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Health Policy
j o u r n a l h o m e p a g e :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l
Unplanned admissions to inpatient psychiatric treatment and services received prior to admission
Solveig Osborg Ose
a,∗, Jorid Kalseth
a, Marian Ådnanes
a, Tone Tveit
b, Solfrid E. Lilleeng
caSINTEFTechnologyandSociety,DepartmentofHealth,Klæbuveien153,7049Trondheim,Norway
bHelseBergenHF,BjørgvinDPS,Tertnesveien37,5113Tertnes,Norway
cTheNorwegianDirectorateofhealth,DepartmentofHealthEconomicsandfinancing,Sluppenveien12C,7037Trondheim,Norway
a r t i c l e i n f o
Articlehistory:
Received10August2017
Receivedinrevisedform3November2017 Accepted14December2017
Keywords:
Mentalhealthpolicy Qualityindicator Servicelevel
Specialisthealthservices Localmentalhealthservices
a b s t r a c t
Background:Inpatientbednumbersarecontinuallybeingreducedbutarenot beingreplaced with adequatealternativesinprimaryhealthcare.Thereisaconsiderableriskthateventuallyallinpatient treatmentwillbeunplanned,becauseplannedorelectivetreatmentsaresupersededbyurgentneeds whencapacityisreduced.
Aimsofthestudy:Toestimatetherateofunplannedadmissionstoinpatientpsychiatrictreatmentfacil- itiesinNorwayandanalysethedifferencebetweenpatientswithunplannedandplannedadmissions regardingservicesreceivedduringthethreemonthspriortoadmissionaswellasclinical,demographical andsocioeconomiccharacteristicsofpatients.
Method: Unplanned admissions were defined as all urgent and involuntary admissions including unplannedreadmissions.Nationalmappingofinpatientswasconductedinallinpatienttreatmentpsy- chiatricwardsinNorwayonaspecificdatein2012.Binarylogitregressionswereperformedtocompare patientswhohadunplannedadmissionswithpatientswhohadplannedadmissions(i.e.,theanalyses wereconditionedonadmissiontoinpatientpsychiatrictreatment).
Results:Patientswithhighriskofunplannedadmissionaresufferingfromseverementalillness,have lowfunctionallevelindicatedbytheneedforhousingservices,highriskforsuicideattemptandofbeing violent,loweducationandbornoutsideNorway.
Conclusion:Specialistmentalhealthservicesshouldsupportthelocalservicesintheireffortstopre- ventunplannedadmissionsbyprovidingcounselling,shortinpatientstays,outpatienttreatmentand ambulatoryoutpatientpsychiatryservices.
Implicationsforhealthpolicies:Thispapersuggeststherateofunplannedadmissionsasaqualityindicator andconsiderstheintroductionofeconomicincentivesintheincomemodelsatbothservicelevels.
©2017TheAuthor(s).PublishedbyElsevierIrelandLtd.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Modernmentalhealthservicestrytoensurethatpeoplewith severementalillnessspendtheminimumamountoftimeinhospi- talbecauseunnecessaryhospitalcareiswasteful,stigmatizingand dislikedbypatients[1].Themainargumentsforshiftingcarefrom institutionstocommunitycareareimprovedaccesstoservices, enablingpeoplewithmentalillnesstomaintainfamilyrelation- ships,friendshipsandemploymentwhilereceivingtreatment,and reducedsegregationandstigma[2].However,thebroadpicture
∗Correspondingauthor.
E-mailaddresses:solveig.ose@sintef.no(S.O.Ose),jorid.kalseth@sintef.no (J.Kalseth),marian.adnanes@sintef.no(M.Ådnanes),tone.tveit@helse-bergen.no (T.Tveit),Solfrid.Elisabeth.Lilleeng@helsedir.no(S.E.Lilleeng).
overthepasttwodecadesshowsaprogressivereductioninhospi- talbeds,alongwithimbalanced,inadequateandslowinvestment incommunityservices[3].Asinmostindustrializedcountries,in recentdecades,mentalhealthservicesforadultsinNorwayhave beencharacterizedbydeinstitutionalizationandredistributionof patientsfromlong-termcaretoshort-durationactivetreatment [4].
Thelocusofcareischangingfrompsychiatrichospitalstothe community,andthisisacontentiouscomponentofmentalhealth carepolicyinmanycountries[5].Althoughbothcommunityand hospitalservicesarenecessary,therelativemixtureoftheservice componentsneededdependsonspecificlocalcircumstances,and mostcareshouldbeprovidedator nearpeople’s homes[6].In linewiththis,theWorldHealthOrganization(WHO)recommends thatcountriesshouldlimitthenumberofmentalhospitals,build communitymentalhealthservices,developmentalhealthservices
https://doi.org/10.1016/j.healthpol.2017.12.006
0168-8510/©2017TheAuthor(s).PublishedbyElsevierIrelandLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by- nc-nd/4.0/).
ingeneralhospitals,integratementalhealthservicesintoprimary healthcare,buildinformalcommunitymentalhealthservicesand promoteself-care[7].
Reducing the number of beds in inpatient treatment with- out providing adequate local alternatives may result in much unplannedoracutetreatmentbecauseplannedorelectivetreat- mentsaresupersededbyurgentneeds.Unplannedadmissionsare muchstudiedinsomaticpatientsbutreceivelessresearchattention wherepatientssufferfrommentalillnesses.Onestudyfoundthat peoplewithmultipleillnessesaremuchmorelikelytobeadmitted tohospitalunexpectedly,andmentalhealthissuesandeconomic hardshipfurtherincreasethelikelihood[8].
Readmissionratesareincreasinglyusedasaperformanceindi- cator[9],eventhoughthevalidityofusingtherateofreadmission asanoutcomemeasurehasbeenquestioned[10–13].Insomatic services,ithasbeensuggestedthatreadmissionratesprovidean incompletepictureofunplannedcareandithasbeensuggested thatpayersand policymakersshouldbroadentheirfocusfrom readmissionmeasurestounplannedcarecompositemeasures[14].
Theysuggestthatacompositemeasureofunplannedcareshould includereadmissions,observationstays and emergencydepart- mentvisits[14].
Thefirstobjectiveofthisstudyistoestimatetheprevalence of unplanned admissions and analyse the difference between patientswithunplannedand plannedadmissionsregardingser- vicesreceivedduringthethree monthspriortoadmission. The second objective is to identify the clinical, demographical and socioeconomiccharacteristicsofpatientswithunplannedtreat- mentcomparedtopatientswithplannedtreatment.Weassume thatelective orplannedtreatmentis moreeffectivethantreat- mentprovidedwithouta treatmentplanandthatbothpatients andclinicianspreferthatthetreatmentfollowsaplan.
Unplannedadmissionsweredefinedasthesumofallurgentor involuntaryadmissions.Thisalsoincludesunplannedreadmissions becausetheseareassumedtobeurgentadmissions.
Basedonthefindings,wediscusswhethertherateofunplanned admissions is a suitable indicator of the quality of the collab- orationbetweenprimaryand secondary services,rather than a performanceindicatorforspecialistservicesonly.Thisstudyalso contributes totheliterature ondeinstitutionalisationand com- munitymental healthcarebystudyingthelinkbetweenuseof communityservicesandtypeofhospitaladmission.
2. Methods 2.1. Setting
Norway is a country with 5.2 million inhabitants, a stable economyanduniversalhealthcare.IntheNorwegiandemocratic welfarestate,publicauthoritiesareresponsibleforprovidingand financinghealthservices.ThehealthserviceinNorwayisfunded throughgeneralincometaxandthroughthemandatoryNational InsuranceScheme,andthequalityoftheservicesishigh[15].
Theresponsibilityforspecialistcarelieswiththestate(admin- isteredbyfourRegionalHealthAuthorities),andthemunicipalities areresponsibleforprimarycare.MentalhealthservicesinNorway areprovidedattwolevels:themunicipalitylevel(primaryhealth care)and the specialist level. Municipal responsibility includes prevention,diagnosisandassessmentoffunctionalability,early interventionand rehabilitation,follow-up, psychosocialsupport andcounselling,andreferraltospecialistservices.Norwayiscur- rently divided into428 municipalities; over half of these have fewerthan5000inhabitants,andnearly40%havefewerthan3000 inhabitants.Thereisanongoingpoliticaldebateaboutmergersof
municipalitiesintolargerunitstostrengthentheireconomicpoten- tialandtoimprovetheprovisionofservices.
At the specialist level, there are district psychiatric centres (DPCs)andhospitals.The75DPCsaroundthecountryarerespon- sibleforprovidingspecializedmentalhealthservicesintheform ofoutpatient,ambulatoryorinpatienttreatment.TheDPCsassist themunicipalmentalhealthserviceswithcounsellingandensure continuityinspecialistservices.Onaverage,eachDPCcoversmore thanfivemunicipalities.Thehospitalsareresponsibleforspecialist healthservicesthatcanonlybeperformedathospitallevel,such assecurewards,closedemergencydepartmentsandsomeother limitedfunctions.
In total,specialist mental health servicesinNorway employ about21,000full-timeequivalents,whilementalhealthservicesin themunicipalitiesemployabout14,000(i.e.,about7person-years perthousandinhabitantsin2015).
Thelong-termpolicyhasbeentoshiftactivityfromhospitals toDPCs,andfrominpatienttreatmenttooutpatientandambula- toryactivity[16].In1998,theNorwegianparliamentadopteda 10-yearNationalProgrammeforMentalHealth,callingformajor investment,expansionand reorganizationoftheservices.There wasa39%reductioninthenumberofinpatientpsychiatricbedsin Norwaybetween1998and2015.Ofthe3664bedsinadultmental healthservicesin2015,54%wereinhospitals,42%wereinDPCs, and4%wereinnursinghomesandotherinstitutions.Thenumber ofoutpatientconsultationsperinhabitanthasincreasedby167%
from1998to2015,andin2015,86%ofconsultationsoccurredat DPCswiththerestathospitals[17].
2.2. Design
Acomprehensivenationalmappingofpatientswasconducted inallpsychiatricwardsanddepartmentsprovidinginpatienttreat- ment on a specific date in 2012. Each patient’s clinician was responsible for completingthe form.This studycomprised full mappingconductedonbehalfofthenationalhealthauthorities.
Written consentwasobtainedfrom thepatients, but theclini- ciancompletedtheformsforallpatients,includingthosewhodid notgivetheirconsent.Inthelattercase,nopersonalidentifica- tionnumberwascollected.Thedatawerenotcombinedwithany datafromregistersinthecurrentstudy,soallmappingformswere included.ThestudywasapprovedbytheRegionalCommitteefor MedicalandHealthResearchEthics(2012/848/REKmidt).
2.3. Datacollection
Thetargetedparticipantgroupcomprisedallinpatientsona givenday(20November2012).Allmentalhealthservicesinpub- licandprivatesectorswereinvitedtoparticipate.Severalmonths priortothemapping,theservicemanagersandcliniciansreceived informationthatdescribedtheprojectandthedatacollectionpro- cedures.Becauseofinformationtechnologyfirewallrestrictionsat theinstitutionsandclinics,itwasnotpossibletocollectthedata electronically,soalloftheunitsreceivedprintedformsaccording tothenumberofpatientsregisteredatthesametimeinthepre- viousyearplus20%incasethenumberofpatientshadincreased.
Theclinicianscompletedoneformperpatient.Excludingthosewho wereexpectedtoreactnegatively,patientswereinvitedtopartic- ipateinthecompletionoftheform,buttheclinicianratherthan thepatientansweredthequestionsduringthemapping.Overhalf ofthepatients(55%)participatedinthecompletionoftheirforms.
Thecompletedformswerereturnedbyregisteredmailtoacom- panythatscannedalloftheformsandperformedcoarsequality control.Furtherqualitycontrolofthedatafileswasperformedby theprojectteam.
2.4. Variables
Theregistrationformwassixpageslongandconsistedofawide rangeoftopics, suchasprevioususeofservices,main andsec- ondarydiagnoses(InternationalClassificationofDiseases,ICD-10), voluntary/involuntarycommitment,demographicscharacteristics (includinggender,age),socioeconomiccharacteristics(including mainsourceofincome,education)andfamilyinformation,placeof residenceandcountryofbirth.
TheICD-10two-digitcodesweregroupedinthefollowingdiag- noses: Substance usedisorders (F10-F19), Schizophrenia (F20), Schizoaffectivedisorder(F25),Otherpsychoticdisorders(F29,F23), Bipolardisorder(F31),Majordepression(F32-F34),Anxietydisor- ders(F40-F42),Reactiontoseverestressandadjustmentdisorders (F43),Hyperkineticdisorder(F90),Eatingdisorders(F50),Person- alitydisorders(F60-F61+F21)andOther(allotherdiagnoses).
Typeof admissionwas definedby two questions: “Wasthe patientadmittedforemergency/urgenthelp?”,and“Atthetimeof admission,hadfewerthan30dayspassedsincethepatientwaslast discharged?”Theanswerstobothquestionsweresimply“yes”or
“no”.Legalreferralinformationwasusedtoidentifypatientswho wereinvoluntaryadmitted.
2.5. Sample
Ninety-fourofthe104inpatientdepartmentsparticipated.Most oftheunitsthatdidnotparticipateweresmallandcitedalackof timeastheirreasonfornotparticipating.Non-participatinginsti- tutionscomprised4%ofallinpatientdaysduring2012.
Datawerereturnedfor2358patients.Basedondatafromthe NationalPatientRegisterforthenumberofinpatientsthespecific date(N=3618),weestimatedthatatleast65%ofallinpatientson thegivendaywereincludedinthemapping.Thisindicatesthat manyoftheparticipatingdepartmentdidnotmapalltheirpatients andtheinclusionratevariedfrom35%to87%betweenthehospital trusts.
2.6. Dataanalyses
ProportionalVenndiagramsandsimplesettheorywasusedto studytheproportion ofdifferenttypes ofadmissions and their combinations.Binomiallogit regressionswereusedtocompare characteristicsofpatientsincludingservicesreceivedduringthe threemonthspriortoadmission.
3. Results
TheproportionalVenndiagramofthesampleisshowninFig.1, andthesizesofthedifferentelementsareshowninTable1.Read- missionsareincludedbecausethisisapotentialqualityindicator.
Becausereadmissionsareoftennoturgent(plannedreadmissions), thisisprobablyaweakqualityindicator.TheshadedareasofFig.1 representtheunplannedadmissions,andthewhiteareasrepresent plannedreadmissions(areaB)andotherplannedadmissions(area outsidethecircles).Allunplannedreadmissionsarealsourgent admissions.
Usingthebasicsettheorysymbols,thefollowingistrue:
1)Emergency admissions (49%)=A∪D∪E∪G 2)Readmissions (21%)=B∪E∪F∪G
3)Involuntary admissions (34%)=C∪D∪F∪G
4)Unplanned admissions=Emergency admissions,involuntary admissions andunplanned readmissions (58%)=
A∪C∪D∪E∪F∪G=Emergency admissions and/orinvoluntary admissions
Fig.1. ProportionalVennDiagramofEmergencyAdmissions,Readmissionswithin 30daysandInvoluntaryAdmissions.Shadedarea=unplannedadmissions.
There were some differences in the composition of type of admissionsbetweenhospitalsandDPCs.While52%ofalladmis- sionsathospitalwardswereurgent,only39%wereurgentinthe DPCs.Involuntaryadmissionsweremuchmorecommonathos- pitalswards(41%) thanDPCs(15%).Thismean thatthere were considerablemoreplannedadmissionstoDPCs(57%)thantohos- pital wards (36%). The main reason for this is that emergency departmentsandsecuritywardsarelocatedatthehospitals.How- ever,therewasaconsiderablerateofunplannedadmissionstoboth hospitalwardsandtheDPCs.
3.1. Descriptivestatistics
Thedescriptivestatisticsaregivenin Table2.Asterisksindi- cate that the univariate analysis shows statisticallydifferences betweenplannedorunplannedtreatmentfor thischaracteristic ofthepatient.Onlythesevariableswereincludedintheregression analysesshownbelow.
3.1.1. Servicesreceivedthreemonthspriortoadmission
Here,wefocusonlyonwhetherthepatientreceivedtreatment orservicesduringthethreemonthspriortotheircurrentadmission anddonotincludeinformationaboutthelengthorcontentofthe treatment.Outpatienttreatmentfrommentalhealthserviceswas receivedduringthethreemonthspriortotheadmissionsfor24%
ofthepatients,whilesomatichospitalserviceswerereceivedby 8%ofpatients.Duringthesameperiod,13%receivedunplanned treatment,definedasurgentorinvoluntarytreatment, while4%
receivedambulatoryservices.
Aboutaquarterofpatientshadoneorseveralconsultationswith theirGPduringthethreemonthspriortotheiradmission,and5%
ofallpatientshadahousingservice(withorwithoutstaff)from theirmunicipality.Homeservices,includingbothhomenursing andhomecareservices,werereceivedby8%ofthepatients,while 9%hadconsultationsortreatmentfromtheirlocalmentalhealth service.Welfareserviceswereprovidedfor9%ofthesample,while 3%hadsupportfromasupportpersonpaidbythemunicipalityor attendedsupportservicesgiventoagroupofpeoplewithsimi- larneeds.Sixpercentoftheinpatientsattendedanemployment oractivityserviceprovidedbythemunicipalityduringthethree
Table1
ElementsintheProportionalVennDiagram,NumberofPatientsandPercentageofAllPatients.
Area NumberofPatients %ofAllPatients
A(Emergencyadmissions) 440 19
B(Readmissions) 159 7
C(Involuntaryadmissions) 167 7
D(Involuntaryemergencyadmissions) 424 18
E(Emergencyreadmissions) 147 6
F(Involuntaryreadmissions) 46 2
G(Involuntaryemergencyreadmissions) 153 6
Involuntaryand/oremergencyand/orreadmission 1536 65
Involuntary,emergencyand/orunplannedreadmission 1377 58
Plannedadmissionsorplannedreadmissions 822 42
Totalnumberofpatients 2358 100
monthspriortotheiradmission,and3%hadmeetingswiththeirco- ordinatororaresponsibilitygroup(apersonalteamofappointed professionals)inthepre-admissionperiod.
3.1.2. Clinicalcharacteristics
Themostcommonmaindiagnosisamongtheinpatientswas schizophrenia(25%),followedbymajordepression(16%).Bipolar disorderswerethemaindiagnosisfor9%ofthepatients.Thirty- sevenpercentofpatientsweretreatedatDPCs,whiletherestwere treatedathospitalwards(63%).Suicideattemptsinrelationtothe currentstayweremadeby5%ofthepatients;whileahighorvery highriskofbeingviolentwasobservedforanother5%ofthesam- ple.Veryfewindividualshadbothsuicideattemptandhighriskof violentbehaviour(n<5).
3.1.3. Demographicandsocioeconomiccharacteristics
Thesamplehadmarginallymorefemale(52%)thanmale(48%) patients.Thelargestagegroupwas30–39yearsold.
Almosthalfofthesamplehadlowlevelsofeducation(49%),and 64%hadhealth-relatedbenefitsastheirmainsourceofincome.
Thirteenpercent ofthe patientswereresponsible forchildren undertheageof18years,and11%ofthepatientshadbeenborn outsideNorway.Twenty-fourpercentofthesamplelivedinthe largestcityintheregion.
3.2. Regressionresults
Table3showstheregressionresultsfromthebinomiallogis- tic regression. Five models were estimated: 1) Probability of unplannedadmissionin associationwithservicesreceiveddur- ingthethree monthsprior toadmission;2)Model1controlled forclinicalvariables;3)Model1controlledforclinicalvariables anddemographicvariables;4)Model1controlledforclinicalvari- ables, demographic variables and socioeconomic variables; and 5) Model 1 controlled for clinical variables, demographic vari- ables and socioeconomic variables, reduced model (excluding non-significantvariableswithp>0.05).
Theresultsaregenerallystableacrosstheestimatedmodels.
Theresultsshowthathavingreceivedoutpatienttreatmentduring thethreemonthspriortoadmissionreducestheprobabilityofhav- ingunplannedadmissionscomparedwithplannedadmissionsin allmodels.Patientswithoneormoreunplannedadmission(urgent and/orinvoluntary)duringthethreemonthspriortoadmissionhad astrongincreaseintheriskofunplannedadmission,afindingthat heldthroughoutthemodelspecifications.Patientswhoreceived housingservicesfromthemunicipalityhadamuchhigherriskof unplannedadmissionthanpatientswhodidnotreceivehousing services.Havinganeedforhousingservicesisprobablyaproxy forhavingalowfunctionallevel;theestimatewasreducedwhen diagnosiswascontrolledfor,buttheassociationprevailedthrough- outthemodelspecifications.Patientswhoreceivedhomeservices (homenurseorhomecare)priortoadmission,hadalowerprob-
abilityofunplannedadmissionthanthosewithoutsuchservices.
Havingcontactwithasupportpersonorasupportgrouppriorto admission,andreceivingserviceswithinemploymentandactivity, reducedtheprobabilityofunplannedadmission.
Patients suffering fromcomorbid substance use and mental disordershadalowerprobabilityofunplannedadmissionsthan patients suffering from schizophrenia, while patients suffering fromschizoaffectivedisorderorotherpsychoticdisordersdidnot differfromthose sufferingfromschizophrenia.Patientswithall otherdiagnoseshad ahigherprobabilityof plannedadmissions thanpatientssufferingfromschizophrenia,withthehighestrateof plannedadmissionsandplannedtreatmentfoundamongpatients sufferingfromeatingdisorders.
Theregressionresultsalsoshowthatthereisahigherriskof unplannedtreatmentcomparedtoplannedtreatmentinhospital wardscomparedtoDPCs.Thisisasexpectedassecurewardsand closedemergencydepartmentsareplacedatthehospitals.
Patientswithasuicideattemptinrelationtothecurrentstay andpatientswithahighriskofbeingviolenthadamuchhigher riskofunplannedadmissionthanpatientswithnosuchbehavioural problems.Loweducationincreasedtheriskofunplannedadmis- sioncomparedwithplannedadmissions.Inthissample,11%ofthe patientsarebornoutsideNorway.Theresultsshowthatpatients bornoutside Norwayhasahigher riskof unplannedadmission comparedtoplannedadmissions.
4. Discussion
Ourassumptionisthatplannedtreatmentismoreeffectivethan treatmentprovidedwithoutaplan,andthatreducingthenum- berof beds in inpatient treatmentwithoutproviding adequate localalternativesmaygivea situationwhereelective treatment aresupersededbyurgentneeds.
Therewasa39%reductioninthenumberofinpatientpsychiatric bedsinNorwaybetween1998and2015.Thelocalmentalhealth serviceshavenotbeenstrengthenedenoughtoaccommodatethis reducedcapacityinspecialistmentalhealthservicesaccordingto theNorwegianOfficeoftheAuditorGeneral[18]. Thesamesit- uationwasobservedinforinstanceEngland:a39%reductionof inpatientpsychiatricbedsbetween1998and2012[19]withan inadequateandslowinvestmentincommunityservices[3].
Ourresultsshowthatreceivingoutpatienttreatment,consul- tationswithaGP,homeservicesandsupportfromtheprimary servicesincludingemploymentandactivityservicespriortoadmis- sionareassociatedwithahigherprobabilityofplannedadmissions, even when clinical,demographic and socioeconomiccharacter- isticsarecontrolledfor.Wealsofoundthatpreviousunplanned admissionduringthethreemonthspriortothecurrentadmission increasedtheprobabilityof unplannedadmission. Previousser- viceuseforinpatienttreatmenthascommonlybeenfoundtobea strongpredictorforrequiringinpatienttreatment[20,21]andfor
Table2
DescriptiveStatisticsofPlannedandUnplannedadmissionstoDPCsandHospitalWards,asPercentageofallPatients.
DPCs HospitalWards
Planned Unplanned Planned Unplanned All Specialisthealthservicesreceivedduringthe3monthspriortoadmission:
Outpatienttreatmenta 33 23 31 16 24
Somatichospitalservices 8 8 10 8 8
Unplannedtreatment(urgentorinvoluntary)a 9 18 5 17 13
AmbulatoryTeamfromDPC/municipality 10 10 6 8 4
Municipalityservices/primaryhealth-careservicesreceivedduringthe3monthspriortoadmission:
GPa 41 34 38 20 24
Housinga 8 10 7 14 5
Homeservices(homenurseorhomecare)a 12 9 14 8 8
Consultation/treatmentfromlocalmentalhealthservicesa 22 18 11 10 9
Welfareservices 22 17 12 15 9
Supportpersonorsupportgroupa 5 2 4 3 3
Workand/oractivitya 15 10 7 5 6
Responsibilitygroup 7 4 3 6 3
Maindiagnosisa
Comorbidsubstanceusedisordersandmentaldisorders 5 5 2 5 5
Schizophrenia 15 26 10 37 25
Schizoaffectivedisorder 3 6 1 5 4
Otherpsychoticdisorders 3 5 5 8 6
Bipolardisorders 13 8 5 10 9
Majordepression 16 19 21 8 14
Anxietydisorders 6 3 5 1 3
Reactiontoseverestressandadjustmentdisorders 8 7 8 3 6
Hyperkineticdisorder 3 1 1 0 1
Eatingdisorders 2 0 11 1 3
Personalitydisorders 8 3 4 3 4
Other 19 17 27 19 20
Treatmentunita
DPC 57 43 37
Hospital 36 64 63
Behaviourvariables Suicideattempta
No 97 94 98 93 95
Yes 3 6 2 7 5
High/veryhighriskofbeingviolenta
No 99 98 98 89 95
Yes 1 2 2 11 5
Demographicvariables Gendera
Women 56 53 64 44 52
Men 44 47 36 56 48
Agegroupa
18–23yearsold 16 12 15 16 15
24–29yearsold 16 13 13 16 15
30–39yearsold 22 22 16 24 21
40–49yearsold 18 24 13 17 18
50–59yearsold 19 16 12 13 14
60–69yearsold 8 8 9 8 8
70+yearsold 2 4 22 7 8
Socioeconomicvariables Educationa
Highlevelofeducation 14 16 22 12 15
Mediumlevelofeducation 44 38 35 32 36
Lowlevelofeducation 42 47 43 56 49
Mainsourceofincomea
Incomefromlabour 10 11 13 8 10
Health-relatedbenefits 74 69 46 66 64
Othereconomicsupport 16 20 41 26 26
Responsibleforchildrenunder18yearsa
No 83 86 86 90 87
Yes 17 14 14 10 13
BornoutsideNorwaya
No 92 89 92 86 89
Yes 8 11 8 14 11
Liveinalargeandcentralmunicipalityintheregiona
No 79 77 79 73 76
Yes 21 23 21 27 24
aStatisticallyassociatedwithunplannedadmissionsatp<0.005inunivariatemodels.
Table3
BinomialLogisticRegressionandOddsRatiosusingPlannedAdmissionsastheBaseOutcome.
Model1 Model2 Model3 Model4 Model5
Servicesreceivedduringthe3monthspriortoadmission
Outpatienttreatment 0.468*** 0.551*** 0.521*** 0.534*** 0.538***
(0.380–0.576) (0.437–0.694) (0.411–0.661) (0.420–0.680) (0.426–0.678) Unplannedadmission(urgentand
orinvoluntary)
3.481*** 2.905*** 2.728*** 2.767*** 2.837***
(2.573–4.709) (2.096–4.027) (1.956–3.805) (1.978–3.870) (2.044–3.939)
GP 0.526*** 0.770* 0.756* 0.774* 0.803*
(0.432–0.640) (0.619–0.958) (0.604–0.947) (0.617–0.972) (0.645–0.999)
Housing 2.329*** 1.760** 1.792** 1.740** 1.695**
(1.691–3.206) (1.248–2.483) (1.259–2.550) (1.217–2.486) (1.198–2.397) Homeservices(home
nurseorhomecare)
0.697* 0.596** 0.703* 0.708 0.697*
(0.511–0.950) (0.429–0.828) (0.496–0.998) (0.498–1.005) (0.497–0.978) Consultation/treatmentfromlocal
mentalhealthservices
0.905 0.966 0.898 0.878
(0.690–1.187) (0.719–1.296) (0.664–1.212) (0.649–1.189) Supportpersonor
supportgroup
0.682 0.623 0.621 0.608 0.570*
(0.409–1.136) (0.361–1.076) (0.356–1.083) (0.347–1.065) (0.330–0.986)
Workand/oractivity 0.620** 0.695* 0.698 0.692 0.680*
(0.445–0.865) (0.486–0.994) (0.483–1.007) (0.478–1.002) (0.475–0.974) Maindiagnosisandunitoftreatment(base:Schizophrenia)
Comorbidsubstanceusedisorders andmentaldisorders
0.576* 0.603* 0.601* 0.580*
(0.359–0.927) (0.371–0.979) (0.369–0.980) (0.360–0.933) Schizoaffective
disorder
1.316 1.485 1.496 1.402
(0.738–2.346) (0.804–2.742) (0.808–2.772) (0.783–2.510) Otherpsychotic
disorders
0.821 0.855 0.854 0.846
(0.524–1.288) (0.536–1.365) (0.533–1.368) (0.538–1.331)
Bipolardisorders 0.509*** 0.536** 0.561** 0.561**
(0.354–0.733) (0.366–0.785) (0.379–0.830) (0.387–0.812)
Majordepression 0.285*** 0.332*** 0.344*** 0.341***
(0.206–0.393) (0.235–0.469) (0.239–0.493) (0.245–0.476)
Anxietydisorders 0.157*** 0.179*** 0.180*** 0.174***
(0.0855–0.287) (0.0965–0.331) (0.0960–0.337) (0.0942–0.32) Reactiontoseverestressand
adjustmentdisorders
0.247*** 0.260*** 0.263*** 0.251***
(0.160–0.383) (0.167–0.406) (0.165–0.418) (0.162–0.391)
Hyperkineticdisorder 0.160*** 0.138*** 0.143*** 0.168***
(0.0572–0.445) (0.0467–0.410) (0.0477–0.428) (0.0601–0.47)
Eatingdisorders 0.0329*** 0.0363*** 0.0379*** 0.0339***
(0.0143–0.0755) (0.0155–0.085) (0.0161–0.089) (0.015–0.078)
Personalitydisorders 0.182*** 0.194*** 0.194*** 0.182***
(0.110–0.299) (0.115–0.326) (0.115–0.328) (0.110–0.301)
Otherdiagnoses 0.294*** 0.337*** 0.345*** 0.331***
(0.221–0.392) (0.249–0.457) (0.251–0.473) (0.247–0.443) Treatedinhospital
(base:DPCs)
2.548*** 2.688*** 2.684*** 2.749***
(2.094–3.101) (2.187–3.304) (2.181–3.304) (2.249–3.360) Behaviouralrisk
Suicideattempt 4.327*** 4.253*** 4.325*** 4.313***
(2.548–7.348) (2.495–7.250) (2.533–7.388) (2.536–7.337) High/veryhighriskof
beingviolent
3.853*** 3.750*** 3.481*** 3.320***
(2.004–7.411) (1.887–7.453) (1.746–6.939) (1.720–6.407) Demographicandsocioeconomicvariables
Male(vsfemale) 1.061 1.037
Age(base:18–23yearsold) (0.865–1.302) (0.844–1.275)
24–29yearsold 0.828 0.858
(0.575–1.191) (0.590–1.247)
30–39yearsold 0.980 1.039
(0.699–1.372) (0.726–1.488)
40–49yearsold 1.102 1.186
(0.773–1.569) (0.812–1.733)
50–59yearsold 0.808 0.874
(0.561–1.164) (0.596–1.281)
60–69yearsold 0.958 1.051
(0.626–1.467) (0.681–1.621) 70+yearsold(Model1–4)Dummy
for70+(Model5)
0.472*** 0.510** 0.502***
(0.304–0.731) (0.320–0.811) (0.352–0.715) Mediumeducation(base:high
levelofeducation)
1.211 1.273
(0.897–1.634) (0.955–1.696) Loweducation(base:highlevelof
education)
1.368* 1.388*
(1.007–1.858) (1.044–1.845) Health-relatedbenefits(base:
Incomefromlabour)
0.898 (0.636–1.268) Othereconomicsupport(base:
Incomefromlabour)
0.874 (0.587–1.301)
Table3(Continued)
Model1 Model2 Model3 Model4 Model5
Responsibleforchildrenunder18 years
0.946 (0.688–1.299)
BornoutsideNorway 1.419* 1.435*
(1.014–1.985) (1.035–1.989) Liveinalargeandcentral
municipalityintheregion
0.986 (0.775–1.254)
Constant 1.822*** 1.975*** 1.967*** 1.596 1.391
(1.624–2.043) (1.532–2.547) (1.333–2.902) (0.899–2.834) (0.972–1.990)
Observations 2358 2358 2251 2251 2358
Confidenceintervalsinparentheses***p<0.001,**p<0.01,*p<0.05.
long-termuseofservices[22].Treatmentapproachesthatpromote empowermentinindividualswithahistoryofinvoluntarypsychi- atrichospitalizationsasapreventivemonitoringprogrammeare suggested[23].
Fewerbedsinpsychiatricinpatienttreatmentindicatethatthe remainingcapacitymustbeutilizedefficiently.Whenmorethan halfoftheadmissionsareunplannedadmissions,theelective(and presumablymoreefficient)treatmentsareatriskofbeingsuper- seded.Thepoliticalgoalshouldprobablybetoreducethenumber ofunplannedadmissionsandtoincreaseplannedadmissionsto increase thetreatmenteffect oftheservice, whichis becoming increasinglyscarce.
Topreventunplannedadmissions,thelocalservicesmustprior- itizepeopleathighriskofunplannedadmissions;thatis,patients sufferingfromseverementalillness,thosewithalowfunctional levelasindicatedbytheneedforhousingservices,thosewithprevi- ousunplannedadmission(urgentandorinvoluntary),thoseathigh riskforsuicideattemptsorbeingviolent,thosewithloweducation levelsandthosebornoutsideNorway.
Educationandincomeareimportantcharacteristicsofsocioe- conomicstatus(SES),andithasbeenfoundthatlowSESincrease all-cause mortality mainly through unhealthy behaviours [24].
However,it hasbeenargued thateducation, incomeand other commonly used SEScharacteristics, measure differentunderly- ingphenomena[25].We findthateducationismoreimportant thanincomeinthestudyofunplannedmentalhealthtreatment compared toplannedmentalhealth treatment.Thisresultmay indicatethateducationisamoreimportantSEScharacteristicthan incomeamongpatientsinmentalhealthservicesinNorway.Thisis probablyreasonableinahighlydevelopedwelfarestatewithgen- erousmedicalbenefitsincaseofsickness.Ourstudyshowsthat patientsbornoutsideNorwayhavehigherriskofunplannedcom- paredtoplannedadmissionthanpatientsborninNorway.Urgent and involuntaryadmissions imply more severe illness and this mayberelatedtosystematicdifferencesinhelpseekingbehaviour.
Previousresearchfoundthatimmigrantshaveloweroddsofacon- sultationaboutmentalhealthissuesinprimaryhealthcarethan theirNorwegiancounterparts[26].
Thespecialistmentalhealthservicesmust,fortheirpart,sup- porttheeffortsmadebylocalservices,givethemthenecessary support, including counselling and short inpatient stays when needed,andprovideresourcesforambulatoryteamstosupportthe preventiveeffortandtoavoidunplannedadmissions.Thisseems tobetheonlywaytoincreasethecapacityforelectivetreatment inthe specialistmental health services,andneitherof theser- viceproviderscanachieve thisalone.Giventhehighershareof unplannedadmissionsinhospitalscomparedtoDPCs,alsohospi- talwardsshouldworkcloselywiththelocalservicestoprevent unplannedadmissionsfortheirpatients.
Userinvolvement—forinstancetheopportunitytoreferthem- selvesforashortinpatientstay—shouldbemademoreavailable, asfindingsshowthatgoodpatientexperiencescanresult[27].
ArecentstudyfromNorwayshowedthatAssertiveCommunity Treatmentteamsreducepresumablyavoidablehospitalizationof highusersandincreasethepresumablyneededinpatientcareof lowusers[28].SimilarresultshavebeenfoundinEngland[29].
Theresultsindicatethatunplannedadmissionsmightbeanade- quatequalityindicatorforco-operationbetweenthetwoservice levelsofmunicipalitiesandspecialistmentalhealthservices.To substituteunplannedadmissionswithplannedadmissions,strong and systematic co-operationbetween theservice levelsis nec- essary.Includingbothservicelevelsinaqualityindicatormight provideameasureofhowwelltheservicelevelsareoperatingcol- lectively.Currently,mostperformanceindicatorstrytomeasure thequalityofonlythespecialistlevel.Thereisalargegeographic variation intherateof unplannedadmissions,both urgentand involuntary [17]. The specialist mental health servicesand the municipalityservicesineachgeographicareashouldplanandact toreduceunplannedadmissions,takingintoaccounttheneedsin thepopulationineacharea.
Onepossibleweaknessofthisindicatoristhatincreasingthe number of bedswould probably reduce the rate of unplanned admissions,thusincreasingthequality.However,thisisanunlikely scenariobecausethereisalackofeconomicandpoliticalincentives.
AmorelogicalstrategywouldbetoestablishAssertiveCommunity Treatmentteamsorotherteamsinco-operationwiththemunici- palitiestoreduceunplannedadmissions.
Anothercomplicatingfactoristhesystemoffinancing,because theservice levelsdo not sharethe samebudget.This couldbe mitigatedbymakingbothbudgetsdependentonthejointquality indicator.Today,theincentivesforstrongco-operationbetween theserviceslevelsseemtobeweakandinsufficient, andthisis supportedbythefindingsoftheNorwegianOfficeoftheAuditor Generalpublishedin2015[18].
4.1. Strengthandweaknesses
The study compared unplanned admissions with planned admissions.Wedonotsayanythingabouttheprobabilityofbeing admitted,asotherdatawouldberequiredforsuchanalysis.
Inthistypeofmappingorcensus,patientsinlong-termtreat- mentwerelikelytobeincludedbecausetheyweremorelikelyto receivetreatmentatanygiventime.Amajorstrengthofthisstudy wasthatitincludedthemajorityofinpatientsreceivingspecialist mentalhealthservicesinNorwayandinformationaboutservices theyreceivedfromthemunicipalitypriortotheadmission.Each patient’sclinicianwasresponsibleforcompletingtheregistration form.Thequalityofthedataisconsideredtobefairlygoodbecause manyclinicianswerefamiliarwiththemethodologyfromsimilar nationalmappingsthathavebeenconductedeveryfiveyearssince 1979.Nevertheless,ourstudyclearlyisnotfreeoflimitations.Ifthe inclusionofpatientsbycliniciansinthemappingwasrandom,then ourdatasetisarepresentativesample.Onelimitationisthatwedo nothaveinformationaboutthepatientswhowerenotincluded inthemapping.Itispossiblethatinpatientswhowereadmitted
ordischargedonthemappingdaywerelesslikelytobemapped.
Becausethedataalsoserveaspartofthebaselinedatafortheeval- uationoftheCo-ordinationReform,theformtobefilledoutby clinicianswasratherlong,whichmayhavecontributedtoalower qualityofanswers.
5. Conclusion
Ashiftfromunplannedtoplannedcarewillonlybepossible withbetterco-operationbetweenservicelevelstopreventurgent andinvoluntaryadmissions.Havingreceivedoutpatienttreatment, consultationswithaGP,homeservicesandsupportfromthepri- maryservices,includingemploymentand activityservicesprior toadmission,areassociatedwithahigherprobabilityofplanned admissionsaftercontrollingforclinicalandsocioeconomiccharac- teristics.
Primaryandsecondaryhealthservicesshouldworktoprevent unplannedcareandtoprovidetreatmentatthesitebestsuitedto thepatient’sneeds.Makingeffectiveuseofbothprimaryandsec- ondaryhealth-careskillsandcompetencemayreduceunplanned admissionsforinpatienttreatmentandimprovetheoverallquality oftheservices.
Sourceoffunding
The Research Council of Norway funded the writing of the manuscript(Grantnumber228991/H10)andthedatacollection wasfundedbyTheNorwegianDirectorateofHealth.
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