Tool Helps Identify Psychiatric Inpatients at Readmission Risk

Megan Brooks

November 02, 2015

LAKE BUENA VISTA, Florida ― A simple tool may help determine the risk for readmission following a psychiatric inpatient stay, according to results of a pilot study.

"There is a huge need to figure out who is at high risk for psychiatric readmission. The tool we developed successfully identified patients with an elevated risk for readmission," Sarah Carpenter, APRN, from the Mayo Clinic, in Rochester, Minnesota, told Medscape Medical News.

Carpenter presented the findings at the American Psychiatric Nurses Association (APNA) 29th Annual Conference. Her poster won first place in the "Practice" category.

Evidence-Based Approach

The tool was developed using an evidence-based approach, which combined a literature review and a chart review of readmitted patients with expert opinion.

From the literature review, several "well-supported" risk factors for psychiatric readmission emerged, including numerous psychiatric hospitalizations, active psychosis, substance use/dual diagnoses, medical comorbidities, homelessness, lack of social support/stable living environment, younger age at illness onset, and suicidality.

"Less-supported" risk factors were educational level, cognitive abilities, medication nonadherence.

The chart review revealed several common factors associated with 30-day readmission ― namely, being single, unemployed/disabled, or homeless, having a diagnosis of psychotic disorder or major depression, historical/current substance abuse, and more than five previous psychiatric readmissions.

"The tool was created to be objective; either the risk factor was present or it was not," Carpenter said. Patients with a score of 0-3 fall into the low-risk category for readmission; those with a score of 4-6 are at moderate risk; a score of 7 or higher indicates a high risk for readmission.

In a pilot trial, six social workers used the risk stratification tool for 1 month at three adult inpatient psychiatric units involving a total of 108 patients; 30% of patients were in the low-risk category, 33% were in the moderate-risk category, and 37% fell in the high-risk category.

"We found that there was a statistically significant level of agreement between readmission and risk level within 30 and 60 days of discharge; more high-risk people were readmitted than moderate- and low-risk people," Carpenter told Medscape Medical News. The percentage of patients readmitted within 60 days was roughly 6.5% for low-risk, 8% for moderate-risk, and 17.5% for high-risk patients.

There was also a statistically significant difference in mean risk score between those who were and were not readmitted at 30 and 60 days, "meaning that higher-scored people were readmitted more often than lower-scored people, so the tool was effective in identifying high-, moderate-, and low-risk people, Carpenter explained.

Table. Mean Scores by Readmission Status

  Not Readmitted Readmitted P-value
30 days 5.43 7.44 .039
60 days 5.41 7.08 .068

 

The authors note in their conference poster that because fewer patients were readmitted than were not readmitted at 30 and 60 days, a P-value of <0.1 is considered statistically significant.

Readmission Common, Costly

Hospital readmissions cost the United States billions of dollars, and mood disorders and psychotic illnesses are among the top diagnoses for hospital readmission, Carpenter noted. Being able to target high-risk individuals will allow more targeted interventions. "Instead of doing interventions for everyone, we want to do certain interventions for the high-risk people, which would use our resources more wisely in addition to hopefully reducing readmission rates," Carpenter commented.

"We are part of a statewide initiative to reduce avoidable readmissions, and this is one piece of the project to objectively identify who is at high risk for readmission vs who is at moderate and low risk. The ultimate goal is to reduce readmissions overall, although that wasn't the aim of this particular piece of the project," Carpenter said.

"The bottom line is that 30-day psychiatric readmissions are common ― probably about 1 in 10 patients are readmitted within 30 days. This is fairly consistent across Canada, the US, and the UK," Simone Vigod, MD, Department of Psychiatry, Women's College Research Institute and Women's College Hospital at the University of Toronto, Ontario, Canada, who was not involved in the study, told Medscape Medical News.

"Readmission so quickly after discharge probably represents either severity of condition at discharge and/or problems with transition of care to the community," Dr Vigod noted.

Dr Vigod and her colleagues have created a clinical risk index tool called READMIT to help predict psychiatric inpatients' risk for readmission within 30 days. "We created READMIT so that we could identity patients who might be at highest risk and benefit most from intervention, and we are now working on proposing clinical evaluations of some interventions to assess their efficacy in Ontario," she told Medscape Medical News.

The study had no commercial funding. The authors and Dr Vigod have reported no relevant financial relationships.

American Psychiatric Nurses Association (APNA) 29th Annual Conference. Poster 61. Presented October 29, 2015.

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