population. We present current concepts of affective disorder that should be clinically relevant to the psychiatrist who works with internists and their patients. Early, accurate diagnosis of depressed medical patients requires increased awareness of depression, observation of the patient's appearance and mood, sensitivity to his or her feelings, and specific questioning about symptoms, losses, and stressors. For depressed medical patients, we present a comprehensive treatment program which often should include: 1) supportive psychotherapy, 2) antidepressant medications; and 3) resocialization or rehabilitation. We outline certain indications for psychiatric referral, and urge psychiatrists and internists to work together closely. Increasing the sensitivity of our colleagues in internal medicine toward affective illness should lead to more prompt identification and treatment of medical patients' depressions.     

Psychopathology in medical inpatients and its relationship to length of hospital stay: a pilot study

A composite screening instrument measuring depression, anxiety, cognitive dysfunction, and pain identified 40 percent of a sample of general medical inpatients (30% of total patients before exclusions) as having significant psychopathology or pain, a reasonable number based on clinical incidence literature. These identified patients' hospital length of stay did not differ from the length of stay for other patients. The screen identified 21 percent as very depressed, 19 percent as very anxious, 15 percent as having cognitive dysfunction, and 11 percent with high pain levels. Depression, anxiety, and pain frequently occurred together. Further study is required to refine the instrument and assess its effectiveness at targeting patients for psychiatric intervention.     

Risk factors for falls in post-stroke patients treated in a neurorehabilitation ward

BACKGROUND AND PURPOSE: Patients with neurological disorders, including post-stroke patients, are at high risk for falls. The purpose of the study was to estimate the number and type of falls and fall-related injuries in patients of a neurological rehabilitation ward and to identify risk factors for falls. MATERIAL AND METHODS: 353 consecutive post-stroke patients of the Neurorehabilitation Unit at the Institute of Psychiatry and Neurology in Warsaw were enrolled into the study and observed during the hospital stay. Falls occurring in patients during their hospital stay were registered and an analysis of fall-related data and the routinely obtained medical data was performed. RESULTS: In the evaluated group, 35 (10%) patients suffered 50 falls, which corresponds to an incidence rate of 5.02 [95% confidence interval (95% CI): 3.70-6.52] falls per 1000 patient-days. Most falls occurred in patients' rooms (80%), most of them taking place while transferring from one place to another or while changing position. 2% of falls caused severe injury. There was a higher percentage of patients with unilateral neglect in the group of fallers (p=0.0007), who also demonstrated poorer performance in activities of daily living as expressed by the Rankin score (p <0.0002) and the Barthel Index (p <0.0001), and greater neurological deficit in the Scandinavian Stroke Scale (SSS) (p=0.002) at admission as well as at discharge from hospital than non-fallers. The risk of a fall showed greatest association with low Barthel Index at admission (<15/20; RR=10.3; 95% CI: 2.8-50.7), performance in the Rankin score of >3 (RR=5.12; 95% CI: 2,41-14,8), low SSS score on admission (0-39; RR=3.40; 95% CI: 1.62-9.14), and the presence of hemispatial neglect (RR=3.42; 95% CI: 1.23-6.53). The multiple-fallers group did not differ significantly from the group of single-fallers. CONCLUSIONS: Among post-stroke patients, falls are a complication especially affecting persons with a large neurological deficit, severe disability and the neglect syndrome.     

Preadmission care as a new mental health performance indicator

OBJECTIVE: This study examined the relationship between receipt of preadmission outpatient care during the month before an episode of hospitalization and the patients' subsequent treatment. METHODS: A total of 37,852 psychiatric inpatients who were discharged from 122 Veterans Affairs medical centers between October 1, 1997, and March 31, 1998, were studied. Linear and logistic regression were used to examine the relationship between receipt of preadmission outpatient care and length of hospital stay, use of postdischarge aftercare, and readmission. RESULTS: Having at least one outpatient visit in the month before admission was associated with a significantly shorter inpatient stay (16 days compared with 26 days, a difference of more than 60 percent) and with significantly greater use of postdischarge aftercare (odds ratio=1.83). However, the number of outpatient visits beyond one visit in the month before admission did not increase the effect on length of stay. These effects were strongest among patients with schizophrenia. CONCLUSIONS: Patients who have received outpatient care before hospital admission have shorter hospital stays and are more likely to use postdischarge aftercare than those who have not received outpatient care in the month before admission. Receipt of preadmission care itself rather than the intensity of such care seems to be the greatest predictor of length of stay.     

Can prediction of violence among psychiatric inpatients be improved?

In an effort to improve the prediction of violence among psychiatric inpatients, the authors retrospectively studied 25 patients who were violent and 34 who were not violent after admission to a psychiatric emergency ward in Norway. The only demographic variable that discriminated between the two groups was violence in the family of origin; the violent group had experienced significantly more. The best single predictor of violence was a history of previous violence by the patient, which correctly classified 80 percent of the patients. The combined information about patients' level of aggression rated at referral and level of anxiety rated at admission correctly classified 78 percent. In a subgrouping of violent patients who inflicted injuries and did not inflict injuries, a higher percentage of the injury-inflicting patients were found to have a diagnosis of schizophrenia. These patients also had a higher level of aggression at referral.     

基于新灰色关联与结构变动度的精神障碍患者住院费用结构分析

目的了解深圳市某精神专科医院2013年-2017年精神障碍患者住院费用的构成及变化趋势,探讨影响住院费用结构变动的主要项目及变化方向。方法收集深圳市某精神专科医院2013年-2017年出院精神障碍患者住院费用信息并建立数据库。运用新灰色关联分析法分析各项目费用与总费用的关联,采用结构变动度分析法分析5年间住院费用的结构变动情况。结果 2013年-2017年精神障碍患者人均住院总费用增加了4 603. 95元,年均增长率为9. 37%。综合医疗服务类费用对总费用的影响最大,其次为诊断类和治疗类费用。5年间住院费用结构变动度为76. 06%,年均结构变动度为19. 02%。影响住院费用结构变动度的主要项目是治疗类、综合医疗服务类和诊断类,三者累计结构变动贡献率为93. 13%。结论总费用构成主要项目由治疗类转为综合医疗服务类,新灰色关联和结构变动度分析法能较好地应用于精神障碍患者住院费用分析。     

Depressed mood, physician-rated prognosis, and comorbidity as independent predictors of 1-year mortality in consecutive medical inpatients

Objective: To determine the independent effects of depressed mood and markers of medical disease severity on mortality in consecutive medical inpatients. Methods: Consecutive general medical inpatients were asked to complete the Hospital Anxiety and Depression Scale (HADS) at admission. Prognostic indicators were obtained from patients' records and physicians' ratings. The study endpoint was mortality from all causes at 1 year. Results: The baseline assessment was completed by 575 patients (87.7%). Survival data were available for 572 of these (86 deaths). HADS depression scores and several physical risk indicators predicted mortality. In multivariate analyses, physicians' rating of prognosis was the best predictor of mortality [adjusted odds ratio (OR) 3.6; 95% confidence interval (CI), 2.5–5.4]. Other independent predictors included a principal diagnosis of hemato-oncological disease, comorbidity scores, and HADS depression (adjusted OR 1.75; 95% CI, 1.10–2.79). Conclusion: Our data demonstrate an independent prognostic effect of depressed mood on mortality in general medical inpatients. Screening for depression may improve risk stratification in these patients over and above that obtained by routinely available physical parameters and physicians' clinical judgement.     

Changes in the pattern of aggressive behaviour among inpatients with changed ward organization

Aggressive behaviour by psychiatric inpatients was investigated on the same ward during two separate 6-month periods before and after a 50% decrease in number of beds but without changes in catchment area. Character of the patient group, patient turnover and medical practices as well as total number of staff on duty on the ward was virtually the same during the two periods. It is therefore assumed that differences in aggressive behaviour are mainly explained by effects due to the decreased number of beds per se. It was found that the 50% reduction did not affect the overall aggression frequency. However, inter-patient violence increased while the number of more severe aggressive incidents towards staff members decreased.