Intensity of Outpatient Monitoring After Discharge and Psychiatric Rehospitalization of Veterans With Depression
ABSTRACT This study assessed whether increased frequency of clinical monitoring during the high-risk period of 12 weeks after discharge from a psychiatric hospitalization reduced subsequent rehospitalization in a national cohort of Veterans Health Administration patients receiving depression treatment between 1999 and 2004.
A case-control design was used. Patients who had at least two inpatient psychiatric hospitalizations were identified (case group, N=17,852) and then individually matched with up to two patients who also had been discharged from psychiatric inpatient settings but were not rehospitalized for the number of days between the case-group patient's discharge and subsequent rehospitalization (N=35,511).
Covariate-adjusted relative risk (RR) did not show an association between increased monitoring and subsequent psychiatric hospitalization, but there was a significant negative interaction between monitoring and a comorbid substance use disorder diagnosis (p<.001). Increased monitoring was positively associated with rehospitalization of patients without a substance use disorder, whereas increased monitoring was not associated with increased risk of rehospitalization of those with a comorbid substance use disorder. The RR of rehospitalization associated with a weekly monitoring visit (12 visits per 84 days) versus no monitoring visit was 1.14 for patients without a substance use disorder, whereas the RR was reduced to .94 for patients with a substance use disorder.
Increased outpatient monitoring during the high-risk period after discharge appears to have a modest protective effect on rehospitalization among depressed patients with a comorbid substance use disorder.
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ABSTRACT: OBJECTIVE Outpatient follow-up after hospitalization for mental health reasons is an important indicator of quality of health systems. Differences among racial-ethnic minority groups in the quality of service use during this period are understudied. This study assessed the quality of outpatient treatment episodes following inpatient psychiatric treatment among blacks, whites, and Latinos in the United States. METHODS The Medical Expenditure Panel Survey (2004-2010) was used to identify adults with any inpatient psychiatric treatment (N=339). Logistic regression models were used to estimate predictors of any outpatient follow-up or the beginning of adequate outpatient follow-up within seven or 30 days following discharge. Predicted disparities were calculated after adjustment for clinical need variables but not for socioeconomic characteristics, consistent with the Institute of Medicine definition of health care disparities as differences that are unrelated to clinical appropriateness, need, or patient preference. RESULTS Rates of follow-up were generally low, particularly rates of adequate treatment (<26%). Outpatient treatment prior to inpatient care was a strong predictor of all measures of follow-up. After adjustment for need and socioeconomic status, the analyses showed that blacks were less likely than whites to receive any treatment or begin adequate follow-up within 30 days of discharge. CONCLUSIONS Poor integration of follow-up treatment in the continuum of psychiatric care leaves many individuals, particularly blacks, with poor-quality treatment. Culturally appropriate interventions that link individuals in inpatient settings to outpatient follow-up are needed to reduce racial-ethnic disparities in outpatient mental health treatment following acute treatment.Psychiatric services (Washington, D.C.) 04/2014; 65(7). DOI:10.1176/appi.ps.201300139 · 1.99 Impact Factor
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ABSTRACT: Hospital readmission rates are increasingly used as a performance indicator. Whether they are a valid, reliable, and actionable measure for behavioral health is unknown. Using the MarketScan Multistate Medicaid Claims Database, this study examined hospital- and patient-level predictors of behavioral health readmission rates. Among hospitals with at least 25 annual admissions, the median behavioral health readmission rate was 11% (10th percentile, 3%; 90th percentile, 18%). Increased follow-up at community mental health centers was associated with lower probabilities of readmission, although follow-up with other types of providers was not significantly associated with hospital readmissions. Hospital average length of stay was positively associated with lower readmission rates; however, the effect size was small. Patients with a prior inpatient stay, a substance use disorder, psychotic illness, and medical comorbidities were more likely to be readmitted. Additional research is needed to further understand how the provision of inpatient services and post-discharge follow-up influence readmissions.The Journal of Behavioral Health Services & Research 02/2013; DOI:10.1007/s11414-013-9323-5 · 1.03 Impact Factor
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ABSTRACT: Despite the recurring nature of the disease process in many psychiatric patients, individual careers and time to readmission rarely have been analysed by statistical models that incorporate sequence and velocity of recurrent hospitalisations. This study aims at comparing four statistical models specifically designed for recurrent event history analysis and evaluating the potential impact of predictor variables from different sources (patient, treatment process, social environment). The so called Andersen-Gil counting process model, two variants of the conditional models of Prentice, Williams, and Peterson (gap time model, conditional probability model), and the so called frailty model were applied to a dataset of 17'415 patients observed during a 12 years period starting from 1996 and leading to 37'697 psychiatric hospitalisations. Potential prognostic factors stem from a standardized patient documentation form. Estimated regression coefficients over different models were highly similar, but the frailty model best represented the sequentiality of individual treatment careers and differing velocities of disease progression. It also avoided otherwise likely misinterpretations of the impact of gender, partnership, historical time and length of stay. A widespread notion of psychiatric diseases as inevitably chronic and worsening could be rejected. Time in community was found to increase over historical time for all patients. Most important protective factors beyond diagnosis were employment, partnership, and sheltered living situation. Risky conditions were urban living and a concurrent substance use disorder. Prognostic factors for course of diseases should be determined only by statistical models capable of adequately incorporating the recurrent nature of psychiatric illnesses.PLoS ONE 12/2013; 8(10):e75612. DOI:10.1371/journal.pone.0075612 · 3.53 Impact Factor