Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

• The roles of the psychiatric hospital, lengths of stay, and transition support services after discharge

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

• Compare the effectiveness of different lengths of hospital stay on addressing various outcomes, including whether the individual and involved family feel that the factors prompting the admission are adequately addressed, whether the individual and involved family felt that the stay was sufficient to address safety and dangerousness concerns, and whether differences in length of stay influence other variables (e.g., satisfaction with care, adherence, insight into illness) in SMI patients with similar diagnoses and disease severity. In this comparison, consider whether factors such as housing stability or social support network, confound the relationship between length of stay and readmission rates.
• Compare the effectiveness of different lengths of hospital stay (e.g. ultra-short stays of 1-4 days vs. longer stays of 7-10 days) in patients with SMI and repeated hospital admissions. This could include assessing the circumstances that are best suited for long-term hospitalization to be more effective and specific interventions that enhance the effectiveness of long-term hospitalization.

– Even 7-10 days can be brief for individuals with severe treatment resistant illness and prominent suicidal or aggressive behavior. We have anecdotally had individuals who stayed much longer on our inpatient service and who were able to achieve stability and remission of symptoms, when their prior course was marked by repeated stays of days to weeks. Thus, it would be worth having a third comparison group for even longer stays. Any such comparisons would need to account for confounding factors that may contribute to longer lengths of stay such as housing availability, neighborhood security/insecurity, financial status, case manager availability, access to specific treatment programs (e.g., ACT, intensive outpatient), family involvement and quality of relationship with patient, symptom severity and general medical comorbidity.

• Compare the effectiveness of diverse models of

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Patients with Serious Mental Illness (SMI)

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

• Subgroups of people with SMI include racial, ethnic, and cultural subgroups.
• The elderly, homeless, and mentally challenged should also be considered.
• People with co-occurring chemical dependency as well as other co-occurring issues –developmental disorders, serious medical illnesses, etc.

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

• Reduction in readmissions
• Patient insight into illness
• Treatment adherence
• Increased housing stability
• Increased social support
• Remission
• Physical health outcomes (positive)
• Increased quality of life
• Increased clinical engagement

Describe any health-related risks, side effects, or harms that you are concerned about.

• Relapse and readmission
• Treatment non-adherence
• Physical health outcomes (negative)
• Criminal justice encounters
• Suicide, suicide attempts, other self-injurious behaviors
• Homicide and other aggressive behaviors
• Relapse into substance use

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Depression and other mental health disorders
• Functional limitations and disability
• Substance abuse

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare

Importance

Describe why this topic is important.

It is important to assess the circumstances that are best suited for long-term hospitalization to be more effective and specific interventions that enhance the effectiveness of long-term hospitalization. The specifics of treatment are important; length of stay should not be treated as a black box.

Short-term hospitalization or treatment must also be considered (i.e., important to assess why and when short term and long-term, respectively, are effective). It is also important to determine the cost-effectiveness of hospitalization vs. alternatives to hospitalization. Individuals and involved families should feel that factors prompting admission are adequately addressed and that the stay was sufficient to address safety and dangerousness concerns. Research is needed to explore the unintended consequences of involuntary treatment. In many cases, the fear of forced treatment may actually keep people from seeking mental health treatment.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

• There is great concern among clinicians about the effectiveness of very short term hospitalization
• The appropriate length of stay to adequately address the acute inpatient needs of an individual is difficult to determine. There is a perception by clinicians and often patients and families that hospital stays have become too brief (in the context of financial pressures) and that issues such as dangerousness to self and others are not always addressed completely. In addition, ultra-short stays do not permit interventions to be adequately initiated and adequate followup to be arranged. Repeated readmissions are disruptive to individuals and families, and contribute to demoralization in patients who may view readmission as a failure on their part. Seemingly premature discharge on one occasion also leads to patient and family concern about future discharges and future safety. Together, these factors contribute to considerable variations in practice and controversy. Enhanced understanding of these issues could permit a more evidence-based approach to developing practice guidelines and policies about hospitalization.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Managed care has confined hospital stays to acute crisis and safety and ultra-short LOS. The question is whether such approaches promote community recovery or lead to rapid re-hospitalization or other bad outcomes.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

Answers to these research questions will be able to inform the development of practice guideline recommendations for psychiatrists relating to psychiatric hospitalization.

Describe the timeframe in which an answer to your question is needed.

As soon as possible. This topic was prioritized during a series of stakeholder meetings focused on SMI, held July-August 2010.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

• Patients in acute hospital settings are disproportionally African-American, poor, and have other minority status.
• “Poor people are hospitalized more frequently with involuntary commitment.” How would this affect long-term treatment engagement? What does that say about health disparities?
• Individuals with serious mental illness are a vulnerable population. Inequities exist for those with mental illness compared to the general population. Inequities also are present in relationship to insurance coverage and utilization review, which have a significant impact on hospitalization related decision making for patients, families, and clinicians.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

Answers to these research questions will be able to inform the development of practice guideline recommendations for psychiatrists relating to psychiatric hospitalization.

Are you making a suggestion as an individual or on behalf of an organization?

Individual

Please tell us how you heard about the Effective Health Care Program

1- The Practice Guidelines project of the American Psychiatric Association was asked for the name of someone to participate; my name was submitted; 2- From AHRQ; 3- Through AHRQ and the Consensus Conference