Relationship Between Continuity of Care and Discharge Planning After Hospital Psychiatric Admission.

OBJECTIVE: This study examined whether communication between inpatient and outpatient mental health providers during patients' inpatient stays was associated with whether patients attended postdischarge appointments. METHODS: Psychiatric inpatient medical records of 189 Medicaid recipients at two hospitals were reviewed to document whether inpatient staff had communicated with current or prior outpatient providers. Medicaid claims provided demographic, clinical, and outpatient attendance data. Associations between provider communications and follow-up care for patients who had or had not received outpatient mental health care within the 30 days prior to admission were evaluated. RESULTS: Inpatient staff communicated with outpatient providers for 118 (62%) patients. For patients who had not received outpatient care within 30 days of admission, compared with those who had, communication was associated with increased odds of attending timely outpatient appointments (odds ratio=2.73, 95% confidence interval=1.09-6.84). CONCLUSIONS: Communication with outpatient providers may be especially important for patients who were not engaged in outpatient care prior to admission.

Family Involvement in Psychiatric Hospitalizations: Associations With Discharge Planning and Prompt Follow-Up Care.

OBJECTIVE: Involving family in the care of inpatients with serious mental illness is known to be beneficial. This study examined frequencies of involvement by family in the care and discharge planning for 179 psychiatric inpatients. METHODS: Involvement by family in care and discharge planning was assessed from randomly selected medical records of inpatients with Medicaid and severe mental illness at two New York hospitals from 2012 to 2013. "Family" also included anyone close to the patient who provided support. Medicaid claims were reviewed for patient demographic and clinical characteristics and for postdischarge outpatient attendance data. Multiple regression models were used to test whether involvement by family was associated with comprehensive discharge planning (contacting outpatient providers, scheduling follow-up appointments, and forwarding a discharge summary to a provider) and initiation of outpatient treatment. RESULTS: Inpatient staff contacted a family member for 134 (75%) patients. Sixty-seven (37%) patients received comprehensive discharge planning, and 96 (53%) and 139 (78%) attended an outpatient appointment within 7 and 30 days of discharge, respectively. Inpatient staff contacting family, communicating about the patient's health and/or mental health, and communicating about the discharge plan were significantly associated with entry into follow-up care by 7 and 30 days postdischarge. Family phone calls and/or visits with patients, attendance at family therapy sessions, and communication with inpatient staff about services available to families were significantly associated with patients receiving comprehensive discharge planning. When analyses controlled for demographic and clinical factors, having any involvement between family members and inpatient staff was significantly associated with patients' attending an outpatient appointment by 7 days (odds ratio [OR]=2.79, 95% confidence interval [CI]=1.28-6.08) or 30 days (OR=3.07, 95% CI=1.29-7.32) after discharge. CONCLUSIONS: The association of family involvement with comprehensive discharge planning and prompt entry into outpatient care underscores the importance of family contact and communication with staff during inpatient hospitalizations.

Racial differences in the use of adjunctive psychotropic medications for patients with schizophrenia.

BACKGROUND: Antidepressants, mood stabilizers and anxiolytics are frequently used in addition to antipsychotic medications in order to control ancillary symptom complexes among patients with schizophrenia. Although extensive data has demonstrated racial disparities in diagnostic and treatment patterns for schizophrenia, little is known about racial differences in the use of adjunctive medications. Since these adjunctive medications may significantly improve clinical outcomes, further investigation is warranted. AIMS OF THE STUDY: The purpose of this study was to determine the rates at which adjunctive antidepressants, mood stabilizers and anxiolytics were prescribed to black patients and white patients with schizophrenia. The authors hypothesized that black patients would be less likely to receive any adjunctive medication as compared to white patients. METHODS: This cross-sectional study utilized data from an academic medical center in Rochester, New York. Three multivariate logistic regression were performed to model the likelihood of receiving each of the three types of adjunctive medication. The primary independent variable was race, and the models also controlled for clinical and sociodemographic factors such as diagnosis, age, gender, living situation, and insurance status. RESULTS: Of the 456 patients included in the study, 37% received an antidepressant, 33% received a mood stabilizer and 23% received an anxiolytic. All patients received an antipsychotic medication. In each multivariate model, race was significantly associated with likelihood of receiving the adjunctive medication (p<.01 for all). None of the covariates was consistently associated with receipt of an adjunctive medication. DISCUSSION: Even after controlling for potentially confounding clinical and sociodemographic factors, race was strongly associated with receipt of adjunctive medications. This finding is consistent with previous work demonstrating racial disparities in the treatment and management of schizophrenia. The cross-sectional study design, however, limits the conclusions that can be drawn from this study, as length-time bias may have led to a misrepresentation of how many patients receive adjunctive medications. Caution should be observed in interpreting our results and replication is necessary. IMPLICATIONS FOR FURTHER RESEARCH: Differences in the use of adjunctive medications may be due to true differences in the frequency of ancillary symptom complexes. Previous work, however, suggests that differences are more likely to be due to underdiagnosis of affective or anxiety symptoms among black patients. Among patients with recognized ancillary symptoms complexes, black patients may also be less likely than white patients to receive treatment. This may be due to racial differences in accessibility of mental health care, physician perceptions of patients, and patient beliefs and preferences. In future work, use of standardized diagnostic tools may help to determine actual rates of ancillary symptom complexes and to identify racial variations. Additionally, further research is needed to clarify the underlying biases and behaviors that affect use of adjunctive medications among patients with schizophrenia in whom ancillary symptom complexes have been identified.

A comparison of ten-year cardiac risk estimates in schizophrenia patients from the CATIE study and matched controls.

OBJECTIVE: Standardized mortality rates are elevated in schizophrenia compared to the general population. The incidence of coronary heart disease (CHD) and the relative contribution of CHD to increased mortality in schizophrenia patients are not clear, despite recent concerns about metabolic complications of certain atypical antipsychotics. METHOD: Ten-year risk for CHD was calculated for 689 subjects who participated in the Clinical Trials of Antipsychotic Treatment Effectiveness (CATIE) Schizophrenia Trial at baseline using the Framingham CHD risk function and were compared with age-, race- and gender-matched controls from the National Health and Nutrition Examination Survey (NHANES) III. RESULTS: Ten-year CHD risk was significantly elevated in male (9.4% vs. 7.0%) and female (6.3% vs. 4.2%) schizophrenia patients compared to controls (p = 0.0001). Schizophrenia patients had significantly higher rates of smoking (68% vs. 35%), diabetes (13% vs. 3%), and hypertension (27% vs. 17%) and lower HDL cholesterol levels (43.7 vs. 49.3 mg/dl) compared to controls (p < 0.001). Only total cholesterol levels did not differ between groups. Ten-year CHD risk remained significantly elevated in schizophrenia patients after controlling for body mass index (p = 0.0001). CONCLUSIONS: These results are consistent with recent evidence of increased cardiac mortality in schizophrenia patients. While the impact of cigarette smoking is clear, the relative contributions to cardiac risk of specific antipsychotic agents, diet, exercise, and quality of medical care remain to be clarified.