Understanding geographic variations in psychiatric inpatient admission rates: width of the variations and associations with the supply of health and social care in France.

BACKGROUND: Inpatient care accounts for the majority of mental health care costs and is not always beneficial. It can indeed have detrimental consequences if not used appropriately, and is unpopular among patients. As a consequence, its reduction is supported by international recommendations. Varying rates of psychiatric inpatient admissions therefore deserve to draw attention of researchers, clinicians and policy makers alike as such variations can challenge quality, equity and efficiency of care. In this context, our objectives were first to describe variations in psychiatric inpatient admission rates across the whole territory of mainland France, and second to identify their association with characteristics of the supply of care, which can be targeted by dedicated health policies. METHODS: Our study was carried out in French psychiatric sectors' catchment areas for the year 2012. Inpatient admission rates per 100,000 adult inhabitants were calculated using data from the national psychiatric discharge database. Their variations were described numerically and graphically. We then carried out a negative binomial regression to identify characteristics of the supply of care (public and private care, health and social care, hospital and community-based care, specialised and non-specialised care) which were associated with these variations while adjusting our analysis for other relevant factors, in particular epidemiological differences. RESULTS: Considerable variations in inpatient admission rates were observed between psychiatric sectors' catchment areas and were widespread on the French territory. Institutional characteristics of the hospital to which each sector was linked (private non-profit status, specialisation in psychiatry and participation to teaching activities and to emergency care) were associated with inpatient admission rates. Similarly, an increase in the availability of community-based private psychiatrists was associated with a decrease in the inpatient admission rate while an increase in the capacity of housing institutions for disabled individuals was associated with an increase in this rate. CONCLUSIONS: Our results advocate for a homogenous repartition of health and social care for mental disorders in lines with the health needs of the population served. This should apply particularly to community-based private psychiatrists, whose heterogeneity of repartition has often been underscored.

Geographic variations in involuntary care and associations with the supply of health and social care: results from a nationwide study.

BACKGROUND: Involuntary psychiatric care remains controversial. Geographic disparities in its use can challenge the appropriateness of the care provided when they do not result from different health needs of the population. These disparities should be reduced through dedicated health policies. However, their association with the supply of health and social care, which could be targeted by such policies, has been insufficiently studied. Our objectives were therefore to describe geographic variations in involuntary admission rates across France and to identify the characteristics of the supply of care which were associated with these variations. METHODS: Involuntary admission rate per 100,000 adult inhabitants was calculated in French psychiatric sectors' catchment areas using 2012 data from the national psychiatric discharge database. Its variations were first described numerically and graphically. Several factors potentially associated with these variations were then considered in a negative binomial regression with an offset term accounting for the size of catchment areas. They included characteristics of the supply of care (public and private care, health and social care, hospital and community-based care, specialised and non-specialised care) as well as adjustment factors related to epidemiological characteristics of the population of each sector's catchment area and its level of urbanization. Such variables were extracted from complementary administrative databases. Supply characteristics associated with geographic variations were identified using a significance level of 0.05. RESULTS: Significant variations in involuntary admission rates were observed between psychiatric sectors' catchment areas with a coefficient of variation close to 80%. These variations were associated with some characteristics of the supply of health and social care in the sectors' catchment areas. Notably, an increase in the availability of community-based private psychiatrists and the capacity of housing institutions for disabled individuals was associated with a decrease in involuntary admission rates while an increase in the availability of general practitioners was associated with an increase in those rates. CONCLUSIONS: There is evidence of considerable variations in involuntary admission rates between psychiatric sectors' catchment areas. Our results provide lines of thoughts to reduce such variations, in particular by supporting an increase in the availability of upstream and downstream care in the community.

Thirty-day Readmission Rates and Associated Factors: A Multilevel Analysis of Practice Variations in French Public Psychiatry.

BACKGROUND: Inpatient psychiatric readmissions are often used as an indicator of the quality of care and their reduction is in line with international recommendations for mental health care. Research on variations in inpatient readmission rates among mental health care providers is therefore of key importance as these variations can impact equity, quality and efficiency of care when they do not result from differences in patients' needs. AIMS OF THE STUDY: Our objectives were first to describe variations in inpatient readmission rates between public mental health care providers in France on a nationwide scale, and second, to identify their association with patient, health care providers and environment characteristics. METHODS: We carried out a study for the year 2012 using data from ten administrative national databases. 30-day readmissions in inpatient care were identified in the French national psychiatric discharge database. Variations were described numerically and graphically between French psychiatric sectors and factors associated with these variations were identified by carrying out a multi-level logistic regression accounting for the hierarchical structure of the data. RESULTS: Significant practice variations in 30-day inpatient readmission rates were observed with a coefficient of variation above 50%. While a majority of those variations was related to differences within sectors, individual patient characteristics explained a lower part of the variations resulting from differences between sectors than the characteristics of sectors and of their environment. In particular, an increase in the mortality rate and in the acute admission rate for somatic disorders in sectors' catchment area was associated with a decrease in the probability of 30-day readmission. Similarly, an increase in the number of psychiatric inpatient beds in private for-profit hospitals per 1,000 inhabitants in sectors' catchment area was associated with a decrease in this probability, which also varied with overall sectors' case-mix characteristics and with the level of urbanisation of the area. DISCUSSION: The extent of the variations and the factors associated with it question the adequacy of care and suggest that some of them may be unwarranted. Our findings should however be interpreted in consideration of several limits inherent to data quality and availability as we relied on information from administrative databases. While we considered a wide range of factors potentially associated with variations in 30-day readmissions, our model indeed only explained a limited part of the variations resulting from differences between sectors. IMPLICATIONS FOR HEALTH POLICIES: Our findings underscored that practice variations in psychiatry are a reality that merits the full attention of decision makers as they can impact the quality, equity and efficiency of care. A specific data system should be established to monitor practice variations in routine to promote transparency and accountability. IMPLICATIONS FOR FURTHER RESEARCH: Few associations were found between variations in 30-day inpatient readmissions and the supply of care. The routine collection of detailed organizational characteristics of health care providers at a national level should be supported to facilitate additional research work, both in France and in other contexts.

Vascular surgeons in France: an endangered species?

BACKGROUND: In France, in the next 10 years, a large number of vascular surgeons will retire, and the risk of them not being replaced has raised the question of our capability to predict future activity in this discipline. Otherwise, the French population is expanding and aging. It will increase by 2.7% in 2020, and the number of individuals aged >65 years is expected to increase by 3.3 million, which represents a 33% rise between 2005 and 2020. As the number of vascular surgery procedures is closely associated with aging population, we can expect a significant increase in vascular surgery workload. We present a model to predict changes in vascular surgery activity according to population aging, including other parameters that could affect workload evolution. METHODS: To meet vascular surgeons' needs in the coming years, we initially performed an overview of the demographics of practitioners and estimated the retirements. The second part of our work consisted in studying three groups of arterial surgical and endovascular procedures used in the treatment of infrarenal abdominal aortic aneurysm, peripheral arterial occlusive disease (PAOD), and carotid artery occlusive disease. Data were selected and extracted from the national Medical Information System Program database. Our predictive model is based on the OMPHALE method developed by the National Institute for Statistics and Economic Studies, and we applied it from the year 2000 to 2030. To integrate other parameters affecting workload, we established, from year 2000 data, a prediction based on aging population for the year 2008. Based on this model, we defined a weighted index for each group by comparing expected and observed workloads. This index has been applied to validate our weighted predictive model for year 2009. RESULTS: Among the 611 vascular surgeons in activity in 2011, nearly two-thirds will retire in the next 15 years. Compared with the number of surgeons in formation, there will be a lack of four surgeons per year in the same period. Our predictive model reported an increase by 61% for the three groups for the period 2000 to 2030. Between 2009 and 2030, nearly 22,700 additional acts are expected, representing a 38% increase. According to the model, between 2000 and 2008 only, vascular procedures increased in total by 52.2%, with an increase of 89% in the PAOD group. Between 2000 and 2009, the global increase was 58.0%, with 3.9% for abdominal aortic aneurysm, 101.7% for PAOD, and +13.2% for carotid artery occlusive disease. Our weighted model based on aging population and corrected by a weighted factor predicted this increase. If the activity for each surgeon remained constant, 183 additional surgeons would be needed according to our refined model. CONCLUSION: In addition to the replacement of numerous retired surgeons, aging population and other factors could result in a significant increase in the demand for vascular surgical services.

Involuntary Psychiatric Admissions and Development of Psychiatric Services as an Alternative to Full-Time Hospitalization in France.

OBJECTIVE: The development of alternatives to full-time hospitalization in psychiatry is limited because consensus about the benefits of such alternatives is lacking. This study assessed whether the development of such alternatives in French psychiatric sectors was associated with a reduction in involuntary inpatient care, taking into account other factors that are potentially associated with involuntary admission. METHODS: Data on whether a patient had at least one involuntary full-time admission in 2012 were extracted from the French national discharge database for psychiatric care. The development of alternatives to full-time hospitalization was estimated as the percentage of human resources allocated to these alternatives out of all human resources allocated to psychiatry, measured at the level of the hospital hosting each sector. Other factors potentially associated with involuntary admission (characteristics of patients, health care providers, and the environment) were extracted from administrative databases, and a multilevel logistic model was carried out to account for the nested structure of the data. RESULTS: Significant variations were observed between psychiatric sectors in rates of involuntary inpatient admissions. A large portion of the variation was explained by characteristics of the sectors. A significant negative association was found between involuntary admissions and the development of alternatives to full-time hospitalization, after adjustment for other factors associated with involuntary admissions. CONCLUSIONS: Findings suggest that the development of alternatives to full-time hospitalization is beneficial for quality of care, given that it is negatively associated with involuntary full-time admissions. The reduction of such admissions aligns with international recommendations for psychiatric care.

The Development of Psychiatric Services Providing an Alternative to Full-Time Hospitalization Is Associated with Shorter Length of Stay in French Public Psychiatry.

International recommendations for mental health care have advocated for a reduction in the length of stay (LOS) in full-time hospitalization and the development of alternatives to full-time hospitalizations (AFTH) could facilitate alignment with those recommendations. Our objective was therefore to assess whether the development of AFTH in French psychiatric sectors was associated with a reduction in the LOS in full-time hospitalization. Using data from the French national discharge database of psychiatric care, we computed the LOS of patients admitted for full-time hospitalization. The level of development of AFTH was estimated by the share of human resources allocated to those alternatives in the hospital enrolling the staff of each sector. Multi-level modelling was carried out to adjust the analysis on other factors potentially associated with the LOS (patients', psychiatric sectors' and environmental characteristics). We observed considerable variations in the LOS between sectors. Although the majority of these variations resulted from patients' characteristics, a significant negative association was found between the LOS and the development of AFTH, after adjusting for other factors. Our results provide first evidence of the impact of the development of AFTH on mental health care and will provide a lever for policy makers to further develop these alternatives.

[Working tools for hospital planning: application to the hospital of Lagny sur Marne]. / Des outils pour la planification hospitalière: l'exemple de l'hôpital de Lagny sur Marne.

The volume of use of beds and other goods and services provided by a hospital is evidently determined by the population of the hospital area, their morbidity, the competition from other hospitals inside and outside the area and so on. When building or renovating an hospital the decision maker needs to know the present situation and, more importantly, what will happen in the future. In general, relevant information on the present situation is lacking. However, the PMSI system, established in 1985 is now operational and provides sufficient basic information on the users and their needs. The article proposes several models for predicting future trends and assessing approximatively what will be seemingly required from the hospital in 20 or 30 years from now.