|Year : 2021 | Volume
| Issue : 4 | Page : 169-174
Frequency of psychiatric readmission causes and associated risk factors: A retrospective cross-sectional study in Qazvin, Iran
Fatemeh Kazemi1, Mostafa Rajabi2, Seyedeh Zahra Hashemi3, Monirsadat Mirzadeh4, Faezeh Zahedian3
1 Faculty of Medicine, Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran
2 Children Growth Research Center, Research Institute for Prevention of Noncommunicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
3 Department of Psychiatry, Clinical Research Development Unit, 22 Bahman Hospital, Qazvin University of Medical Sciences, Qazvin, Iran
4 Metabolic Diseases Research Center, Research Institute for Prevention of Noncommunicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
|Date of Submission||08-May-2021|
|Date of Decision||20-Jul-2021|
|Date of Acceptance||12-Aug-2021|
|Date of Web Publication||29-Sep-2021|
Seyedeh Zahra Hashemi
Department of Psychiatry, Clinical Research Development Unit, 22 Bahman Hospital, Qazvin University of Medical Sciences, Qazvin
Source of Support: None, Conflict of Interest: None
Introduction: Readmission after discharge is recognized as one of the major indicators of the quality of care provided in hospitals. Recurrent hospitalization is common among patients in psychiatric wards and is caused by a myriad of factors. The present study aimed to identify the causes of readmission and associated risk factors in patients with a history of recurrent hospitalization in 22 Bahman Psychiatric Hospital in Qazvin, Iran. Methods: This retrospective cross-sectional study was performed by the census method in Psychiatric Hospital in Qazvin, Iran, on all the patients who were admitted at least three times from 2015 to 2019. The following data were extracted from patient profiles using certain checklists: age, gender, educational level, residential location, occupation, marital status, clinical diagnosis, number of hospitalizations, duration of disease, intervals between admissions, substance abuse, regular outpatient visits, and regular use of medications. Data were analyzed in SPSS software (version 22). A P < 0.05 was considered statistically significant. Results: The current study was conducted on 182 patients with a history of readmission who were selected by the census method. The majority of subjects (n = 131) were male, and their mean age score was reported as 39.96 ± 10.41 years. Furthermore, the most frequent clinical diagnosis based on which the patients were admitted included bipolar I disorder (manic phase) (29.7%) and schizophrenia (22.2%), respectively. The number of hospitalizations was significantly correlated with education level (0.013), marital status (0.012), residential location (0.049), intervals between admissions (0.009), follow-up pattern (<0.001), and treatment pattern (<0.001). Conclusion: As evidenced by the results of the present study, clinical diagnosis, education level, marital status, residential location, intervals between admissions, treatment patterns, and follow-up patterns of patients were effective in the frequency of recurrent hospitalization in patients with mental disorders.
Keywords: Psychiatry, readmission, risk factors
|How to cite this article:|
Kazemi F, Rajabi M, Hashemi SZ, Mirzadeh M, Zahedian F. Frequency of psychiatric readmission causes and associated risk factors: A retrospective cross-sectional study in Qazvin, Iran. Asian J Soc Health Behav 2021;4:169-74
|How to cite this URL:|
Kazemi F, Rajabi M, Hashemi SZ, Mirzadeh M, Zahedian F. Frequency of psychiatric readmission causes and associated risk factors: A retrospective cross-sectional study in Qazvin, Iran. Asian J Soc Health Behav [serial online] 2021 [cited 2021 Oct 24];4:169-74. Available from: http://www.healthandbehavior.com/text.asp?2021/4/4/169/326953
| Introduction|| |
Readmission after discharge is recognized as one of the major indicators of the quality of care provided in hospitals. High frequency of readmission may lead to various consequences, such as social pressures, increased patient costs, and economic burden on the health care system., Based on the related studies, it was estimated that in 2004, 17.4 billion dollars were spent on hospitalized patients who were readmitted within 30 days after discharge, and 60% of hospital costs were related to readmissions., This issue also exacerbates the shortage of beds in psychiatric hospitals, especially in developing countries. In addition, readmission causes severe psychological disorders and distress for patients and their families. If the course of the disease is worsened, it may lead to loss of social and occupational function of patients, necessitating the adoption of new treatment options.,,
Furthermore, the frequency of readmission is an indicator to evaluate recurrence or complications after hospitalization, type of disease, the impact of environmental factors, discharge with inadequate postdischarge care, early discharge, as well as lack of response to treatment, adherence to treatments, and coordination or follow-up by outpatient clinics.,, Based on available studies, the prevalence of readmission in psychiatric wards has been reported from <10% to more than 80% and periods from 1 month to 7 years. Therefore, it can be concluded that readmissions in psychiatric wards are caused by different factors which are highly crucial to be investigated.
The risk factors identified by psychiatrists include male gender, marital status, educational level, poor economic status, diagnosis of schizophrenia and seasonal affective disorder, severe symptoms and disorders in self-care, younger age at first admission, use of restrictors and inhibitors at admission, number of previous admissions, alcohol poisoning, and putting others at risk at initial admission.,,, In addition, the type of disease in patients admitted to psychiatric wards is also effective in their readmission. In studies that only included patients with schizophrenia, the risk of readmission was higher than other diseases. The risk factors included the number of previous admissions, substance abuse, lack of adherence to medication after discharge, lack of complete recovery at the time of discharge, and lack of referring to outpatient clinics for follow-up.
The provision of postdischarge care and patients' follow-up is another factor affecting the readmission rate not only in patients in psychiatric wards but also in all patients. The studies performed in this area pointed out that the provision of appropriate outpatient care and follow-up, along with appropriate care and treatment in hospitals, can affect the readmission rate., Postdischarge follow-up sessions can increase the readiness of the care team to address the immediate postdischarge care needs of patients, such as assessing the clinical condition and intensifying treatment if necessary, evaluating the medications, as well as educating the patient and family, which can prevent readmission in patients.
There is a dearth of studies on the risk factors affecting the readmission of psychiatric patients in Iran. Nonetheless, a better understanding of these factors helps identify patients who are at greater risk of hospital stay and readmission, provides them with more targeted and cost-effective services, and avoids the secondary effects of long-term and frequent hospitalizations, as well as unnecessary costs. In light of the aforementioned issues, the present study was conducted to evaluate the frequency of readmission causes and associated risk factors in patients admitted to 22 Bahman Psychiatric Hospital in Qazvin, Iran.
| Methods|| |
This retrospective cross-sectional study was conducted on patients admitted to 22 Bahman Psychiatric Hospital in Qazvin, Iran from 2015 to 2019. The participants were selected via the convenience sampling method. The inclusion criteria entailed all the patients who had been hospitalized in 22 Bahman Psychiatric Hospital in Qazvin at least three times during 2015–2019. On the other hand, the exclusion criterion was insufficient information in data collection due to incomplete files. After obtaining consent and code of ethics from the Ethics Committee of Qazvin University of Medical Sciences (IR. QUMS. REC.1398.338) and arrangements with hospital officials and full explanation of the objectives of the study and receiving their oral consent, the profiles of all patients with at least three hospitalizations in the target period were extracted from hospital archives.
In order to collect file information, a researcher-made checklist which was reviewed by 30 psychiatrists and residents for validity assessment, was used. After reviewing the profiles, the data was extracted from the profiles by the intern and entered into the relevant checklist. Checklist information included: age, gender, educational level, residential location, occupation, marital status, cause of hospitalization and diagnosis, duration of illness, number of hospitalizations, intervals between admissions, substance abuse, regular outpatient visits (based on information provided by the psychiatric resident in “past psychiatric history” section in patient profile), and regular use of medications. In order to keep the information confidential, data were recorded based on the profile number.
The data collection checklist was completed by an intern based on the information in the medical history collected by the psychiatric resident and the final diagnosis made by a psychiatrist on the first sheet of the profile. After the completion of the checklists and extraction of the required information, the data were categorized for analysis. To analyze the data, the Kolmogorov–Smirnov test was used to determine the normal distribution of data. Moreover, independent t-test and analysis of variance were employed for data with normal distribution, while Mann–Whitney, Kruskal–Wallis, and Chi-square tests were used for data without normal distribution. The data were analyzed using SPSS software (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Crop), and a P < 0.05 was considered statistically significant.
| Results|| |
The current study was conducted on 182 patients with a history of readmission who were selected by the census method. The majority of subjects (n = 131) were male, and their mean age score was reported as 39.96 ± 10.41 years. Other demographic information is presented in [Table 1]. As shown in [Table 1], educational level, marital status, and residential location were significantly correlated with the number of hospitalizations.
|Table 1: Frequency distribution of sociodemographic characteristics of the rehospitalized psychiatric patients (n=182) and its relationship with number of hospitalization|
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Regarding the clinical status of patients, the mean scores of illness duration and the intervals between readmissions of patients were reported as 2.65 ± 1.41 years and 8.35 ± 7.40 months, respectively. The most frequent clinical diagnosis based on which the patients were admitted included bipolar I disorder (manic phase) (29.7%) and schizophrenia (22.2%), respectively, which were not significantly correlated with the number of hospitalizations. Other clinical information is illustrated in [Table 2]. Based on this table, intervals between admissions, follow-up pattern, and treatment pattern were significantly correlated with the number of hospitalizations. Regarding the relationship between the causes of patients' readmission and the number of hospitalizations, marital status, intervals between readmission, treatment pattern, and follow-up pattern were significantly correlated with the number of hospitalizations [Table 3] and [Table 4].
|Table 3: The significance and correlation coefficients between some readmission causes and number of hospitalization|
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|Table 4: The significance and correlation coefficients between some readmission causes and number of hospitalization by regression|
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| Discussion|| |
Hospitals are the most important institution in the field of health services, and we have witnessed an increasing demand for health services over the past years. This highlights the need for the provision of necessary conditions and facilities to meet the needs of patients.,, It is clear that one of the effective ways to meet these needs is to provide appropriate services and prevent readmission of patients which will mitigate the costs of care.,, In order to achieve this goal, the causes of patient readmission and associated risk factors should first be discovered, and the relevant planning can be developed accordingly. Therefore, to determine the frequency of readmission and associated risk factors in 22 Bahman Psychiatric Hospital in Qazvin, Iran, the present study was conducted as an attempt to provide relevant information.
The obtained results pointed out that the number of hospitalizations was significantly correlated with the education level, marital status, and residential location of patients, and 94% of patients had a high school diploma or less education. Consistent with the results of the present research, in a number of studies,,, education level has been mentioned as one of the predictive factors in the frequency of readmission, and a low level of education was related to the high frequency of readmission. In their study, Cristiana et al. referred to higher education as a protective factor against readmissions after discharge. The effect of education on understanding the importance of adherence to treatment deserved assiduous consideration. A review article by Machado et al. pointed out that the people who are deprived of citizenship rights, such as access to higher levels of education, are generally the ones who are readmitted. Deprivation of these rights may be associated with cognitive and social disorders resulting from the development of chronic mental disorders.
Furthermore, in line with the findings of the current study regarding the relationship between marital status and the number of hospitalizations, various studies,, indicated the protective effect of marriage and family support against readmission, highlighting the importance of emotional support from people living with the patient. In terms of the relationship between residential location and the number of hospitalizations, studies pointed to the effective role of residential location in the number of hospitalizations. In this regard, people living in cities have a higher rate of readmission, as compared to those residing in rural areas. This finding is consistent with the results of the present study. This can be attributed to rural people's lack of access to hospitals for readmission and their more tolerance, as well as faster identification of symptoms in patients living in cities and faster transfer to hospitals for treatment.
Regarding the follow-up pattern and its relationship with the number of hospitalizations, regular outpatient visits had a significant relationship with the number of hospitalizations. This finding is in accordance with the results of a study by Donisi et al. and systematic review articles by Kalseth et al. and Donisi et al. This result can be ascribed to regular monitoring of the patient and the prevention of problems that may lead to readmission.
Adherence to treatment and regular treatment patterns were significantly correlated with readmission in the present study. The frequency of readmission was higher in patients who did not follow the treatment properly and did not follow a regular pattern, compared to other patients. This is in agreement with the results of studies by Al-Shehhi et al., de Castro et al., and Barnett et al. Nonadherence to treatment is a common problem among psychiatric patients, especially schizophrenic patients. It usually occurs due to improper follow-up after hospital discharge, indicating poor follow-up of psychiatric patients. Considering the effect of regular follow-up patterns on the use of medications and the frequency of readmission, discovering the causes of nonadherence to follow-up and performing outpatient visits after discharge to eliminate these causes can reduce the frequency of readmissions.
Furthermore, regarding postdischarge care and follow-up of patients in Iran, various reasons have been reported for the inadequacy of this care. The following factors make the patient alone after discharge and lead to the recurrence of patients' disorder and the need for readmission: the existence of private, public, and charitable sectors with insufficient services and lack of consistency between them, lack of referral of patients requiring a higher level of care to other centers, insufficient responsibility of the private sector in providing services at the community level, and lack of comprehensive services.
The development of effective plans to address these issues and provide postdischarge care, especially home care and telephone follow-up, can contribute to evaluating patients' conditions and monitoring them on an ongoing basis, leading to timely measures when necessary. As a result, patients will not be forgotten and left alone after discharge, and consequently, patient readmission will be prevented.
Among the notable limitations of the present study, we can refer to the lack of selection and evaluation of psychiatric patients admitted to other hospitals in Qazvin. Moreover, patients' records were reviewed only in 5 years, and it is suggested to review information over a more extended period in future studies.
| Conclusion|| |
Based on the results of the present study, educational level, marital status, intervals between admissions, the pattern of treatment, adherence to treatment, and regular follow-up were significantly correlated with the number of hospitalizations in patients admitted to the psychiatric ward. The results of this study can be used to reduce the frequency of readmissions in patients, especially to put greater emphasis on impersonal factors that can be considered and changed, such as treatment pattern, adherence to treatment, and regular follow-ups. The causes of the aforementioned issues should be evaluated in future studies, and effective measures should be taken to eliminate them in an attempt to reduce the readmission of patients with psychiatric disorders and their subsequent problems. The results of the present study highlighted the need for regular aftercare, including telephone follow-up and home visits, which is a part of the community-based program. Despite their crucial importance, these issues are neglected in many educational-medical psychiatric hospitals in Iran, including Qazvin province, and it is expected that this regular care will reduce the frequency of readmission.
We are grateful for the cooperation of the Clinical Research Development Center of 22 Bahman Hospital and the Student Research Committee of Qazvin University of Medical Sciences, Qazvin, Iran. In addition, the authors would like to appreciate very much for kind collaboration of Dr. Samira Dodangeh.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tedeschi F, Donisi V, Salazzari D, Cresswell-Smith J, Wahlbeck K, Amaddeo F. Clinical and organizational factors predicting readmission for mental health patients across Italy. Soc Psychiatry Psychiatr Epidemiol 2020;55:187-96.
Barnett BS, Kusunzi V, Magola L, Borba CP, Udedi M, Kulisewa K, et al.
Risk factors for readmission among a cohort of psychiatric inpatients in Lilongwe, Malawi. Int J Psychiatry Clin Pract 2020;24:25-30.
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009;360:1418-28.
Katsantonis GP. The evaluation and treatment of snoring. Otolaryngol Head Neck Surg 1995;112:52.
Ng C, Loh H, Yee H, Zainal N. The prevalence and associated factors of psychiatric early readmission in a teaching hospital, Malaysia. Malaysian J Psychiatry 2012;21:1.
Dimitri G, Giacco D, Bauer M, Bird VJ, Greenberg L, Lasalvia A, et al.
Predictors of length of stay in psychiatric inpatient units: Does their effect vary across countries? Eur Psychiatry 2018;48:6-12.
Pfiffner C, Steinert T, Kilian R, Becker T, Frasch K, Eschweiler G, et al.
Rehospitalization risk of former voluntary and involuntary patients with schizophrenia. Soc Psychiatry Psychiatr Epidemiol 2014;49:1719-27.
Page AC, Cunningham NK, Hooke GR. Using daily monitoring of psychiatric symptoms to evaluate hospital length of stay. BJPsych Open 2016;2:341-5.
Donisi V, Tedeschi F, Wahlbeck K, Haaramo P, Amaddeo F. Pre-discharge factors predicting readmissions of psychiatric patients: A systematic review of the literature. BMC Psychiatry 2016;16:449.
Kalseth J, Lassemo E, Wahlbeck K, Haaramo P, Magnussen J. Psychiatric readmissions and their association with environmental and health system characteristics: A systematic review of the literature. BMC Psychiatry 2016;16:376.
Cristiana M, Vincenzo V, Paola R. Factors associated with 30-daysand 180-days psychiatric readmissions: A snapshot of ametropolitan area. Psychiatry Research. 2020;292:113309.
Donisi V, Tedeschi F, Salazzari D, Amaddeo F. Pre- and post-discharge factors influencing early readmission to acute psychiatric wards: Implications for quality-of-care indicators in psychiatry. Gen Hosp Psychiatry 2016;39:53-8.
Yaghoubi M, Yazdani M, Omranifard V, Namdari M. Noncompliance and its causes resulting in psychiatric readmissions. Iran J Psychiatry 2008;3:37-42.
Al-Shehhi AI, Al-Sinawi HN, Jose S, Youssef R. Rate and predictors of 1-year readmission in tertiary psychiatric hospitals. Saudi J Med Med Sci 2017;5:224-31.
] [Full text]
Lorine K, Goenjian H, Kim S, Steinberg AM, Schmidt K, Goenjian AK. Risk factors associated with psychiatric readmission. J Nerv Ment Dis 2015;203:425-30.
Cook JA, Burke-Miller JK, Razzano LA, Steigman PJ, Jonikas JA, Santos A. Serious mental illness, other mental health disorders, and outpatient health care as predictors of 30-day readmissions following medical hospitalization. Gen Hosp Psychiatry 2021;70:10-7.
Cook JA, Burke-Miller JK, Jonikas JA, Aranda F, Santos A. Factors associated with 30-day readmissions following medical hospitalizations among Medicaid beneficiaries with schizophrenia, bipolar disorder, and major depressive disorder. Psychiatry Res 2020;291:113168.
Shen E, Koyama SY, Huynh DN, Watson HL, Mittman B, Kanter MH, et al.
Association of a dedicated post-hospital discharge follow-up visit and 30-day readmission risk in a Medicare advantage population. JAMA Intern Med 2017;177:132-5.
Sajadi S, Hosseini SM, Alimohammadzadeh K. Assessment of prevalence of readmission in admitted ward of Tehran Oil Company's Hospital in 2016. Nurs Midwifery J 2018;16:1-11.
Dobkin C, Finkelstein A, Kluender R, Notowidigdo MJ. The economic consequences of hospital admissions. Am Econ Rev 2018;108:308-52.
Misky GJ, Burke RE, Johnson T, Del Pino Jones A, Hanson JL, Reid MB. Hospital readmission from the perspective of Medicaid and uninsured patients. J Healthc Qual 2018;40:44-50.
Berry JG, Hall DE, Kuo DZ, Cohen E, Agrawal R, Feudtner C, et al.
Hospital utilization and characteristics of patients experiencing recurrent readmissions within children's hospitals. JAMA 2011;305:682-90.
Kocher RP, Adashi EY. Hospital readmissions and the Affordable Care Act: Paying for coordinated quality care. JAMA 2011;306:1794-5.
Ryan CJ, Bierle RS, Vuckovic KM. The three Rs for preventing heart failure readmission: Review, reassess, and reeducate. Crit Care Nurse 2019;39:85-93.
Pieterse D, Temmingh H, Vogel W. Factors associated with readmission in South African adolescents discharged from two inpatient psychosocial rehabilitation units. J Child Adolesc Ment Health 2016;28:199-212.
Saleh ES, El-Hadidy MA. Predictors of psychiatric early readmission in two Arab hospitals. Arab J Psychiatry 2012;23:12-21.
Warnke I, Nordt C, Ajdacic-Gross V, Haug A, Salize HJ, RösslerW.Clinical and social risk factors for the readmission of patientswith schizophrenia to psychiatric inpatient care: a long-termanalysis. Neuropsychiatrie: Klinik, Diagnostik, Therapie undRehabilitation: Organ der Gesellschaft OsterreichischerNervenarzte und Psychiater. 2010;24:243-51.
Machado V, Leonidas C, Santos MA, Santos MA. Psychiatric readmission: An integrative review of the literature. Int Nurs Rev 2012;59:447-57.
Nxasana T, Thupayagale-Tshweneagae G. Nurses' perceptions on the readmission of psychiatric patients one year after discharge. Afr J Nurs Midwifery 2014;16:89-102.
Behr GM, Christie C, Soderlund N, Lee T. Patterns and determinants of acute psychiatric readmissions. S Afr Med J 2002;92:369-74.
Husted J, Jorgens A. Best practices: Population density as a factor in the rehospitalization of persons with serious and persistent mental illness. Psychiatr Serv 2000;51:603-5.
de Castro SA, Furegato AR, Santos JL. Sociodemographic and clinical characteristics of psychiatric re-hospitalizations. Rev Lat Am Enfermagem 2010;18:800-8.
Sharifi V, Abolhasani F, Farhoudian A, Amin-Esmaeili M. Community mental health centers in Iran: Planning evidence-based services. Iran J Psychiatry Clin Psychol 2013;19:163-76.
[Table 1], [Table 2], [Table 3], [Table 4]