Rehospitalization Larry Kirstein
A
LTHOUGH a tremendous investment of time, energy, and monies are spent in providing in-patient psychiatric treatment, many patients do not succeed in making the transition back into the community and require rehospitalization. Characteristics of treatment environments, social support systems. and patient variables play a role in rehospitalization. Studies of rehospitalization have focused on patients returning within a month of discharge and patients who are chronically readmitted (the revolving door syndrome). The number of previous hospitalizations and posthospital community social adjustment have been shown to influence rehospitalization.‘-6 Methodological factors make comparisons between studies difficult: length of hospitalization varies from a few weeks to many months, proportions of chronic patients vary between studies, and treatment facilities vary from custodial care to active treatment settings. Although patient variables including diagnosis? mental statusP life events,6 severity of illnessP and follow-up careg*10 have been studied, less attention has been given to the role of the treatment setting in rehospitalization. In a study where diagnosis and chronicity were controlled, it was noted that an inverse relationship existed between length of stay and rate of rehospitalization across diagnosis. As the author pointed out, other factors such as administrative policy, third party payment, and physician differences could explain the relationship between the rate of readmission and length of stay.” For many reasons the military psychiatric hospital provides an interesting arena in which to study rehospitalization. Insurance considerations are minimized since only soldiers and their families are eligible for treatment. Preinduction tests, medical screening, and rigorous regulations regarding fitness for duty exclude a significant number of patients from chronic use of military services. The author has previously identified various aspects of military in-patient psychiatric treatment. In one study, trends in utilization of the hospital during peace time were identified, and the need for a decentralized military psychiatric health care delivery system was discussed.” In a separate study of female soldiers, social adjustment was examined,13 and in a third report, the impact of sociodemographic factors of military psychiatric treatment was discussed. It was shown that younger, less experienced soldiers received different treatment than more senior personnel (in terms of duration of hospitalization and likelihood of being medically separated from the service) and that black soldiers were overrepresented in the hospital population.14
From Meant Sinai Hospital, New York, N. Y. Larry Kirstein. M.D.Assistant Professor of Psychiatry, Meant Sinai Hospital, New York, N. Y. Address reprint requests to Larry Kirstein, M.D., Assistant Professor of Psychiatry, Morrnt Sinai Hospital, Nebts York, N. Y. 10029. @ 1979 by Grune & Stratton, Inc. 0010-440X/79/2002-0002$01.00/0 110
Comprehensive
Psychiatry,
Vol. 20, No. 2 (March/April), 1979
111
REHOSPITALIZATION
The purpose of investigating relatively
unburdened
mine distinguishing to identify
socioclinical
clinical
practice
in an acute treatment setting. coverage, was to deter-
rehospitalization
by the constraints
of insurance
characteristics
of rehospitalized
that may influence
MATERIALS
patients
and
service delivery.
health care
AND METHODS
Settitix This \tLldy tooli place at D;\vid Grant Force
regional
from
referral
the western
entry
p;tthw;rys
hospitals,
third
of the United
to the
referred
from
hospital
inpatient
psychiatr-ic
the out-patient wards.
by plane or ambulance of 4 treatment
teams,
of the tt-eatment facility
long-ter~m
psychiatric
tary
data
wit\
utilized
throughout
the ink\
cud
ximisGnr~. patient
exclusively installation\.
screening
tt-eatment honorably
over
over
a 7 month
listing.
which
By reviewing
period
the admissions was a yearly
in lY7h-1977 1975-lY77.
in the la\t
13 ca\es.
a\Ggned
to
teams.
Each
their
I
it\ an itcute
we1.e felt
and included Two
listed
alphabetical
also transported
functioned
who
were
and the other
to
require
continued
mili-
the set-vice.
period
both lists and confirming
xknowledgment
from
which
were
compromised
during book,
room.
The ward
problems
Four different
and particular-
Patients
.Ait
patients
Wldiet-\I
were trnndomly
patient\
pzychiatri\t.
yepat-ared
theatre.
soldiers)
The patients
orientation.
whose
(medically)
a 21 month
this study:
staff
community
and patients
active-duty
State\
Ireceived
and active-duty emergency
of particular
6nited
hospital
pacific
(civilians
the hospital
military
no selective
collected
admitted
clinic,
one of jix The
to the entire
Patients
(almost
a therapeutic
were
patient\
other
health
(DGMCI.
California.
in addition
existed.
was led hy a full-time
with
performance
The
with
teams
treatment
Patients
Center-
in northet-n
States
ward
mental
from
Medical
located
listing
\ources
information
:thout
of infot-matton
were
name and date of admission. of sociodemographic
the data through
chart
data
and
on ~11
review
in 1111case\.
a list of 33 C’;IW\ of reho~pit~tlizatic,n
at DGMC‘
and w:t\
generated. The charts of the 33 cases and a control lace.
‘rnd age t
3 years
\ociodemographic clinical
variables
interval
hetween
the initial charts.
were obtained
variable (chief
race.
hospitalizations.
hospitalization.
Diagnoses
(age.
complaint.
group
from rank,
marital
status.
length
of stay.
charting
of intergroup
comparisons,
psychosis.
neurosis.
etc.
categorized
variables
and Student’s
t
and
length
previous
groups
test for continuous
LX civilian). form
of military
zex.
covering
set vice)
on each of the 66 ca\e\
of Mental
into major tested
variables.
and
outcome,
that the data W;I\ av:tilahle
Manual were
duty
hospitalization,
M as completed
were classified
between
(active
The data recording
guaranteed
and Statistical
patients
Differences
physician) standards
were based on Diagnostic
purposes
for- status room.
diagnosis. and treating
Hospital
matched
the records
Disorder
diagnostic by
0.054
chi
(DSM
II 1. For
groupings:
square
level
folin all
heing
i.e..
analysis
for
accepted
a\
signitbmt. RESULTS
Of the 302 admissions
were active-duty pitalized pitalized entiated marital
(10%
included
soldiers
of civilians
patients
in this study. 94 were civilians
(69%).
Nine
and IX
and the control
the civilian
status. discharge
of soldiers). group
and active-duty diagnosis,
civilians
were
A comparison
is presented
rehospitalized
(31%‘) and 208
and 24 soldiers in Table
rehos-
of the rehosI. Age differ-
patients (I> < 0.001).
and length of treatment
while
of the initial
hos-
pitalization were similar. Rehospitalized soldiers had shorter initial hospitalizations than the control group (p < O.OOl), while no differences were noted for the civilians. It was noted that 58% of rehospitalized patients were initially hospitalized for 3 weeks or less, compared with only 27% of the control patients (p
A
LTHOUGH a tremendous investment of time, energy, and monies are spent in providing in-patient psychiatric treatment, many patients do not succeed in making the transition back into the community and require rehospitalization. Characteristics of treatment environments, social support systems. and patient variables play a role in rehospitalization. Studies of rehospitalization have focused on patients returning within a month of discharge and patients who are chronically readmitted (the revolving door syndrome). The number of previous hospitalizations and posthospital community social adjustment have been shown to influence rehospitalization.‘-6 Methodological factors make comparisons between studies difficult: length of hospitalization varies from a few weeks to many months, proportions of chronic patients vary between studies, and treatment facilities vary from custodial care to active treatment settings. Although patient variables including diagnosis? mental statusP life events,6 severity of illnessP and follow-up careg*10 have been studied, less attention has been given to the role of the treatment setting in rehospitalization. In a study where diagnosis and chronicity were controlled, it was noted that an inverse relationship existed between length of stay and rate of rehospitalization across diagnosis. As the author pointed out, other factors such as administrative policy, third party payment, and physician differences could explain the relationship between the rate of readmission and length of stay.” For many reasons the military psychiatric hospital provides an interesting arena in which to study rehospitalization. Insurance considerations are minimized since only soldiers and their families are eligible for treatment. Preinduction tests, medical screening, and rigorous regulations regarding fitness for duty exclude a significant number of patients from chronic use of military services. The author has previously identified various aspects of military in-patient psychiatric treatment. In one study, trends in utilization of the hospital during peace time were identified, and the need for a decentralized military psychiatric health care delivery system was discussed.” In a separate study of female soldiers, social adjustment was examined,13 and in a third report, the impact of sociodemographic factors of military psychiatric treatment was discussed. It was shown that younger, less experienced soldiers received different treatment than more senior personnel (in terms of duration of hospitalization and likelihood of being medically separated from the service) and that black soldiers were overrepresented in the hospital population.14
From Meant Sinai Hospital, New York, N. Y. Larry Kirstein. M.D.Assistant Professor of Psychiatry, Meant Sinai Hospital, New York, N. Y. Address reprint requests to Larry Kirstein, M.D., Assistant Professor of Psychiatry, Morrnt Sinai Hospital, Nebts York, N. Y. 10029. @ 1979 by Grune & Stratton, Inc. 0010-440X/79/2002-0002$01.00/0 110
Comprehensive
Psychiatry,
Vol. 20, No. 2 (March/April), 1979
111
REHOSPITALIZATION
The purpose of investigating relatively
unburdened
mine distinguishing to identify
socioclinical
clinical
practice
in an acute treatment setting. coverage, was to deter-
rehospitalization
by the constraints
of insurance
characteristics
of rehospitalized
that may influence
MATERIALS
patients
and
service delivery.
health care
AND METHODS
Settitix This \tLldy tooli place at D;\vid Grant Force
regional
from
referral
the western
entry
p;tthw;rys
hospitals,
third
of the United
to the
referred
from
hospital
inpatient
psychiatr-ic
the out-patient wards.
by plane or ambulance of 4 treatment
teams,
of the tt-eatment facility
long-ter~m
psychiatric
tary
data
wit\
utilized
throughout
the ink\
cud
ximisGnr~. patient
exclusively installation\.
screening
tt-eatment honorably
over
over
a 7 month
listing.
which
By reviewing
period
the admissions was a yearly
in lY7h-1977 1975-lY77.
in the la\t
13 ca\es.
a\Ggned
to
teams.
Each
their
I
it\ an itcute
we1.e felt
and included Two
listed
alphabetical
also transported
functioned
who
were
and the other
to
require
continued
mili-
the set-vice.
period
both lists and confirming
xknowledgment
from
which
were
compromised
during book,
room.
The ward
problems
Four different
and particular-
Patients
.Ait
patients
Wldiet-\I
were trnndomly
patient\
pzychiatri\t.
yepat-ared
theatre.
soldiers)
The patients
orientation.
whose
(medically)
a 21 month
this study:
staff
community
and patients
active-duty
State\
Ireceived
and active-duty emergency
of particular
6nited
hospital
pacific
(civilians
the hospital
military
no selective
collected
admitted
clinic,
one of jix The
to the entire
Patients
(almost
a therapeutic
were
patient\
other
health
(DGMCI.
California.
in addition
existed.
was led hy a full-time
with
performance
The
with
teams
treatment
Patients
Center-
in northet-n
States
ward
mental
from
Medical
located
listing
\ources
information
:thout
of infot-matton
were
name and date of admission. of sociodemographic
the data through
chart
data
and
on ~11
review
in 1111case\.
a list of 33 C’;IW\ of reho~pit~tlizatic,n
at DGMC‘
and w:t\
generated. The charts of the 33 cases and a control lace.
‘rnd age t
3 years
\ociodemographic clinical
variables
interval
hetween
the initial charts.
were obtained
variable (chief
race.
hospitalizations.
hospitalization.
Diagnoses
(age.
complaint.
group
from rank,
marital
status.
length
of stay.
charting
of intergroup
comparisons,
psychosis.
neurosis.
etc.
categorized
variables
and Student’s
t
and
length
previous
groups
test for continuous
LX civilian). form
of military
zex.
covering
set vice)
on each of the 66 ca\e\
of Mental
into major tested
variables.
and
outcome,
that the data W;I\ av:tilahle
Manual were
duty
hospitalization,
M as completed
were classified
between
(active
The data recording
guaranteed
and Statistical
patients
Differences
physician) standards
were based on Diagnostic
purposes
for- status room.
diagnosis. and treating
Hospital
matched
the records
Disorder
diagnostic by
0.054
chi
(DSM
II 1. For
groupings:
square
level
folin all
heing
i.e..
analysis
for
accepted
a\
signitbmt. RESULTS
Of the 302 admissions
were active-duty pitalized pitalized entiated marital
(10%
included
soldiers
of civilians
patients
in this study. 94 were civilians
(69%).
Nine
and IX
and the control
the civilian
status. discharge
of soldiers). group
and active-duty diagnosis,
civilians
were
A comparison
is presented
rehospitalized
(31%‘) and 208
and 24 soldiers in Table
rehos-
of the rehosI. Age differ-
patients (I> < 0.001).
and length of treatment
while
of the initial
hos-
pitalization were similar. Rehospitalized soldiers had shorter initial hospitalizations than the control group (p < O.OOl), while no differences were noted for the civilians. It was noted that 58% of rehospitalized patients were initially hospitalized for 3 weeks or less, compared with only 27% of the control patients (p
