The new remuneration system TARPSY in Swiss psychiatric hospitals: effects on length of stay and readmissions?

BACKGROUND: In 2018, Switzerland introduced a nationwide case-based prospective remuneration system (TARPSY), with decreasing daily rates for reimbursement of inpatient care in mental health facilities. Initially, there were concerns that declining daily rates could result in early discharges and increased readmission rates. METHODS: We compared length of stay (LOS) and readmission rates for patients in adult and geriatric psychiatry treatment at four psychiatric hospitals between 2017 (the last year with the traditional remuneration system) and 2018 (the first year with TARPSY). RESULTS: A total of 26,324 treatment episodes of 15,464 patients were analysed. The reduction of average LOS was not statistically significant in the first year after the implementation of TARPSY, neither in adult (mean –0.6 days, 95% confidence interval [CI] –1.6 to 0.4; p = 0.226) nor in geriatric psychiatry (mean −1.6 days, 95% CI −3.8 to 0.7; p = 0.178). When compared with the traditional remuneration system with fixed daily rates, the readmission risk was statistically significantly reduced by −9.1% (95% CI −4.9 to −13.1%; p <0.001) in adult psychiatry but not in geriatric psychiatry (−6.8%, 95% CI −19.2 to 7.4%; p = 0.329). CONCLUSIONS: If being evident at all, the effects of the new remuneration system TARPSY on LOS and readmission rates seem to be small. Concerns that declining daily rates in TARPSY would result in early discharges and increased readmission rates did not prove true in adult and geriatric psychiatry.  .

[Suicidality in the elderly - what the general practitioner can do]. / Suizidalität im Alter - was kann der Hausarzt tun?

Suicide rates in Switzerland and most other countries are higher among the elderly than among the population as a whole. Suicidality in the old age is commonly associated with the presence of a mental disorder, especially depression. Medical doctors in primary healthcare have outstanding prominence in detecting suicidal states within elderly patients, because of their common long-standing and confidential relationship and the fact that suicidality is often concealed behind somatisation or other medical complaints. A new practical approach called PRISM-S task enables an assessment of the degree of suicidality in less than five minutes with a simple, visual instrument. Besides the importance of public mental health measures PRISM-S offers a brief, easy-to-administer method for all healthcare professionals to assess suicidality in adult patients (18-65 years). Further investigation will explore its specific usefulness for elderly patients (over 65 years).

Le taux de suicide en Suisse et dans la plupart des autres pays est plus élevé chez les personnes âgées que dans la population générale. Chez les personnes âgées le suicide est communément associé à un désordre mental, la dépression en particulier. Les médecins de premier recours jouent un rôle très important dans la détection des tendances suicidaires chez les personnes âgées, ceci grâce à leur relation souvent prolongée et confidentielle avec ces dernières et du fait que le risque de suicide se cache souvent derrière des troubles somatiques ou d'autres plaintes médicales. Une nouvelle approche pratique (PRISM-S task) permet d'évaluer en moins de 5 minutes le degré de risque de suicide grâce à un instrument simple et visuel. En plus de l'importance sur le plan de la santé mentale, l'approche PRISM-S représente pour tous les professionnels de la santé une méthode rapide et facilement réalisable pour évaluer le risque suicidaires chez les adultes de 18 à 65 ans. Des investigations supplémentaires seront effectuées pour tester l'utilité de cette approche sélectivement chez les personnes âgées de plus de 65 ans.

Comparison of the incidence and predicted risk of early surgical site infections after breast reduction.

In plastic surgery, clean, elective operations such as breast reductions are anticipated to have low risk factors for infections (1.1-2.1%). To further lower or prevent surgical site infections (SSI), the efficacy of a prophylactic administration of anti-microbacterials remains a current controversial issue in plastic surgery. We report here the findings of a retrospective study in which we examined two groups of patients with breast reductions, one of which received a single-shot antimicrobacterial prophylaxis with cefuroxime preoperatively and the other who were given no anti-microbacterials. The aims were to determine the early SSI incidence of both groups, to classify breast reductions with respect to their inherent SSI risk by two widespread, combined risk scores, i.e., the National Nosocomial Infection Surveillance (NNIS) score and the Study on the Efficacy of Nosocomial Infection Control (SENIC) score, and to compare the actual SSI incidence to the predicted risk of the scores. In the divisions of plastic surgery at two hospitals, 153 patients (group I) and 136 patients (group II) could be included in the study in the 4-year period April 1997 to December 2001. Excluded were all patients with unilateral breast reduction or breast reconstruction and patients who were followed up less than 30 days postoperatively. The two groups were comparable with respect to demographic and clinical features such as age and risk factors, and there were no detectable significant intergroup differences in the general perioperative data. According to the NNIS and the SENIC scores, all operations were "clean," and the American Society of Anesthesiologists (ASA) score was < 3 in all patients. Although the mean duration of the operation was significantly different in the two groups (190 min in group I, 160 min in group II; p < 0.001, Mann-Whitney test; 75th percentile at and 4 and 3 h, respectively), it was longer than 2 h in both groups. The incidence of early infections was 3.9% in the first group, compared with 3.6% in the second group (p = 1.0, odds ratio = 1.07, 95% CI = 0.32-3.6). All infections were local and superficial; no general symptoms were noticed. Three patients had to be readmitted and two of these were reoperated. The rate of infections for both groups was higher than generally anticipated for this kind of clean operations and higher than predicted by the NNIS score for medium risk (predicted risk of 2.9%). The reason for this discrepancy is that the NNIS score is an inpatient risk score which does not include a postdischarge SSI surveillance. Using the NNIS definition of SSI we would have had an infection rate of 0% in both groups in our study. According to the SENIC score, breast reductions can be classified also as medium risk of SSI with a predicted risk of 3.9%, which showed a nearly perfect correspondence with the actual SSI incidence in both study groups. The reason for this increased, medium risk is the factor "operation time > 2 h," which is obviously an inherent risk factor in breast reductions. Among the multitude of patient and nonpatient SSI risk factors, in healthy women operation time was the only factor which could be clearly identified.