Psychiatric readmissions and their association with environmental and health system characteristics: A systematic review of the literature.Jorid Kalseth, Eva Lassemo SINTEF Health Research, Norway

1. Psychiatric readmissions and their association with
environmental and health system characteristics: A
systematic review of the literature
Jorid Kalseth1, Eva Lassemo1, Kristian Wahlbeck 2 , Peija Haaramo 2, Jon Magnussen3
1 SINTEF Health Research, Norway
2 National Institute for Health and Welfare (THL), Finland
3 Norwegian University of Science and Technology, Norway
This project has received funding from the European Union’s Seventh Framework Programme
for research, technological development and demonstration under grant agreement no 603264

2. Aim
The objective of the present study was to
systematically review what type of aggregate
system level and environmental characteristics
have been studied and examine their
association with readmission after discharge
from psychiatric in-patient hospital care.
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3. Patient vs system characterisitcs
• Previous review have typically identified and discussed
effects of pre- or post-discharge service use of psychiatric
patients as system variables. Ex. LOS, follow-up visitis
• Often not a clear cut separation between patient
characteristics and systems characteristics. A patient level
predictor (pre- or post-discharge) is likely to reflect case-mix
characteristics as well as, and sometimes rather than,
system characteristics.
• System level: Here defined as aggregate level characteristics
as opposed to patient level characteristics
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4. System level characterisitcs
• Regulation, financing system and governance
• Service capacity, organization and structure
• Environmental variables
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5. Method
• Search in Ovid Medline, PsycINFO, ProQuest Health Management,
OpenGrey and Google Scholar
• Published January 1990 throughout June 2014
• No (psychiatric) diagnostic, time frame, language or publication
status restrictions
• Only quantitative study designs
• Patients 18+ years with psychiatric diagnoses discharged from and
readmitted to in-patient hospital care
• Includes aggregate level variables
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6. Results
• 35 articles included in the review
(Of 734 unique articles identifies in the CHEPOS-LINK search, 33 was
included and 2 were added after checking the reference lists)
– 22 observational studies
• 6 on aggregate readmission rates
• 16 on patient level
– 5 "natural experiments"
– 8 interventions
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7. Regulation, financing system, and
governance structures
• 3 studies identified
• Passing of rehabilitation legistation in Israel (-)
• Utilisation Management programs, US (+)
• Behavioural health carve-outs, US (0)
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8. Capacity, organization and structure
Variable Results
Hospital size (4)
(# beds, staff, patient volume)
Most no association,
1 size +
Capacity (6)
(per capita beds, staff, spending patient volume)
Most no association,
2 capacity +
Resource availability/utilisation/quality (4)
(staff-patient ratios, staff composition)
2 no association,
2 high resource utilisation/low availability +
Institutional length of stay/patient turn-over (6) All: high ALoS/low patient turn-over –
Case-mix (2) 2 find associations
(1 % CMI+, 1 % compulsory admitted -)
Treatment policies/orientation (4) 1 no association
3 find associations
Hospital type (4)
(specialisation, ownership, type of hospital ward)
1 no association (type ward)
3 specialisation and ownership
Community aftercare (10)
(follow-up visits, interventions)
Most: aftercare follow up –
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9. Environment
Variable Results
Geographical characteristics (15)
- Location 2 no area differences, 10 area differences found
- Urban regions 1 no differences by urbanity, 2 urban -
- Population density 2 no association, 1 density +
Demographic composition (4)
- Age or Gender or Ethnicity 4 no association
- Foreign born population 2 high share +
Socioeconomic characteristics (6)
- Income 2 no association, 1 high income communities –
- Education 2 no association, 1 high education communities –
- Unemployment 2 No association
- Poverty 2 No association
- Deprivation and social class 2 no association, 1 low social status communities –
- Family structure and crowded households 1 no association, 1 % female-headed households +
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10. Discussion
• Included studies are heterogeneous
– type and measurement both of readmission and system/environmental
variables,
– patient population studied
– number of observations,
– type and level of analysis,
– few studies for most types of variables.
→ generally no basis for drawing strong conclusions on impact of spesific
variables.
But:
1) Area differences - strong indication that the risk of readmission not only
relates to patient characteristics but also to system and/or environmental
factors that varies between areas.
2) ALOS found to be negatively associated with readmission
3) Aftercare mostly found to be negatively associated with readmission
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11. Conclusion
• This review identifies gaps in the literature on hospital readmissions
for patients with psychiatric diagnoses.
– Studies of health care system and environmental variables are
scarse.
– Very few studies on regulation, financing system and governance
structure.
– Also surprisingly few studies of variables capturing capacity,
organization and structure, and environmental variables like
distance to services.
– Little policy relevance to draw from studies of area differences
without information about system and environmental
characteristics.
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