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Research Study

  1. 1. Psychiatry 67(3) Fail 2004 294 Follow-Up After Inpatient Psychiatric Hospitalization With Partial Control of the System Responsiveness Variable Rif S. El-Mallakh, Tina James, Tehmina Khan, Marina Katz, Bethany McGovern, Sunil Nair, Scott Tallent, and Gregory Williams One of the most significant predictors of prompt rehospitalization following psy- chiatric hospital discharge is missing follow-up out-patient appointments. Previ- ous studies have suggested that system responsiveness accounted for much of the variance in predicting compliance with aftercare. Collaborations established at our institution allowed us to partially control this variable, opening the way to explore other obstacles to aftercare. All severely mentally ill subjects discharged from our hospital are provided follow-up appointments within two weeks. We retrospec- tively evaluated compliance with aftercare appointment and investigated factors that were associated with compliance. Eighty-one subjects were evaluated. Twenty-seven (33.8 %) did not attend their first follow-up appointment. Subjects with a primary substance-related syndrome were the most likely to miss their ap- pointment (83.3%, X2 = 17.02,p = .0045), as were uninsured patients (51.6%, X2 = 8.79, P = .003). There was a trend for individuals not previously involved with their aftercare providers to miss their appointment (48.9%, X2 = 3.35, P = .067). Despite partial control of the system responsiveness variable, compliance with aftercare was suboptimal. This was due to a combination of client vulnerability variables and uncontrollable system responsiveness factors. For the severe and persistently men- ducing the missed appointment rate has been tally ill, one of the major determinants of min- seen as an important step towards overall im- imizing psychiatric hospitalizations is provement of prognosis (Byers and Cohen ongoing outpatient care (Klinkenberg and 1979; Solomon, Davis, and Gordon 1984; Calsyn 1996; Sparr, Moffitt, and Ward Winston, Pardes, Papernick, and Breslin 1993). This begins with the first appointment 1977). r after discharge from the hospital. In general, In their model of predictors of receipt the rates of compliance with the first of aftercare and recidivism, Klinkenberg and post-hospital discharge appointment range Calsyn (1996) defined the major contributors from 13% (Green 1988) to 90% (Sullivan as client vulnerability, community support, and Bonovitz 1981) and average around 50 and system responsiveness. Of these, system to 60% (Klinkenberg and Calsyn 1996). Re- responsiveness, including such factors as Rif S. El-Mallakh, MD, Tina James, MD, Tehmina Khan, MD, Marina Katz, MD, Bethany McGovern. MD, Sunil Nair, MD, Scott Tallent, MD, and Gregory Williams, DO are affiliated with the Mood Disorders Research Program, Department of Psychiatry and Behavioral Sciences, University of Lou- isville School of Medicine, Louisville, Kentucky 40291. Address correspondence to Dr. Rif S. El-Mallakh at the Mood Disorders Research Program; E-mail:
  2. 2. El-Mallakh et al. 295 proximal and convenient scheduling of after- their aftercare provider prior to admission care appointments, were felt to be "more con- (for those patients for whom this was not the sistent predictors of receipt of aftercare than first hospitalization), whether hospitalization variables related to either community support was voluntary, and the use of substances in in- or client vulnerability" (Klinkenberg and dividuals whose primary diagnosis was not Calsyn 1996). This, in many ways, is good substance-related (e.g., a person with sub- news, since potentially, we have more control stance-induced mood disorder would be con- over system responsiveness than other sidered to have a primary substance-related variables. disorder, while a person with recurrent major In Louisville, the community mental depression who used marijuana would be health agency (Seven Counties Services) and considered to have a primary mood disorder the University Hospital (which serves as the and secondary substance use). acute care facility for most of the area's se- Since all data was categorical, Chi verely mentally ill) have collaborated to en- square was utilized for analysis. Variables sure that the first follow-up appointment after were investigated individually because we hospital discharge occur within two weeks of wanted to determine which of the three cate- discharge. This occurred whether the patient gories defined by Klinkenberg and Calsyn was insured, new to the system, or a non-resi- (1996) accounted for missed appointments. dent of Kentucky. This setup provided an ex- For example, since community support fac- cellent opportunity to determine, with system tors might be related to system responsiveness responsiveness at least partially controlled, variables, a statistical method that evaluated what additional factors might be associated relationships between the individual variables with aftercare compliance. (such as multiple regression) would have pre- vented us from determining the specific category responsible. METHOD RESULTS The University of Louisville Hospital operates a 40-bed inpatient facility which serves as the acute care inpatient facility for Eighty-one subjects were reviewed. The severely ill individuals within the greater Lou- average age was 34.6 years (range 18 - 67, SD isville area. Seven Counties Services provides = 11.9 years). There were 53 women (65.4%) most of the outpatient services to these pa- and 28 men (34.6%). Table 1 summarizes the tients. Among the several collaborations be- data as a function of whether or not patients tween the two organizations is the effort to were compliant with their first follow-up ap- ensure that all severely ill patients be given a pointment. Individuals admitted with a pri- follow-up appointment within two weeks of mary substance-related disorder (specifically, discharge. Seven Counties has several sites lo- substance-induced mood or psychotic disor- cated throughout the city, and appointments ders) were least likely to make it to their fol- were made in the most convenient site. .Addi- low-up appointment (16.7%, p = .0045). tionally, case managers were available to take However, substance abuse, per se, did not patients to their appointments if needed. predict noncompliance. We reviewed the records of 81 patients Missed first appointments were higher discharged in the month of February 2001 in subjects with a primary mental illness who and collected data regarding age, gender, pri- also used substances (41.3 %) than those who mary diagnosis for which they were admitted did not use substances (26.5%), but this dif- (many had other secondary psychiatric diag- ference was not significant in the current sam- noses), type of insurance, homelessness status, ple (p = .3). Similarly, there was no difference whether this was the patient's first hospital- if follow-up was scheduled in a primary psy- ization, whether the patient was involved with chiatric setting (30.9%) or a substance treat-
  3. 3. 296 Follow-Up after Inpatient Psychiatric Hospitalization Table 1. Variables Examined in Subjects Who Attended or Missed Their First Appointment Following Discharge from Psychiatric Hospitalization. Data are presented as numbers (and percentages) of patients in each category. Analysis utilized Chi square. Variable Attended Follow-Up Missed Follow-Up X2 r. Diagnosis 17.02 .0045 Bipolar 14 (66.7%) 7 (33.3%) Schizophrenia 21 (75.0%) 7 (25.0%) Depression 11 (84.6%) 2 (15.4%) Substance-induced 2 (16.7%) 10 (83.3%) Insurance 8.79 .032 Medicaid 23 (85.2%) 4 (14.8%) Medicare 13 (68.4%) 6 (31.6%) Private Insurance 2 (66.7%) 1 (33.3%) None 15 (48.4%) 16 (51.6%) Previous Involvement with Outpatient Care 3.35 .067 Yes 33 (73.3%) 12 (26.7%) No 17(53.1%) 15 (46.9%) First Hospitalization 1.58 .21 Yes 12 (54.6%) 10 (45.6%) No 41 (69.5%) 18 (30.5%) Presence Of Substance Abuse 2.44 .30 Yes 27 (58.7%) 19 (41.3%) No 25 (73.5%) 9 (26.5%) Voluntary Status 1.08 .30 Involuntary 15 (75.0%) 5 (25.0%) Voluntary 38 (62.3%) 23 (37.7%) Homelessness 0.88 .35 Homeless 4 (50.0%) 4 (50.0%) Not homeless 48 (66.7%) 24 (33.3%) Gender 0.002 0.96 Male 23 (65.7%) 12 (34.3%) Female 30 (65.2%) 16 (34.8%) ment center (50.0%, X2 == 2.62, P == .27). hospitalizations (69.5%, P == .21). Patients without any insurance had the lowest Surprisingly, involuntary hospitalization, rate of compliance with aftercare when this homelessness, and gender were not associated particular variable was examined (48.4%) with aftercare noncompliance (see Table 1). while those with Medicaid had the highest rate (85.2%, p == .032). DISCUSSION There was a trend for those compliant with preadmission outpatient care to predict An interplay between client vulnerabil- compliance with post-discharge aftercare ity, community support, and system respon- (73.3% versus 53.1% for those without siveness determines the likelihood of preadmission involvement, p == .067). This compliance with post-discharge aftercare contrasts with the lack of significance in show (Klinkenberg and Calsyn 1996). Klinkenberg rate between those experiencing a first hospi- and Calsyn (1996) defined client vulnerability talization (54.6%) and those with previous to include easily measured items such as diag-
  4. 4. EI-Mallakh et al. 297 nosis, demographics, and socioeconomic sta- hospitalization did not have a significantly tus, as well as more abstract items such as different compliance rate from those with interpersonal skills and insight. previous hospitalizations. Community support constitutes the liv- The only system responsiveness factor ing situation and relationship to family mem- which could not be controlled, lack of insur- bers and other social support. System ance, showed a nonspecific trend towards responsiveness encompasses items that are ex- contributing to noncompliance. This may clusively under the control of mental health seem self-explanatory, but subjects without providers. These include issues such as conve- insurance are usually offered services at re- nient and proximal appointments and case duced cost. Availability of insurance has not management (defined as services to assist cli- been routinely examined in previous studies. ents with navigating complicated procedures, Correlates of insurance, such as educational such as applying for public housing assis- level or employment status, are generally not tance, or simple tasks, such as shopping for correlated with aftercare compliance food) (Klinkenberg and Calsyn 1996). (Klinkenberg and Calsyn 1996), and in- In their review of the literature, creased state funding of outpatient services Klinkenberg and Calsyn (1996) concluded did not reduce recidivism (Fisher, Geller, that system responsiveness was the most sig- Altaffer, and Bennett 1992). nificant set of variables in reducing recidivism. Additionally, one may also argue that To understand the relative role of other fac- insurance availability is not under the exclu- tors, we examined the rate of follow-up after sive control of mental health providers, and is discharge in a group of people in whom sys- therefore misclassified as a system responsive- tem responsiveness variables were partially ness variable; rather, it is most closely related controlled. to socioeconomic status, and is better classi- Our data suggest that client vulnerabil- fied as a client vulnerability factor. ity and community support factors appear to playa major role in noncompliance with ini- There are several shortcomings in our tial aftercare visits. Specifically, if the admis- study. For example, we were unable to exam- sion was due to a primary substance-related ine several important factors in our retrospec- syndrome, patients were unlikely to keep their tive design. Specifically, we examined only appointments. However, substance use, per se one community support factor, homelessness. (specifically, when it is not related to the pri- Our results are compatible with previous re- mary reason for admission), was not predic- ports that found no relationship between tive of poor compliance. This is consistent compliance with aftercare and homelessness. with previous studies that those with isolated However, a homelessness outreach program substance use disorders have a lower compli- conducted by the community mental health ance rate (Allan 1987; Bander, Stilwell, Fein, agency may have also improved compliance and Bishop 1983), but that psychiatric diag- among the homeless patients. The effect of nosis was not a major predictor of noncompli- this program could not be examined in our ance (Byers and Cohen 1979; Klinkenberg retrospective design. and Calsyn 1996; Solomon, Davis, and Despite these shortcomings, our data Gordon 1984). does suggest that when the system responsive- Involvement with the outpatient care ness variable is partially controlled by ensur- clinic prior to hospitalization was a positive ing that all appointments are made within two predictor to keeping an appointment after weeks of hospital discharge, that compliance hospital discharge. This appears to be specifi- remains suboptimal at 72.2%. Our design cally related to the established therapeutic re- could not explore community support factors lationship, since subjects with first effectively.
  5. 5. 298 Follow-Up after Inpatient Psychiatric Hospitalization REFERENCES Allan, C. (1987). Seeking help for drinking prob- Klinkenberg, W.D., and Calsyn, R.J. (1996). lems from a community-based voluntary Predictors of receipt of aftercare and recidivism agency: Patterns of compliance amongst men among persons with severe mental illness: A re- and women. British Journal of Addiction, view. Psychiatric Services, 47, 487-496. 82,1143-1147. Solomon, P., Davis, J., and Gordon, B. (1984). Bander, K.W., Stilwell, N.A., Fein, E., and Discharged state hospital patients' characteris- Bishop, G. (1983). Relationship of patient char- tics and use of aftercare: Effect on community acteristics to program attendance by women al- tenure. American Journal of Psychiatry, 141, coholics. Journal of Studies on Alcohol, 44, 1566-1570. 318-327. Sparr, L.F., Moffitt, M.C., and Ward, M.F. Byers, E.S., and Cohen, S.E. (1979). Predicting (1993). Missed psychiatric appointments: Who patient outcome: The contribution of returns and who stays away. American Journal prehospital, in hospital, and posthospital fac- of Psychiatry 150,801-805. tors. Hospital and Community Psychiatry, 30, 327-331. Sullivan, K., and Bonovitz, J.S. (1981). Using predischarge appointments to improve continu- Fisher, W.H., Geller, J.L., Altaffer, F., and ity of care for high-risk patients. Hospital and Bennett, M.B. (1992). The relationship between Community Psychiatry, 32, 638-639. community resources and state hospital recidi- Winston, A., Pardes, H., Papernick, D.S., and vism. American Journal of Psychiatry, 149, Breslin, L. (1977). Aftercare of psychiatric pa- 385-390. tients and its relation to rehospitalization. Hos- Green, J.H. (1988). Frequent rehospitalization pital and Community Psychiatry, 28, 118-121. and noncompliance with treatment. Hospital and Community Psychiatry, 39, 963-966.