Predicting psychiatric emergency admissions and hospital outcome.

OBJECTIVES: A decision support tool for psychiatric hospital admissions was developed and validated to provide reliable, clinically relevant information to providers and case managers. METHODS: Using the Severity of Psychiatric Illness rating system, an empirical model of psychiatric emergency decision-making was constructed and validated on a spilt sample of 254 crisis cases. RESULTS: Three dimensions of the Severity of Psychiatric Illness system-Suicide Potential, Danger to Others, and Severity of Symptoms-were used to construct a model that successfully predicted 73% of decisions about level of care (inpatient or outpatient). Clear misses, patients with a 0.20 probability of being hospitalized who were admitted, and patients with an 0.80 probability or greater of being hospitalized who were not admitted were reviewed to allow for utilization review. This decision support tool then was validated by predicting hospital outcomes in two additional samples. First, a random sample of consecutive admissions to a not-for-profit psychiatric hospital were studied. Second, a panel of admissions from a large managed care firm were evaluated. CONCLUSIONS: Results demonstrate that the decision to hospitalize patients in psychiatric hospitals is rational and that models predicting admission also can predict in-hospital outcomes.

Predicting readmission to the psychiatric hospital in a managed care environment: implications for quality indicators.

OBJECTIVE: This study examined predictors of hospital readmission to determine whether readmissions can serve as a quality indicator for an inpatient psychiatric service. METHOD: A series of 255 patients consecutively admitted to any of seven psychiatric hospitals in a regional managed care program were followed to determine whether they were readmitted within 6 months of discharge. Case managers assessed patients with the use of a reliable outcome management/decision support system designed for acute psychiatric services. RESULTS: Patients with greater impairment in self-care, more severe symptoms, and more persistent illnesses were more likely to be readmitted than other patients. Suicidal patients were less likely to be readmitted. There was no evidence to suggest that poor hospital outcome or premature discharge was associated with readmission either within 30 days or within 6 months. CONCLUSIONS: Although patients at risk for hospital admission can be identified, it does not appear that the success of the hospital intervention per se influences the likelihood of readmission. Use of readmission rates as quality indicators for hospital care providers is not recommended.

The treatment of dangerous patients in managed care. Psychiatric hospital utilization and outcome.

The legal criteria for civil commitment dictates that individuals must be mentally ill, and either a danger to themselves, a danger to others, or substantially impaired in their ability to provide for their basic needs. These criteria, which have been adopted as medical necessity criteria by managed care programs, may result in a change in the clinical mix of the psychiatric inpatient population. The present study assesses the incidence of dangerousness among psychiatric inpatients and compares dangerous and nondangerous patients in terms of characteristics and treatment outcomes. The results indicate that for a large regional managed care program, 30% of psychiatric inpatients have a history of dangerousness in the past year. Patients who are rated as dangerous to others during admission have higher rates of complications for treatment and psychiatric disorders such as residential and vocational instability, family disruption, and higher premorbid dysfunction. They are also more likely to engage in disruptive and aggressive behavior during their hospital stays. Despite the higher incidence of acute and long-term dysfunction for dangerous patients, their hospitalization length of stay was comparable to that of patients not rated as dangerous.

Serotonin reuptake inhibitors and the adequacy of antidepressant treatment.

OBJECTIVE: To determine whether the use of serotonin reuptake inhibitors (SSRIs) improves antidepressant medication prescribing patterns for both psychiatric and non-psychiatric physicians. DATA SOURCES/SETTING: Drug utilization review of 4,103 prescriptions for antidepressant medications with patients diagnosed with depressive disorders over an eighteen-month period from the formulary records of a large insurance company. DESIGN: Using standards developed for clinical guidelines, variation in trial and treatment adequacy between drug types and physician specialty was studied. PRINCIPAL FINDINGS: Thirty-five percent of initial antidepressant trials were not prescribed for an adequate duration or at an adequate dosage level. SSRIs were more likely to be prescribed adequately than any other antidepressant reviewed. Psychiatrists were more likely to prescribe antidepressants at an adequate dosage level, whereas non-psychiatric physicians were more likely to attain adequate duration of treatment. CONCLUSIONS: A greater reliance on SSRIs may increase the likelihood of maintaining adequacy in antidepressant treatments. Although higher in cost than other treatment choices, their lower side effect profile is likely to maximize patient satisfaction and physician and patient adherence to guidelines. In order to ensure effective and efficient antidepressant usage, such patterns must be identified and appropriate performance improvement strategies (e.g., Total Quality Improvement, critical pathways) may be employed.

Plasma aspirin esterase activity in elderly patients undergoing elective hip replacement and with fractured neck of femur.

Plasma aspirin esterase activity was measured in eight elderly patients undergoing elective hip replacement, and in 11 presenting with femoral-neck fracture. Elective hip surgery was associated with a marked and significant decline in esterase, from 330 +/- 35.9 (SE) (nmol salicylate/ml plasma/min) pre-operatively to 236 +/- 35.6 on the third post-operative day, and returning to normal (359 +/- 24.3) at recovery phase. Patients with fractured neck of femur showed a depressed esterase activity on admission (221 +/- 12.7), rising towards normal (290 +/- 15.4) on recovery. All of these changes were accompanied by a marked acute-phase response, both to injury and surgery. The data suggest that elderly patients experiencing injury or undergoing surgery may have significantly impaired drug metabolism, at least as far as this enzyme is concerned.

Patterns of psychotherapy utilization.

Epidemiologic research indicates that a small minority of patients make the great majority of outpatient mental health visits. This small group of long-term patients constitutes the bulk of psychotherapeutic practice and creates a disproportionate impression on mental health professionals. The authors confirmed this finding by studying 405 patients in a clinical setting with an orientation toward long-term psychotherapy: 68% of the patients attended 26 or fewer psychotherapy sessions, representing 23.3% of the total number of sessions used by all patients; 32% attended more than 26 sessions, representing 77% of the total number of sessions used by all patients.

Crisis intervention following severe psychological trauma in late pregnancy.

Following the violent death of a Lamaze group instructor, a team of three psychologists provided crisis intervention to the group members to help them deal with the sudden death. All of the women in the group were in the advanced stages of pregnancy at the time. The team constructed an environment of group and couple support, presented and encouraged specific cognitive discussion of the event, and helped develop a temporary safe community. During the intervention, group members were able to express their anger, fear, guilt, and anxieties caused by the death. Comments by group members and the new group leader over the following weeks indicate the intervention was successful.

Renal failure during intermittent rifampicin therapy.

Two patients who developed reversible renal failure during intermittent rifampicin therapy are described. Both had febrile reactions to rifampicin. The first was also found to have uraemia associated with swelling of the glomerular endothelial cells. The second developed tubular necrosis unassociated with haemolysis or shock. The pathogenesis of the renal lesion in these two patients, as revealed by light microscopy, immunofluorescence studies and electron microscopy, is discussed.