This study was undertaken to determine if a measure of severity of illness for psychiatric patients, the Psychiatric Severity of Illness Index, could produce psychiatric case mix groups that are more homogeneous with respect to resource use than the diagnosis-related groups (DRGs). Psychiatric Severity of Illness data were collected on 1,672 cases in ten hospitals of various types. Of these cases, 1,418 had enough information in the medical record to be scored using the Psychiatric Severity Index, 1,173 of which were in MDC 19 (mental diseases and disorders). We found that four Psychiatric Severity of Illness groups explained between 34% and 50% of the variation in length of stay of the combined hospital data in MDC 19, whereas nine DRGs explained between 6% and 14%. DRGs subdivided by Psychiatric Severity of Illness groups explained between 40% and 54% of the variation in length of stay. The implications of these results for cross-hospital comparisons are discussed.

Psychiatric severity of illness. A case mix study.

This study examined clinical correlates of rapid readmission to a psychiatric inpatient service (less than 3 months after discharge) compared to delayed readmissions (3-12 months) in first-admission patients diagnosed with schizophrenia, bipolar disorder with psychosis, and major depression with psychosis. After reviewing the clinical records and research summaries of all patients who were readmitted withine 1 year of discharge, we compared the two readmission groups with respect to demographic and clinical characteristics and subsequent clinical course. Rapid readmission was significantly associated with instability of clinical condition at first discharge (especially mood symptoms) and, to a lesser degree, with failure to prescribe specific medication for affective psychosis patients. Regardless of duration of community tenure, readmission was strongly associated with medication nonprescription or discontinuation. The results suggest that managed care protocols aimed at preventing rapid readmission may require specific symptom assessment and pharmacotherapeutic intervention during the initial hospitalization. Readmission can be used as a quality indicator of both clinical processes (hospital vand outpatient care) so long as duration of community tenure prior to readmission is taken into account.

Rapid versus delayed readmission in first-admission psychosis: quality indicators for managed care?

Objective. 1. To identify risk factors associated with psychiatric rehospitalization within six months, using global clinical assessments and demographic information and; 2. To determine if risk factors for a hospital in a rural region are similar to those reported for urban hospitals. Method. The setting was a psychiatric unit within a general hospital. All adult admissions for one year were assigned scores on the North Carolina Functional Assessment Scale (NCFAS) and the Global Assessment of Functioning (GAF) scale. Patients were interviewed six months after discharge to determine if they had been rehospitalized and to assign new NCFAS and GAF scores. Results. Significant risk of rehospitalization was predicted by: 1. NCFAS score >90; 2. history of prior hospitalization; 3. nursing home residence; 4. referral from a small community hospital and; 5. non-compliance with outpatient appointments. Conclusions. Global assessments and demographic information collected during an index admission can generate factors to identify patients at risk for rehospitalization within six months. History of prior admissions and non-compliance with outpatient treatment, reported as risk factors in urban settings, were found also to be risk factors in a rural region.

High risk factors for rehospitalization within six months

Setting An important limitation of the T-SPOT(®).TB assay is its inability to distinguish active tuberculosis (TB) from latent tuberculous infection (LTBI). Objective We proposed a new calculation method for the T-SPOT assay and assessed its effect on distinguishing active TB from LTBI. Design A total of 162 active TB patients and 97 LTBI individuals were diagnosed according to conventional tests and the T-SPOT assay. Results The results of early secreted antigenic target 6 (ESAT-6) and culture filtrate protein 10 (CFP-10) in T-SPOT cannot be recommended for distinguishing TB from LTBI. The number of phytohaemagglutinin (PHA) spot-forming cells (sfc) in the T-SPOT assay was reduced in active TB patients. The ESAT-6/PHA or CFP-10/PHA ratios in active TB patients were significantly higher than in individuals with LTBI. Using 0.295 as the threshold ratio of Mycobacterium tuberculosis-specific antigen (TBAg) sfc to PHA sfc (TBAg/PHA ratio, the larger of ESAT-6/PHA and CFP-10/PHA), the sensitivity and specificity were 82.1% and 90.7% in distinguishing active TB from LTBI. The TBAg/PHA ratio might also be used to monitor the effect of anti-tuberculosis treatment. Conclusions Calculating the TBAg/PHA ratio might have the potential to diagnose active TB and distinguish TB disease from LTBI.

Using the TBAg/PHA ratio in the T-SPOT ® .TB assay to distinguish TB disease from LTBI in an endemic area

This study examined predictors of readmission to a general hospital psychiatric unit that provided acute inpatient care. Participants were 370 patients admitted to the inpatient unit over a 15-month period. During this period, 105 (28%) patients were readmitted to the unit. Readmitted patients were compared to patients who were not readmitted on (a) symptom improvement during hospitalization, (b) psychosocial and clinical variables, and (c) length of hospitalization. The readmitted patients presented with levels of psychological symptoms similar to those of patients who were not readmitted. Moreover, readmitted patients and patients who were not readmitted reported comparable relief in symptom severity during hospitalization. Readmitted patients were more likely to have at least one previous psychiatric hospitalization, be unemployed, be participating in day treatment, and receiving medicare and social security disability insurance. Rehospitalization is a significant problem and the patients' self-reported symptomatology is not a major determinant of readmission for inpatient treatment.

Rehospitalization of Psychiatric Patients in a Managed Care Environment

Readmissions to a General Hospital's Psychiatric Unit

Foreign-born patients.

One outcome of psychiatry's increasingly medical orientation has been a reconsideration of the psychiatrist's traditional taboo against treating members of the same family individually. The author argues that by modeling themselves after family physicians, psychiatrists can learn more about the psychological, genetic, and dynamic factors underlying the psychiatric problems of family members and can better diagnose and treat them. The family model of psychiatric treatment also reduces family members' resistance to psychiatric intervention and fortifies the psychiatrist's position as a member of professional organizations providing total health care services. The author presents case histories of two families whose various members he has seen periodically for more than ten years.

Anil Godbole

Papers

Readmissions to a General Hospital's Psychiatric Unit

Foreign-born patients.

The psychiatrist as family physician.