Does socioeconomic status affect the use of community-based psychiatric services? A South Verona case register study.

OBJECTIVE: To assess the effect of socioeconomic status (SES) on psychiatric service use in an Italian area with a well-developed community-based psychiatric service. METHOD: An index of SES was calculated from nine census variables and grouped into four categories, ranging from SES-I-affluent to SES-IV-deprived, for each of 328 census blocks (CB). Fifteen indicators of psychiatric service use were collected using the psychiatric case register. All patients resident in the catchment area, who had at least one psychiatric contact in 1996 (n=989), were included in the study. RESULTS: Indicators of in-patient, day-patient, out-patient and community service use showed an inverse association with SES. Only first-ever and long-term psychotic patients were equally distributed in the four SES groups. CONCLUSION: The inverse association between SES and most indicators of psychiatric service use suggests that the planning of community-based services and resource allocation should take into account the SES of residents.

[For a more rational funding system of mental health services. Analyses of costs for services supplied by community mental health services during a 7-year period]. / Per un più razionale sistema di finanziamento dei Dipartimenti di Salute Mentale. Analisi dei costi delle prestazioni erogate da un Servizio Psichiatrico Territoriale in un periodo di 7 anni.

AIMS: In the last years, in Italy as well as in many other developed countries, there has been a growing interest for health economics by researchers. As for as the psychiatric care is concerned, more recently, many research's groups have pointed their attention on new possible funding systems for mental health services and on their effects on services' functioning. The aim of this study is to define a new list of services' costs based on services actually delivered by a Community Mental Health Service (CMHS). METHODS: All psychiatric contacts recorded by the South-Verona Psychiatric Case Register during a 7-year period (1992-1998) have been included in the study (125,623 contacts made by 2,819 patients). Contacts were grouped into 19 type of services. The cost function methodology was used to describe, also reporting elasticity values, costs' behaviour in the South-Verona CMHS. The cost of each service includes expenses for professionals involved (directly or indirectly) in the contacts with the patients and capital costs. RESULTS: For each service were reported a) the cost of the service as it is actually supplied in our CMHS, b) the cost per minute, c) an estimate of the cost of service delivered with standard modalities (duration equal to the mode value registered; staff composition take into account either the actual functioning of the CMHS either indication about a good clinical practice) and, finally, d) cost of the eight services included into the reimbursement system currently in use in Italy. CONCLUSIONS: Our results showed that services' definition used in this study allow to describe different types of psychiatric care supplied from the South-Verona CMHS. The national list currently adopted for the reimbursement in Italy should allowed to describe only 28% of the registered psychiatric contacts (35,230 vs. 125,632). The urgent need for a new list of psychiatric services, accepted at a national level, was confirmed. Cost values obtained clearly show that the funding system currently used underestimates the true costs of care delivered by the CMHS. The cost function makes available a tool to test a prospective per-capita funding system as provided in the Act No. 229 of the Italian Government.

Using health production functions to evaluate treatment effectiveness: an application to a community mental health service.

The randomized controlled trial (RCT) is the recommended means of evaluating health care effectiveness and cost-effectiveness. Whilst representing a 'gold-standard' in health services research, RCT evidence on the clinical and economic desirability of services and treatments is often absent. Where RCT evidence is lacking, or where it is infeasible to implement randomized controlled comparisons, longitudinal observational and naturalistic data sources when analysed appropriately can yield useful insights regarding the clinical effectiveness and economic efficiency of treatments. In this paper we demonstrate the utility of applying panel estimation methods to data from an Italian psychiatric case register as a means of modelling the mental health outcomes of patients referred to a community-based mental health service. Emphasis is placed on quantifying the clinical effectiveness of consultations with different mental health professionals (including in-patient days) and whether service outcomes are affected by psychiatric diagnosis. The impact of service consultations and their interaction with different types of psychiatric diagnosis on a measure of patient mental health are found to be statistically significant, although the size of these effects are not substantial from a clinical perspective.

Community-based mental health care: to what extent are service costs associated with clinical, social and service history variables?

BACKGROUND: The growing movement in many European countries towards capitation-based systems for financing mental health care has generated increasing interest in developing appropriate models capitation formulae. The aims of the study were: to detect and compare any differences in service costs between patients with different diagnoses; and to analyse the associations between patient characteristics and service costs. METHODS: All patients in contact with the South-Verona Community Mental Health Service during the last quarter of 1996 were included in the study. Clinical and service-related variables were collected at first index contact; 3 months later, patients were interviewed using the Client Services Recipient Interview. For those who completed both the clinical assessments and the services receipt schedule (N = 339), 1-year psychiatric and non-psychiatric direct care costs were calculated. Weighted backward regression analyses were performed. RESULTS: The most significant variables associated with psychiatric costs were: admission to hospital in the previous year; intensity and duration of previous contacts with South-Verona CMHS; being unemployed; having a diagnosis of affective disorder; and, Global Assessment of Functioning score. The final model explained 66% of the variation in costs of psychiatric care and 13 % of variation in non-psychiatric medical costs. CONCLUSIONS: The model presented in this study explains a higher degree of cost variance than previously published studies. In community-based services more resources are targeted towards the most disabled patients. Previous psychiatric history (number of admissions in the previous year and intensity of psychiatric contacts lifetime) is strongly associated with psychiatric costs.

Collecting psychiatric resources utilisation data to calculate costs of care: a comparison between a service receipt interview and a case register.

BACKGROUND: Economic assessment of interventions and policies is becoming increasingly common, in large measure because of the growing emphasis on cost containment within health care. Comprehensive and reliable outcome and cost data are required to advise policy makers and clinicians as to the best use of their limited resources. The process of costing can be broken down into three connected tasks: the collection of service receipt or utilisation data relative to individual clients or patients over a defined period; the costing of each of the services used; and the combination of these two sets of information in order to calculate individual costs. The aim of this study was to compare two methodologies of collecting data on individual service use - a customized interview schedule, ICAP, and the psychiatric case register (PCR) - and to calculate costs, testing the extent of agreement between them. METHOD: The agreement between the ICAP and the PCR costs measurement was evaluated using the concordance correlation coefficient rho(c). From all patients (n = 543) who had at least one contact with a psychiatrist or a psychologist during the period October-December 1996, 339 patients were interviewed using the ICAP. The overall number of patients in contact with the South-Verona CPS in the same period was 630. RESULTS: The agreement between the two sources was very different for each diagnostic group and each professional category. However, the overall agreement on total costs was satisfactory (rho(c) < 0.95). This result is probably due to the effect of the good agreement observed on more costly services: inpatient care and sheltered accommodation. CONCLUSION: The results suggested practical implications for the use of the service receipt interview: interviewers should be trained in order to avoid misinterpretation of the definitions given in the form; the sources of information should be clearly defined to tease out all the items of services provided for the users; the professionals (i.e. psychiatrists) could influence the reliability of data collection by underestimating services provided by different professionals (nurses, social workers, etc.). The findings confirm that it is possible to use this approach when the aim is to estimate the whole cost of the services; however, the importance of adopting adequate procedures for analysing the complexity of cost components should be pointed out. Only a trained interviewer who thoroughly knows each component of the health and social services provided could guarantee an accurate data collection.

Evaluating psychiatric morbidity in a general hospital: a two-phase epidemiological survey.

BACKGROUND: This study aimed to assess psychiatric morbidity and to collect information on disability, life events and family support in a representative sample of patients admitted to a general hospital. METHODS: On the basis of information collected in a pilot study a systematic sample of patients consecutively admitted to seven general medical and seven surgical wards of the Academic General Hospital of Verona was selected and interviewed using a two-phase screening procedure and standardized instruments (GHQ-12, HADS, BDQ and CIDI-PHC). All data were analysed using appropriately weighted logistic regression procedures. RESULTS: A total of 1039 patients completed the GHQ-12 and 298 (28.7%) were high-scorers: 363 patients were interviewed with CIDI-PHC. The prevalence of ICD-10 cases was 26.1%. The most common psychiatric diagnoses were current depression (12.8%) and generalized anxiety disorder (10.8%), followed by alcohol related disorders (5 %). A higher prevalence of ICD-10 cases was found in medical wards, among females, patients older than 24 years, unemployed and separated/divorced people. Life events were associated with psychopathology, and so was the number of disability days. Although 49.8% of ICD-10 cases were identified by the hospital doctors as having a psychological disorder, 23.1% of ICD-10 cases were referred to the liaison psychiatric service. CONCLUSION: The results of the present study stress the need to collect epidemiologically-based data on psychological disorders and their recognition not only in general practice, but also in general hospital settings, in order to have a more complete picture of the pathways to specialist care.

The costs of community-based psychiatric care for first-ever patients. A case register study.

BACKGROUND: Analysing costs measures in conjunction with psychiatric case register (PCR) data can provide important epidemiologically-based information on resource utilization. Costing the service use patterns of first-ever patients can indicate the shape and likely resource consequences for mental health services operating within a community-based system of care. METHODS: Yearly costs were calculated for the 299 first-ever patients and 768 longer-term patients who contacted the South-Verona Psychiatric Case Register between 1 January 1992 and 31 December 1993. Bivariate and multivariate analyses were used to compare costs between these groups and to test the associations between costs and the sociodemographic and diagnostic data recorded on the PCR. RESULTS: For all diagnostic groups identified, first-ever patients were found to be less costly to support than longer-term patients, even after adjustment for various factors, including whether patients were single consulters. When multivariate analyses were employed, between 20% and 69% of the cost variation for first-ever patients could be explained by patient and other characteristics, and the effect of the contact (first or subsequent) variable was reduced. CONCLUSION: This study considered only the costs to the specialist psychiatric services but the methodology allows the likely annual resource implications of supporting new patients to be predicted from data collected at first contact. Such information can help ensure that services are adequately funded and that the resources are deployed appropriately between client groups.

The use of a case register to evaluate the costs of psychiatric care.

The aim of this study was to show the usefulness of adding cost information to a routine data collection provided by a case register for analysing the association between patients' characteristics and the direct costs of the psychiatric care actually provided. All patients (n = 706) who in 1992 had at least one contact with services which report to the South Verona psychiatric case register and who received an ICD-10 diagnosis were included in the study. The costs of specialist psychiatric care provided during the 365 days following the first contact in 1992 were calculated using a unit cost list. A bespoke software, linked to the case register, was designed to produce the individual information on costs directly. For each patient, costs were categorized as in-patient costs, sheltered accommodation costs, day-care costs, out-patient costs and community costs. All costs, grouped by service type, were found to differ significantly (P < 0.01) between diagnostic groups (affective disorders, neurotic and somatoform disorders, schizophrenia and related disorders, and other diagnoses). The multivariate analyses showed that costs are significantly higher for patients with a diagnosis of schizophrenia and related disorders than for patients belonging to the other diagnostic groups. However, only 6% of the variation could be explained by diagnostic group alone. On the other hand, between 40 and 50% of the costs of mental health care was predicted by patients' personal characteristics and other measures recorded on the case register. The results of the present study show that, where service use is monitored regularly, the base from which decisions on community provision and placement are made can be informed by careful analysis of routinely or easily available data on direct costs.

Mortality among patients with psychiatric illness. A ten-year case register study in an area with a community-based system of care.

BACKGROUND: Most studies which showed an excess mortality in psychiatric patients have been conducted on hospitalised samples. METHOD: This was a case register study. All South Verona patients with an ICD diagnosis who had psychiatric contacts with specialist services in 1982-1991 were included. Mortality was studied in relation to sex, age, diagnosis, pattern of care and interval from registration. Standardised Mortality Rates (SMRs) and Poisson regression analysis were calculated. RESULTS: The overall SMR was 1.63 (95% Cl = 1.5-1.8), which is the lowest value reported so far. Mortality was higher among men (SMR = 2.24; 95% Cl = 1.9-2.6), among patients who were admitted to hospital (SMR = 2.23; 95% Cl = 1.9-2.6), among younger age groups (SMR = 8.82; 95% Cl = 4.9-14.6) and in the first year after registration (SMR = 2.32; 95% CL = 1.8-2.9). Higher mortality was found in patients with a diagnosis of alcohol and drug dependence (SMR = 3.87; 95% Cl = 3.0-4.9). The SMR for suicide was 17.41. Using a Poisson regression model, diagnosis, pattern of care and interval from registration were all found to be significantly associated with mortality. When all these variables were entered together in the model, each maintained its predictive role. CONCLUSIONS: The overall mortality of psychiatric patients treated in a community-based system of care was higher than expected, but lower than the mortality reported in other psychiatric settings. The highest mortality risk was found in the first year after registration.