Thesis Project: นพ.กิตต์กวี โพธิ์โน Examiner: ดร.นพ.พิทักษ์พล บุณยมาลิก

Thesis Project: นพ.กิ�ตต�กิวี� โพธิ์��โนExaminer: ดร.นพ.พ�ทั�กิษ์�พล บุ�ณยมาล�กิ

Association of Length of Stay and Readmission Rate among Schizophrenia Patients in Nakorn Phanom Psychiatric Hospital, Thailand

Background and Rationale

Background and Rationale Importance of Schizophrenia

Schizophrenia is a chronic psychiatric disorders, affecting the quality of life of patients and relativ

es as well as social obligations.(WHO,2001)

The prevalence rate for schizophrenia is 1.1 percent of population over the age of 18 (at any one time), which approximately 51 million people worldwide suffer from schizophrenia. The life time prevalence is 1%.

(Van OS J, Kaper S, 2009 )(Kaplan and Sadock’s Synopsis of Psychiatry,2003)

Importance of Schizophrenia: Burden of disease

Burden of disease of schizophrenia is one of the most important public health problems in the modern world.

According to the World Health Organization, it rank 9th among all medical illnesses in term of the Global Burden of Disease above cancer, AIDs, heart disease diabetes, and other important illnesses.

(Marianne C, et all, 2007)


Nature of Schizophrenia: Problem in Public Health

Readmission or re-hospitalization is the

most common characteristic in schizophrenia, given the impact on cost containment.

(Lin HC, Lee HC, 2008).


Policy/Hospitalization for Schizophrenia:

Currently, many psychiatric hospitals have changed as well as the number of psychiatric beds has declined.

(Lay B, et all, 2007).

Therefore, managed care has reduced number of hospital beds and reduced length of stay for psychiatric hospitalizations, which resulted in decreased costs and has raised concerns about the quality of care.

(Heeren O, et al: 2002).


Health Policy in Thailand: Impact of inpatient care policy in

Thailand was changed significantly. Some studies recently shown the effect of health care reform policy especially the universal coverage (30 Baht), that caused the decrease in a number of patients as well as their length of stay in many psychiatric hospitals.

(Bupawarn P, Supasit P,2003) .


The effect of the reduction in Length of Stay:

Evidence of interest regarding the return read mitted to correlate with duration of hospitaliza

tion as “readmission rates was increased for shorter length of stay”

(Lin HC, et all, 2006).

‘revealed that shorter initial hospital stays were related to higher rates of readmission’

(CIHI, 2007)

Association reflected a causal relationship between decreasing length of stay and readmission rate and help better characterize patients who are at the highest risk of readmission.

(Oscar Heeren, et all, 2002)


In Thailand, there was no research or study on the relationship of shorter duration or length of stay and readmitted to the hospital .

Therefore, Nakhon Phanom Psychiatric Hospital has been selected as examples for studying the relationship between length of stay and readmission in the schizophrenic patients .

Research Gaps

1. What is the average length of stay in schizophrenic patients in Nakhon Phanom Psychiatric Hospital?

2. What length of stay is related to readmission rate in schizophrenic patients in Nakhon Phanom Psychiatric Hospital?

3. How is length of stay related to readmission rate in schizophrenic patients in Nakhon Phanom Psychiatric Hospital?

Research Questions

Research Objectives

1. To study average length of stay in Nakhon Phanom Psychiatric Hospital.

2. To explain demographic characteristics associated with readmission rate in Nakhon Phanom Psychiatric Hospital.

3. To analyze factors influencing readmission in Nakhon Phanom Psychiatric Hospital.

4. To study the association between length of stay and readmission rate in Nakhon Phanom Psychiatric Hospital.

Hypothesis

“A decrease in length of stay is associated with an

increase in the readmission rate among schizophrenic patients.”

Conceptual Framework

General demographic characteristics: gender, age, marital status, education, occupation, and birthplaces. General clinical characteristics: diagnosis, length of stay in hospital, and number of readmissions

Readmission

Independent variables Dependent variables

Methodology

Methodology

Research Design: (Unmatched) Case-Control Study

Study Period: 1 January 2009 – 31 December

2009

Study Population

All of cases Systematic sampling every 5

cases

Case gr.= 91

Population sampled: schizophrenic patients, Nakhon Phanom Psychiatric Hospital, past 1

year-Dx.

Control gr.=100

Target population: schizophrenic patients, Thailand

Methodology Inclusion Criteria:

1.Patients were diagnosed as having schizophrenia according to criteria of the 10th International Classification of Diseases (ICD-10) of World Health Organization.

2.Patients with history of treatment in the Nakhon Phanom Psychiatric Hospital within 1 year.

3.Patients with history of readmission or repeated treatment who returned within 90 days of initial admission to the Nakhon Phanom Psychiatric Hospital.

Methodology Exclusion Criteria:

1.Patients who were diagnosed as schizophrenia but discharged from hospital while the procedures are not completed, for example, refer to general hospitals with physical complications, the family get back to treat themselves at home or other hospitals.

2.For control group; Patients who do not follow the treatment after leaving hospital within 90 days after discharged.

Measurement Tool Measurement tool was developed by the

researcher which includes all interesting variables.

Reliability of diagnosis of schizophrenia was recorded diagnosis by using the record at discharged day, and diagnosed by psychiatrists.

Reliability of recorded basic information of patients with schizophrenia admitted in hospitals including readmission and non-readmission group was recorded by attending nurses, data can be searched from records of admission center and records from inpatient wards.

Method of Data Collection

The processes of data collection was follows:

1. The researcher has been allowed to study in Nakhon Phanom Psychiatric Hospital after getting approval from advisor and the Dean of the College of Public Health Sciences, Chulalongkorn University.

2. The researcher conducted data collection by reviewing treatment history of each patient in his/her clinical records from both out-patients cards (OPD cards) and in-patient charts (IPD charts).

Data Analysis Analyzed by computerized statistical software; 1. The distribution of demographic characteristics

of sample groups presented by frequency and percentage.

2. The comparison of demographic characteristics between case and control group was tested by Chi Square.

3. The comparison of length of stay and number of readmissions between case and control group was test by t-test.

4. Factor associated between independent variables and dependent variables was analyzed by Regression Analysis.

Ethical Consideration

The proposal was submitted to the Ethical in Research Committee, Chulalongkorn University.

Permission of using this data set from the

director of Nakom Phanom Psychiatric Hospital, Department of Mental Health, Ministry of Public Health., and patients information will confidentially not to be disclosed to public.

Results

Demographic data Number (Percent) x2

(N=191) Group 1 Group 2 Total

(non-readmission) (readmission)

Gender Male 95 (55.88) 75 (44.12) 170 (100) .005*Female 5 (23.80) 16 (76.20) 21 (100)

Age (years)< 20 7 (70.0) 3 (30.0) 10 (100)20-29 40 (60.60) 26 (39.40) 66 (100) 30-39 38 (48.10) 41 (51.90) 79 (100)40-49 14 (48.27) 15 (51.13) 29 (100)50-59 1 (33.33) 2 (66.67) 3 (100)60-69 0 (0) 3 (100) 3 (100)>70 0 (0) 3 (100) 3 (100)

Marital status Single 79 (53.37) 71 (46.63) 148 (100)Married 16 (61.53) 10 (38.47) 26 (100)Divorced 5 (33.33) 10 (66.67) 15 (100)

Table 1. Comparison demographic data schizophrenic patients with non-readmission group and schizophrenic patients with readmission group.




Education No education 1 (25.0) 3 (75.0) 4 (100) Primary school 43 (42.15) 59 (57.85) 102 (100) Secondary school 55 (67.90) 26 (32.10) 81 (100) Bachelor degree 1 (25.0) 3 (75.0) 4 (100)

Occupation No occupation 66 (44.0) 84 (56.0) 150 (100)

Agriculture 22 (100) 0 (0) 22 (0) Employee 6 (60.0) 4 (40.0) 10 (100)

Commercial 3 (60.0) 2 (40.0) 5 (100) Other 3 (75.0) 1 (25.0) 4 (100)

Table 1. Comparison demographic data schizophrenic patients with non-readmission group and schizophrenic patients with readmission group. (cont.1)




Birthplaces (provinces) Nakhon Phanom 54 (58.69) 38 (41.31) 92 (100) Sakon Nakhon 19 (38.0) 31 (62.0) 50(100) Mukdahan 17 (62.96) 10 (54.55) 27 (100)

Other 10 (40.54) 12 (59.46) 22 (100)

Major diagnosis F 20.0 86 (48.86) 90 (51.14) 176 (100) F 20.2 1 (50) 1 (50) 2 (100) F 20.3 2 (100) 0 (0) 2 (100) F 20.5 4 (100) 0 (0) 4 (100) F 20.9 7 (100) 0 (0) 7 (100)

Table 1. Comparison demographic data schizophrenic patients with non-readmission group and schizophrenic patients with readmission group. (cont.2)

Data Mean (x) t-test (N=191) Group 1 Group 2 Total (Non-readmission) (Readmission)

Length of stay (days) 21.10 16.27 18.79 (SD 11.88) .00*

Number of readmissions 4.63 3.08 3.88 (SD 2.68) .00*

Table 2. Comparison length of stay between non-readmission group and schizophrenic patients with readmission group.

Factors AOR p-value 95% CI

Gender 6.312 .003* 1.905-20.914

Age 1.487 .041* 1.016-2.178

Occupation .649 .011* .465-.907

Length of stay .962 .014* .932- .992

Number of readmissions .739 .00* .631- .866

Table 3. Factors associated with readmission

Summary Demographic Characteristic Data

The general characteristics between readmission and non-readmission groups were comparable as we found that the majority of subjects were…

Male 89.01%

Age 30-39 years (41.36%),

Marital status single status (77.48%)

Education Primary school (53.40%)

Occupation Unemployed (48.32%)

Place of birth Nakhon Phanom Province (48.16%)

Diagnosis Schizophrenia paranoid type (92.14%)

Summary

Length of Stay and Number of Readmissions

The average length of stay in

Readmission group 16.27 days

Non-readmission group 21.10 days (significant different p <0.0001)

The average mean of length of stay in Nakhon Phanom Psychiatric Hospital is 18.72 days.

Summary

Factors Associated with Readmission

Factors associated with readmission included

- Gender - Age- Occupation- Length of stay- The number of readmission

Discussion

Demographic Characteristic DataDemographic and some epidemiological characteristics of schizophrenia in this study were consistent with past study such as the Synopsis of Psychiatry 20031 and the study of incidence and epidemiology of schizophrenia2

1; (Benjamin J Sadock and Virginia A Sadock. 2003)

2; (John McGrath, et all, 2008)

Discussion Factors Associated with Readmission

Several other studies regarding factors associated with readmission which focus on treatment especially partial compliance including; poor insight, negative attitude or subjective response toward medication, no previous adherence, substance abuse, shorter illness duration, inadequate discharge planning, after care environment, and poorer therapeutic alliance are the most important factors affecting of readmission of schizophrenia3; (Liorca PM, 2008; Rummel Kluge C, et all, 2008, Weiden PJ,et all, 2004)

4; (Lin HC, et all, 2006).

Discussion

Factors Associated with Readmission

Although previous studies did not focus and demonstrated the influence of demographic data, this study shows that demographic factors such as gender, age, and occupation were statistically associated with readmission rate.

Discussion Association of Length of Stay and

Readmission

This study found that shorter length of stay was associated with higher rate of readmission.

The average mean length of stay of readmission group was less than those in non-readmission group (16.27 vs. 21.10 days) with statistically significant difference p <.001.

The average mean length of stay in Nakhon Phanom psychiatric hospital is 18.79 days (SD +11.88).


Readmission According to some studies in Taiwan5, Canada6, and U.S.A.7, the results showed that shorter length of stay association with high rate of readmission.

However, some studies such as study in Australia8 reported that length of stay in hospital was not significantly associated with readmission among schizophrenic patients. 5;(Lin HC, et all, 2006) 6; (CIHI, 2007) 7; (Roberto and et all, 2003)

8; (Browne G, Courtney M, Meehan T., 2004)..


Readmission

In Thailand, some p sychiatric h ospitals have reduced the length of stay of patients in the hospitals, and the number of beds mostly as a result of the Health Care Reform Policy 30 Baht9

Our finding showed that the average length of stay tended to be decreased. The average length of stay in a previous study (200310) was 92.31 days, while the LOS in this study (2009) was 18.79 days.

9; (Bupawan P, Supasit P, 2003)

10; (Bunchai N, and et all, 2003)

Discussion

Association of Length of Stay and Readmission

Shorter length of stay seems to affect the efficacy of treatment which in turn increase the chance of readmission to hospital.

Therefore, preparing patients and communities before discharge is recommended as a major priority to reduce the chances of returning or readmission to hospital

Limitations

1. This study is a case control study; therefore, data may have some degree of credibility, and secondary data bias.

2. Limitation on gathering information of some patients with schizophrenia, such as those who went to received treatment in other hospitals

3. There are many factors involved readmission rate which did not include in this study.

Recommendations

1. The future study should use data from the records of those by the researcher, and the study should be the prospective or cohort study.

2. further study should control or distinguish the difference between these case and control groups that are similar in most studies, including multi-center/hospitals to see the results of an overview study of Thailand.

Policy ImplicationsLocal hospital level 1. Extending the hospital stay for

schizophrenic patients by adjusting proper treatment including rehabilitation for all patients before sending them back to the community will reduce the hospital re-admission rate.

2. Improve the efficiency of treatment process within restricted budget will reduce the expense burden psychiatric hospital.

3. Participation from both public and private organizations on comprehensive system of treatment and rehabilitation will reduce the re-admission rate of hospitals.

Policy Implications

National level

1. Increasing the payment for schizophrenic patients on longer hospital stay.

2. For the future, in order to reduce all expense (both direct and indirect expenses) on milder cases of schizophrenic patients, the local and general hospitals should improve the treatment process and health watch in collaboration with the community.

THANK YOU

Documents

Thesis Project: นพ.กิตต์กวี โพธิ์โน Examiner: ดร.นพ.พิทักษ์พล บุณยมาลิก