Length of Stay in a General Hospital Psychiatric Unit Betty E. Herr, M.D., Ph.D., Henry David Abraham, William Anderson, M.D.
Abstract: Fifty psychiatric inpatients with a prolonged length of stay were compared to 50 control admissions for factors associated with prolonged hospitalizations in a general hospital. Seven variables were found to be significantly overrepresented among the long stayers, including treatment with electroconvulsive therapy, medical consultations, underemployment, dementia, disposition to a place other than home, absence of alcohol or drug abuse, and presence of psychosis without affective symptoms. The clinical and policy implications of these finding are discussed.
Medical cost containment is an urgent contemporary concern with clinical, economic, and ethical dimensions. From 1955 to 1977 the number of acute psychiatric beds in general hospitals increased in the U.S. by 271%. By 1982 psychiatric admissions accounted for 6.85 billion dollars a year 111. Predicting duration of stay would be useful for policy purposes. Diagnostic related groups do not estimate duration of stay effectively [2], necessitating more robust predictors of length of stay (LOS). In public institutions the “long-stay patients” are elderly with dementia and younger patients with psychosis. The former outnumber the latter [3,4]. Patient factors accounting for an increased LOS in private and general hospitals include severity of illness, poor adaptive diagnosis, functioning, advanced age, and female gender. Electroconvulsive therapy (ECT) has been implicated in long LOS [5,6]. Environmental factors Fromthe Departmentsof Psychiatry, St. Elizabeth’s Hospital of Boston and the Harvard Medical School, Boston, Massachusetts. Address reprint requests to: Dr. Betty Herr, St. Elizabeth’s Hospital of Boston, 736 Cambridge Street, Boston, MA 02135. 68 ISSN 0163~8343/91/$3.50
M.D., and
include severity of psychosocial stressors, uneminadequate financial and social reployment, and unavailability of aftercare and sources, housing [7]. Treatment philosophy of the unit may also contribute to long LOS [S]. Studies of extended LOS have been regression analyses or surveys of professional attitudes. Controlled studies attempting to define factors associated with long LOS in short-term general hospital units are just beginning to emerge. Accordingly, we conducted the following controlled study. Choice of variables was based in part on previous findings in the literature. We also chose objective variables that could be scored by a psychiatrist reviewer from medical records. In virtually all previous studies female gender and advanced age were associated with long LOS. To highlight other factors and avoid confounds we matched patients by age and sex as well as race.
Methods The St. Elizabeth’s Hospital of Boston operates a 56-bed psychiatric unit in a 385-bed general hospital. In 1985, the unit admitted 787 patients, records of which were surveyed for LOS. Sixty-three percent of the patients were female. The mean age + SD of the inpatient admissions for that year was 49.7 + 19.9 years. A distribution of their LOSS revealed a single mode with a mean + SD of 21.9 + 16.4 days, and a tail to the right with a skewness of 1.02, suggesting that a small number of patients required a particularly long period of hospitalization. Fifty patients whose LOSS were greater than 40 days were selected as an index group, and General ffospitd Psychiatry 13, 68-70, 1991 D 1991 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
LOS in a General Hospital Psychiatric Unit
Table 1. Factors associated psychiatric hospital
with prolonged hospitalizations in a general
Study variable Number of medical consults (mean) ECT (%) Full-time employment (%) Dementia (%) Disposition other than home (%) Alcohol/drug abuse (%) Psychosis without affective disorder (%)
Patients with prolonged Control stays patients
p
2.78 60.0 10.0 14.0
1.38 24.0 29.2 2.0
Abstract: Fifty psychiatric inpatients with a prolonged length of stay were compared to 50 control admissions for factors associated with prolonged hospitalizations in a general hospital. Seven variables were found to be significantly overrepresented among the long stayers, including treatment with electroconvulsive therapy, medical consultations, underemployment, dementia, disposition to a place other than home, absence of alcohol or drug abuse, and presence of psychosis without affective symptoms. The clinical and policy implications of these finding are discussed.
Medical cost containment is an urgent contemporary concern with clinical, economic, and ethical dimensions. From 1955 to 1977 the number of acute psychiatric beds in general hospitals increased in the U.S. by 271%. By 1982 psychiatric admissions accounted for 6.85 billion dollars a year 111. Predicting duration of stay would be useful for policy purposes. Diagnostic related groups do not estimate duration of stay effectively [2], necessitating more robust predictors of length of stay (LOS). In public institutions the “long-stay patients” are elderly with dementia and younger patients with psychosis. The former outnumber the latter [3,4]. Patient factors accounting for an increased LOS in private and general hospitals include severity of illness, poor adaptive diagnosis, functioning, advanced age, and female gender. Electroconvulsive therapy (ECT) has been implicated in long LOS [5,6]. Environmental factors Fromthe Departmentsof Psychiatry, St. Elizabeth’s Hospital of Boston and the Harvard Medical School, Boston, Massachusetts. Address reprint requests to: Dr. Betty Herr, St. Elizabeth’s Hospital of Boston, 736 Cambridge Street, Boston, MA 02135. 68 ISSN 0163~8343/91/$3.50
M.D., and
include severity of psychosocial stressors, uneminadequate financial and social reployment, and unavailability of aftercare and sources, housing [7]. Treatment philosophy of the unit may also contribute to long LOS [S]. Studies of extended LOS have been regression analyses or surveys of professional attitudes. Controlled studies attempting to define factors associated with long LOS in short-term general hospital units are just beginning to emerge. Accordingly, we conducted the following controlled study. Choice of variables was based in part on previous findings in the literature. We also chose objective variables that could be scored by a psychiatrist reviewer from medical records. In virtually all previous studies female gender and advanced age were associated with long LOS. To highlight other factors and avoid confounds we matched patients by age and sex as well as race.
Methods The St. Elizabeth’s Hospital of Boston operates a 56-bed psychiatric unit in a 385-bed general hospital. In 1985, the unit admitted 787 patients, records of which were surveyed for LOS. Sixty-three percent of the patients were female. The mean age + SD of the inpatient admissions for that year was 49.7 + 19.9 years. A distribution of their LOSS revealed a single mode with a mean + SD of 21.9 + 16.4 days, and a tail to the right with a skewness of 1.02, suggesting that a small number of patients required a particularly long period of hospitalization. Fifty patients whose LOSS were greater than 40 days were selected as an index group, and General ffospitd Psychiatry 13, 68-70, 1991 D 1991 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
LOS in a General Hospital Psychiatric Unit
Table 1. Factors associated psychiatric hospital
with prolonged hospitalizations in a general
Study variable Number of medical consults (mean) ECT (%) Full-time employment (%) Dementia (%) Disposition other than home (%) Alcohol/drug abuse (%) Psychosis without affective disorder (%)
Patients with prolonged Control stays patients
p
2.78 60.0 10.0 14.0
1.38 24.0 29.2 2.0
