Inpatient Bed Days Research Articles

Reducing Injury During Restraint by Crisis Intervention in Psychiatric Wards in Singapore.

The application of restraints during psychiatric crises is a serious adverse event. We aimed to reduce the number of injuries sustained by patients during the application of restraints. Structured interviews were conducted with 10 staff to determine six root causes of patient injury during restraint. Three plan-do-study-act cycles were implemented: (1) reorganising shift rosters to pair trained staff with inexperienced staff, (2) holding monthly session for practising de-escalation and restraint techniques as a team in a supervised setting, and (3) rotating the responsibility for leading the de-escalation in real crises. Pre-intervention period was from January 2014 to December 2014 (28 251 inpatient bed days). Intervention period was from January 2015 to March 2015 (7121 inpatient bed days). Post-intervention period was from April 2015 to December 2016 (51 735 inpatient bed days). Data extracted included the dates and numbers of crises, activation of the crisis team, use of restraints, and injuries. During pre-intervention and intervention periods, only two minor and three moderate injuries were recorded. During post-intervention period, no injury was recorded and the number of restraints decreased gradually although the number of crisis team activations increased in the early phase. Eventually restraints were used only upon arrival of the crisis team. Our quality improvement project identified six root causes and implemented three plan-do-study-act cycles to successfully eliminated patient injuries during the use of restraints.

The Burden on a Urologist of Percutaneous Nephrostomies and Antegrade Ureteric Stents: Should Trainee Urologists Learn to Perform these Procedures?

Background and Objective Renal obstruction is a common urological emergency potentially requiring urgent decompression by percutaneous nephrostomy (PCN) or antegrade ureteric stent (AUrS), procedures performed by interventional radiologists, or retrograde stenting in theatre by a urologist. The study aimed to assess the burden of PCN / AUrS on the overall workload of a urology department and evaluate impact of procedural delays in terms of bed-occupancy and cost. The findings serve to explore whether formal PCN / AUrS training would be desirable for UK trainees in urology. Material and Methods Prospective study of all patients admitted under urology at Queen Elizabeth Hospital Birmingham (QEHB) between 20thOctober - 18thNovember 2018. Electronic records to retrieve data pertaining to admission, treatment provided, length of in-patient stay and delay awaiting PCN / AUrS. Results n=148 patients identified. n=22 (14.8% of total) primary admission reason and/or main treatment provided related to PCN / AUrS. 601 urology in-patient days occupied for all causes, 166 (27.6%) related to PCN / AUrS and 66 (10.9%) awaiting PCN / AUrS (delays cost �11,361 / month). Conclusion PCN / AUrS constituted a noteworthy proportion of all admissions and in-patient bed days in QEHB urology. Clinically non-urgent patients experienced notable cumulative delays whilst awaiting PCN / AUrS which adversely impacted bed occupancy. A suitably trained urologist competent at PCN / AUrS may positively address these issues. The findings merit consideration of a call for UK urology trainees to be trained in PCN / AUrS as part of CCT requirements.

764. Patients with Substance Use Disorder Discharged from Safety Net Hospital to Skilled Nursing Facility for OPAT: Baseline Characteristics and Clinical Outcomes

BackgroundSelf-administered Outpatient Parenteral Antimicrobial Therapy (S-OPAT) is offered at Parkland Memorial Hospital for uninsured patients requiring an extended course of intravenous (IV) antibiotics to complete treatment at home.1 At Parkland, S-OPAT has been demonstrated to be safe and effective with >70,000 inpatient bed days avoided to date, lower 30-day readmission rates, and significant cost savings.1 Patients with a history of substance use are not eligible for S-OPAT and are discharged to skilled nursing facilities (SNF) to complete IV antibiotic therapy. This study aims to describe clinical outcomes of a patient population with history of substance use discharged to SNF for OPAT.MethodsThe electronic medical record was used to identify patients with substance use discharged to an SNF for OPAT between January 1, 2017 and April 30, 2018. Data were retrospectively reviewed for demographics, substance use history, treatment plan and clinical outcomes.Results76 patients with history of substance use were discharged to SNFs for OPAT in the study period. 62% of patients reported non-IV drug use and 38% reported IV drug use (IVDU). The mean age for patients with non-IV drug use was 47 (83% male) vs. 43 years for patients with IVDU (86% male). Of patients with non-IV drug use, 30% reported cocaine use, 11% methamphetamine use and 59% polysubstance use or other. Of patients with IVDU, 38% reported heroin use, 10% methamphetamine use and 52% polysubstance use or other. When comparing outcomes of IVDU vs. non-IV drug use patients, 34% vs. 21% did not complete the prescribed treatment course, 28% vs. 11% left against medical advice (AMA), and 20% vs. 15% were readmitted to the hospital within 30 days.ConclusionThe majority of patients with substance use, 74%, completed their prescribed IV antibiotic course when sent to an SNF. However, a subset of these patients is at risk for poor clinical outcomes. A greater proportion of patients with prior IVDU compared with patients with prior non-IV drug use left treatment AMA and were readmitted to our hospital within 30 days of discharge. Future efforts to identify patients with substance use disorder who may be appropriate for S-OPAT with integration of addiction medicine services may improve clinical outcomes. DisclosuresAnk E. Nijhawan, MD, MPH, Gilead Sciences, Inc.: Research Grant.

Person-centred, integrated and pro-active care for multi-morbid elderly with advanced care needs: a propensity score-matched controlled trial

BackgroundPerson-centred care (PCC) focusing on personalised goals and care plans derived from “What matters to you?” has an impact on single disease outcomes, but studies on multi-morbid elderly are lacking. Furthermore, the combination of PCC, Integrated Care (IC) and Pro-active care are widely recognised as desirable for multi-morbid elderly, yet previous studies focus on single components only, leaving synergies unexplored. The effect of a synergistic intervention, which implements 1) Person-centred goal-oriented care driven by “What matters to you?” with 2) IC and 3) pro-active care is unknown.MethodsInspired by theoretical foundations, complexity science, previous health service research and a patient-driven evaluation of care quality, we designed the Patient-Centred Team (PACT) intervention across primary and secondary care. The PACT team collaborate with the patient to make and deliver a person-centred, integrated and proactive multi-morbidity care-plan. The control group receives conventional care. The study design is a pragmatic six months prospective, controlled clinical trial based on hospital electronic health record data of 439 multi-morbid frail elderly at risk for emergency (re) admissions referred to PACT and 779 propensity score matched controls in Norway, 2014–2016. Outcomes are emergency admissions, the sum of emergency inpatient bed days, 30-day readmissions, planned and emergency outpatient visits and mortality at three and six months follow-up.ResultsThe Rate Ratios (RR) for emergency admissions was 0,9 (95%CI: 0,82-0,99), for sum of emergency bed days 0,68 (95%CI:0,52-0,79) and for 30-days emergency readmissions 0,72 (95%CI: 0,41-1,24). RRs were 2,3 (95%CI: 2,02-2,55) and 0,9 (95%CI: 0,68-1,20) for planned and emergency outpatient visits respectively. The RR for death at 3 months was 0,39 (95% CI: 0,22-0,70) and 0,57 (95% CI: 0,34-0,94) at 6 months.ConclusionCompared with propensity score matched controls, the care process of frail multi-morbid elderly who received the PACT intervention had a reduced risk of high-level emergency care, increased use of low-level planned care, and substantially reduced mortality risk. Further study of process differences between groups is warranted to understand the genesis of these results better.Trial registrationClinicalTrials.gov (identifier: NCT02541474), registered Sept 2015.

The Population Health Value Framework: Creating Value by Reducing Costs of Care for Patient Subpopulations With Chronic Conditions.

With the growth in risk-based and accountable care organization contracts, creating value by redesigning care to reduce costs and improve outcomes and the patient experience has become an urgent priority for health care systems. In 2016, UCLA (University of California, Los Angeles) Health implemented a system-wide population health approach to identify patient populations with high expenses and promote proactive, value-based care. The authors created the Patient Health Value framework to guide value creation: (1) identify patient populations with high expenses and reasons for spending, (2) create design teams to understand the patient story, (3) create custom analytics and spending-based risk stratification, and (4) develop care pathways based on spending risk tiers. Primary care patients with three chronic conditions-dementia, chronic kidney disease (CKD), and cancer-were identified as high-cost subpopulations. For each patient subpopulation, a multispecialty, multidisciplinary design team identified reasons for spending and created care pathways to meet patient needs according to spending risk. Larger, lower-risk cohorts received necessary but less intensive interventions, while smaller, higher-risk cohorts received more intensive interventions. Preliminary analyses showed a 1% monthly decrease in inpatient bed day utilization among dementia patients (incident rate ratio [IRR] 0.99, P < .03) and a 2% monthly decrease in hospitalizations (IRR 0.98, P < .001) among CKD patients. Use of the Patient Health Value framework is expanding across other high-cost subpopulations with chronic conditions. UCLA Health is using the framework to organize care across specialties, build capacity, and grow a culture for value.

The effect of telehealth versus usual care for home-care patients with long-term conditions: A systematic review, meta-analysis and qualitative synthesis

Introduction Approximately 26 million people in the United Kingdom are living with one long-term condition and 10 million are living with two or more; these figures are projected to continue increasing (NHS England 2018). People with long-term conditions are two to three times more likely to have poor psychological wellbeing and utilise 50% of GP appointments, 64% of outpatient appointments and over 70 of inpatient bed days. Research in this population could help with increasing constraints on healthcare budgets and resources. Technology-enabled healthcare in the community might help improve quality of life and reduce healthcare costs of managing chronic disease but the overall impact is unclear, we therefore conducted a systematic review. Methods Keywords and MeSH terms were used to search MEDLINE and CINAHL. We included qualitative and quantitative studies that reported on adult home-care patients diagnosed with at least one long-term condition, comparing telehealth to usual home care. Meta-analyses and sensitivity analyses were conducted using RevMan 5. Qualitative findings were thematically synthesised and reported narratively. Results In total, 2568 studies were identified and nine (2611 participants) were included. Telehealth was not statistically significantly different versus standard home care for quality of life, psychological wellbeing, physical function, anxiety, depression, disease specific outcomes or bed days of care at 3, 6, 9 and 12 months. Qualitative findings showed patients found telehealth was beneficial for providing peace of mind and legitimising access to healthcare. Conclusion Telehealth may offer reassurance to those living in the community with long-term conditions; however, a lack of high-quality studies and heterogeneity between interventions makes conclusions difficult.

Distribution of hospital care among pediatric and young adult Hodgkin lymphoma survivors-A population-based cohort study from Sweden and Denmark.

The burden of late effects among Hodgkin lymphoma (HL) survivors treated according to contemporary protocols remains poorly characterized. We used nation‐wide registers to assess number of inpatient bed‐days and specialist outpatient visits among 1048 HL‐patients (<25 years, diagnosed 1990‐2010) and 5175 country‐, sex‐, and age‐matched comparators. We followed them for up to 24 years, with time‐dependent assessment of relapse status. International Classification of Diseases (ICD‐10) chapter‐specific hazard ratios (HRs) were assessed in Cox regression analyses, and nonparametric statistics described patterns of health‐care‐use. Relative to comparators, relapse‐free survivors were at increased risk of infections, diseases of the blood, endocrine, circulatory and respiratory systems, and unspecific symptoms, HRs ranging from 1.86 to 3.05. Relative to comparators, relapsed survivors had at statistically significantly increased risk of diseases reflecting practically all investigated disease‐chapters, HRs ranging from 1.60 to 18.7. Among relapse‐free survivors, 10% of the patients accounted for 80% of all hospital bed days, and 55% were never hospitalized during follow‐up. Among relapsed‐survivors, 10% of the patients accounted for 50% of the bed days, and only 24% were never hospitalized during follow‐up. In contrast, 10% of the comparators accounted for 90% of hospital bed days and 75% were never hospitalized. These findings challenge the impression of a uniformly distributed long‐term morbidity among all HL survivors and emphasize the need for early identification and attention to patients particularly susceptible to late effects, such as relapsed survivors.

Changing inpatient diabetes care in a district general hospital

Introduction: People with diabetes in hospital have longer lengths of stay and are at higher risk of experiencing avoidable harm. This has a significant impact on patient flow and capacity in any hospital Trust.Aims and Methods: A Trust-wide peripatetic inpatient diabetes service redesign was performed to deliver reduced medication errors, improved patient flow, reduced length of stay and reduced inpatient risk. The service redesign was delivered without new recurring expenditure on senior staff. The model of care was multidisciplinary and introduced consensus and evidence-based care with clear governance processes.Results: Following introduction of the new service on 7 December 2017 to 1 June 2018, a reduction in length of stay in both medicine and surgical divisions was seen with 2,168 ‘saved’ inpatient bed days compared with the same time period in the preceding year, which represented a significant cost saving for the Trust and improvement in patient flow. This was associated with a reduction in the number of diabetes-related Datix reports and serious untoward incidents.Conclusions: This is the first major diabetes service redesign in a small district general hospital. The introduction of a dedicated inpatient diabetes service has led to Trust-wide improvements in patient care and patient flow without additional cost to the Trust.

Effect of an integrated care pathway on use of primary and secondary healthcare by patients at high risk of emergency inpatient admission: a matched control cohort study in Tower Hamlets

ObjectivesTo assess the effects of an integrated care pathway on the use of primary and secondary healthcare by patients at high risk of emergency inpatient admission.DesignObservational study of a real-life...

TB or not TB? That is the question regarding TB treatment in a remote provincial hospital in Solomon Islands.

Tuberculosis (TB) remains a significant public health challenge in Solomon Islands. Limited healthcare resources, geography, and sociocultural beliefs, coupled with lack of laboratory diagnostic tools, leads to diagnostic and treatment outcome uncertainty. Kirakira Hospital (KKH) is the main provincial hospital of Makira-Ulawa Province in Solomon Islands. A retrospective clinical audit of hospitalised TB patients in KKH over a 2-year period between July 2015 and July 2017 was conducted. The cost of TB treatment was estimated by calculating the total number of inpatient bed days of treatment. Data were available for 42 of 78 listed TB patients including 23 males and 19 females, and 9 children aged less than 16 years. The average age was 35 years (range 9 months - 74 years). Thirty-five of these received a chest X-ray. All patients had at least one of the following: fever, night sweats, chronic cough and haemoptysis as part of their clinical TB presentation. Thirty-six completed the full 8-week duration of intensive HRZE treatment as inpatients of KKH. The audit shows the treatment of TB consumes 15% of the current healthcare budget of Makira-Ulawa Province. TB remains a common clinical diagnosis in KKH. TB consumes 15% of the current healthcare budget of Makira-Ulawa Province. The limited capacity and data about the management of TB in Makira province mean that it is not currently possible to measure if there has been any progress towards eradicating TB in Solomon Islands. Laboratory investigations for TB available in Makira including sputum analysis and the GeneXpert are required to improve the accuracy of diagnosis and identify multidrug resistant strains of TB. This needs to be coupled with robust monitoring and data collection of both inpatients and outpatients to ensure the current treatment protocols for TB are being followed in Makira-Ulawa Province. These steps are essential if TB is to be eradicated from the provinces of Solomon Islands by 2030.

PMH67 USING REAL WORLD DATA TO PROFILE CURRENT STANDARD OF CARE FOR SCHIZOPHRENIA PATIENTS AT A MENTAL HEALTH HOSPITAL IN RWANDA, AFRICA

This study was set up to collect real world data for patients in Rwanda receiving treatments for schizophrenia and to use this data to profile the current standard of schizophrenia care in Rwanda. Staff at Ndera Neuropsychiatric Hospital in Kigali independently identified a randomized group of patients with schizophrenia. Paper notes for 79 patients (58 male, 21 female) were extracted and provided to a qualified psychiatrist appointed by Rwanda Biomedical Centre (RBC). Notes were a combination of free-form notes in French, payment slips, prescription records and demographic forms. The psychiatrist reviewed the notes and transferred anonymous, non-identifiable patient data for recording by the research team. Supporting information collected included the annual report and other documents on hospital tariffs, travel costs from all districts, medicines formulary, etc. Patient records covered a span of 1-36 years (average 10 years treatment in hospital). At initial diagnosis, 80% of patients were under the age of 35 (age at first referral 16-56 yrs). Only 4% of patients did not have any inpatient admissions. Nearly 75% of carers were immediate family members. Regarding pharmaceutical treatments, 90% of patients were prescribed haloperidol and/or chlorpromazine (70/79). The only second-generation antipsychotics used were olanzapine and risperidone (18/79). Nearly 50% (37/79) had physical health checks done, most systematically in recent (<5) years. Weighted across patients and years in which activity was recorded, outpatient visits per year was 6.1 (range 2.6-9.4), inpatient admissions per patient per year was 1.2 (range 1.0-3.0), inpatient bed days per admission was 39.2 (range 9.5-135.0). A significant proportion of patients (19/79; 24%) had co-morbidities (biggest of these were alcohol and drugs). This pioneering study using real world data from schizophrenia patients in Rwanda shows that the current care pathway involves first-generation antipsychotics, long inpatient stays and significant travel burden.

Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data

SummaryBackgroundEvidence suggests that black, Asian and minority ethnic (BAME) groups have an increased risk of involuntary psychiatric care. However, to our knowledge, there is no published meta-analysis that brings together both international and UK literature and allows for comparison of the two. This study examined compulsory detention in BAME and migrant groups in the UK and internationally, and aimed to expand upon existing systematic reviews and meta-analyses of the rates of detention for BAME populations.MethodsFor this systematic review and meta-analysis, we searched five databases (PsychINFO, MEDLINE, Cochrane Controlled Register of Trials, Embase, and CINAHL) for quantitative studies comparing involuntary admission, readmission, and inpatient bed days between BAME or migrant groups and majority or native groups, published between inception and Dec 3, 2018. We extracted data on study characteristics, patient-level data on diagnosis, age, sex, ethnicity, marital status, and occupational status, and our outcomes of interest (involuntary admission to hospital, readmission to hospital, and inpatient bed days) for meta-analysis. We used a random-effects model to compare disparate outcome measures. We assessed explanations offered for the differences between minority and majority groups for the strength of the evidence supporting them. This study is prospectively registered with PROSPERO, number CRD42017078137.FindingsOur search identified 9511 studies for title and abstract screening, from which we identified 296 potentially relevant full-text articles. Of these, 67 met the inclusion criteria and were reviewed in depth. We added four studies after reference and citation searches, meaning 71 studies in total were included. 1 953 135 participants were included in the studies. Black Caribbean patients were significantly more likely to be compulsorily admitted to hospital compared with those in white ethnic groups (odds ratio 2·53, 95% CI 2·03–3·16, p<0·0001). Black African patients also had significantly increased odds of being compulsorily admitted to hospital compared with white ethnic groups (2·27, 1·62–3·19, p<0·0001), as did, to a lesser extent, south Asian patients (1·33, 1·07–1·65, p=0·0091). Black Caribbean patients were also significantly more likely to be readmitted to hospital compared with white ethnic groups (2·30, 1·22–4·34, p=0·0102). Migrant groups were significantly more likely to be compulsorily admitted to hospital compared with native groups (1·50, 1·21–1·87, p=0·0003). The most common explanations for the increased risk of detainment in BAME populations included increased prevalence of psychosis, increased perceived risk of violence, increased police contact, absence of or mistrust of general practitioners, and ethnic disadvantages.InterpretationBAME and migrant groups are at a greater risk of psychiatric detention than are majority groups, although there is variation across ethnic groups. Attempts to explain increased detention in ethnic groups should avoid amalgamation and instead carry out culturally-specific, hypothesis-driven studies to examine the numerous contributors to varying rates of detention.FundingUniversity College London Hospitals National Institute for Health Research (NIHR) Biomedical Research Centre, NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust, King's College London, and NIHR Collaboration for Leadership in Applied Health Research and Care North Thames at Bart's Health NHS Trust.

Acute hospital at home – an integrated, holistic and multidisciplinary service

To assess the impact, effectiveness and ongoing development of an acute hospital at home (AH@H) service, created in January 2014. Retrospective review of AH@H patients between January 2014 and September 2017 specifically focusing on patient satisfaction, inpatient hospital bed days saved, main conditions treated and re-admission rates. Of discharge to assess (D2A) patients between April 2016 and September 2017 focusing on bed days saved, reduction of care needs and regained independence. AH@H is a virtual inpatient ward run by a multidisciplinary team, who provide aspects of inpatient care to people in …

The impact of clozapine initiation and cessation on psychiatric hospital admissions and bed days: a mirror image cohort study.

Clozapine is the most effective medication for the positive symptoms of treatment-refractory schizophrenia. Although clozapine use is associated with fewer admissions, less is known about the impact of clozapine cessation on hospitalisation. The aims of this study were to investigate whether clozapine-reduced psychiatric inpatient admissions and bed days, and investigate patient factors associated with these changes from a sample of 1906 people commenced on clozapine. All people commencing clozapine during an acute hospitalisation over a 10-year period in Queensland, Australia, were included in this retrospective cohort study. A mirror image design was used to compare psychiatric bed days and hospitalisations 2years before and after clozapine treatment, and the impact of clozapine continuation or early cessation. Changes in psychiatric bed days and hospitalisations were analysed using linear regression, adjusting for the duration on clozapine, sex, age, indigenous status, country of origin and time to clozapine commencement. There was a significant reduction in bed days (29.55days vs 24.46days, p< 0.001) and admissions (2.27 vs 1.87< 0.001) associated with clozapine commencement. This remained significant among clozapine continuers, but not among those with early cessation. Longer duration on clozapine was associated with greater reductions in psychiatric bed days and admissions. Age, sex and time to clozapine commencement, indigeneity and country of origin did not impact outcomes. Longer clozapine therapy led to a greater reduction in psychiatric bed days and hospitalisations. Early cessation was associated with a return to pre-clozapine levels of bed days and admissions.

Economic Performance Analysis of Selected Military Hospitals Using Hospital Indicators and Inpatient Bed-Day Cost

Background: Hospitals, the main providers of healthcare services, are costly centers which account for about 80% of the health sector budget and have a huge share of resources. Objective: This study aimed to analyze the economic performance of selected military hospitals in Tehran using hospital indicators and inpatient bed-day costs. Methods: This descriptive, cross-sectional, retrospective study conducted in hospitals affiliated with a military medical university. Data was collected with forms completed by referring to the hospitals’ finance and accounting, medical records, staffing, and logistics departments. The extracted data converted to hospital indicators using the appropriate formulas and analyzed using Excel and SPSS software with the T-test. Results: The average bed occupancy rate (BOR) was 71%, the average length of stay (ALOS) was 2.5 days, the average bed turnover (BT) was 31 times, and the average bed turnover interval (BTI) was one day. The comparison of means of all the above-mentioned indicators other than BOR with the national standards was statistically significant (P &lt; 0.05). Inpatient bedday costs with and without capital costs were calculated to be 3312353 IRR and 12253775 IRR, respectively. Conclusion: Higher BOR and BT and lower ALOS and BTI indicators were appropriate compared with the national standards, but the cost performance was not appropriate. An unreasonable increase in inpatient bed-day cost revealed that there were unused beds and that hospitals had no monitoring systems for revenues and expenditures. Therefore, serious attention must be given to the scientific criteria and principles of health economics to improve resource productivity.

Early Results of the Prince of Wales Hospital Rapid Access Cardiology Clinic (RACC)

Background: Due to low bed availability at the Prince of Wales Hospital, a safe and timely pathway for low-risk cardiology outpatient evaluation was established. Similar clinics have limited their focus to chest pain presentations, whereas the scope of this clinic encompassed all general cardiology presentations. Our objective was to evaluate the implementation and benefit of the first six months of the Rapid Access Cardiology Clinic (RACC). Methods: Patient, presentation, and clinical outcome data was retrospectively audited between August 2018 and February 2019. Results: 63 patients were reviewed in the RACC (63% male, mean age 52.7 years). 79% of patients were reviewed within 3 days of referral. 59% of referrals were for assessment of chest pain, with the remainder including AF/flutter, SVT, palpitations, and syncope. Polypharmacy was present in 8% of patients. The predominant investigations performed were rest and stress echocardiography (43% and 49% respectively). 24 patients had subsequent outpatient investigations arranged, with 11 patients having a new medication prescribed. Only 1 patient required direct admission following review, with 33 (52%) being referred for ongoing cardiology follow up, and 25 (40%) being discharged from cardiology services. An estimated 31 inpatient bed days were saved as a result of this clinic Conclusion: A Rapid Access Cardiology Clinic provides an alternative pathway to inpatient investigation for a subset of low-risk general cardiology presentations, not only chest pain. Results indicate a safe and efficient means of accessing outpatient cardiology investigation.

Medicaid's Institutions for Mental Diseases (IMD) Exclusion Rule: A Policy Debate-Argument to Retain the IMD Rule.

Medicaid's Institutions for Mental Diseases (IMD) Exclusion Rule: A Policy Debate-Argument to Retain the IMD Rule.

Efficacy and cost-effectiveness of a community-based model of care for older patients with complex needs: a study protocol for a multicentre randomised controlled trial using a stepped wedge cluster design

BackgroundCommunity-dwelling older persons with complex care needs may deteriorate rapidly and require hospitalisation if they receive inadequate support for their conditions in the community.InterventionA comprehensive, multidimensional geriatric assessment with care coordination was performed in a community setting—Older Persons ENablement And Rehabilitation for Complex Health conditions (OPEN ARCH).ObjectivesThis study will assess the acceptability and determine the impact of the OPEN ARCH intervention on the health and quality of life outcomes, health and social services utilisation of older people with multiple chronic conditions and emerging complex care needs. An economic evaluation will determine whether OPEN ARCH is cost-effective when compared to the standard care.Methods/designThis multicentre randomised controlled trial uses a stepped wedge cluster design with repeated cross-sectional samples. General practitioners (GPs; n ≥ 10) will be randomised as ‘clusters’ at baseline using simple randomisation. Each GP cluster will recruit 10–12 participants. Data will be collected on each participant at 3-month intervals (− 3, 0, 3, 6 and 9 months). The primary outcome is health and social service utilisation as measured by Emergency Department presentations, hospital admissions, in-patient bed days, allied health and community support services. Secondary outcomes include functional status, quality of life and participants’ satisfaction. Cost-effectiveness of the intervention will be assessed as the change to cost outcomes, including the cost of implementing the intervention and subsequent use of services, and the change to health benefits represented by quality adjusted life years.DiscussionThe results will have direct implications for the design and wider implementation of this new model of care for community-dwelling older persons with complex care needs. Additionally, it will contribute to the evidence base on acceptability, efficacy and cost-effectiveness of the intervention for this high-risk group of older people.Trial registrationAustralian New Zealand Clinical Trials Registry, ACTRN12617000198325p. Registered on 6 February 2017.

1909. Do Infectious Disease Services Save Money? Accounting Analysis Before and After Introduction of a New Clinical Infectious Disease Service at a Tertiary Hospital in New Zealand

BackgroundInfectious disease and antimicrobial stewardship services are generally held to be cost-saving in large healthcare facilities. Actual comparisons comparing costs before and after implementation of a clinical infectious disease (CID) service are lacking.MethodsOur 600+ bed tertiary hospital funded a CID service in 2015. Prior to this, CID expertise was largely provided by telephone consultation to a microbiologist and/or a part-time CID specialist with no nursing, pharmacy or resident medical officer (RMO) support. Out-patient IV antibiotics (OPIVA) were provided at the discretion of individual clinicians. The new CID team introduced an in-patient consult and OPIVA service. A management accounting analysis was undertaken to compare the total costs of care for patients admitted to OPIVA in financial years (FY) 2011 and 2012 (FY11/12) and 2016 (FY16). Short courses of out-patient therapy for cellulitis were excluded during both periods.ResultsIn FY11/12 and FY16, 144 and 145 patients were discharged to OPIVA. 51 of 191 patients (27%) with CID consults for suspected or proven bacterial infection were admitted to OPIVA in 2016. Age, sex, and diagnosis were similar in both groups. Ceftriaxone and glycopeptide use increased in the 2016 cohort. Drug-related adverse events were more common in 2016 whilst line complications did not change. There were two unexpected OPIVA deaths in FY11/12 and none in FY16. Reduced in-patient bed-days in 2016 saved NZD 1.45 million, with an additional NZD 157,000 saving in total drug costs. This represented a 276% return on investment against wage costs for the CID team.ConclusionIn our hospital, a CID team significantly reduced bed-days and drug costs for common infectious diseases.Disclosures All authors: No reported disclosures.

Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis

SummaryBackgroundCompulsory community treatment (CCT) aims to reduce hospital readmissions among people with mental illness. However, research examining the usefulness of CCT is inconclusive. We aimed to assess the effectiveness of CCT in reducing readmission and length of stay in hospital and increasing community service use and treatment adherence.MethodsFor this systematic review and meta-analysis, we searched three databases (PsycINFO, MEDLINE and Embase) for quantitative studies on CCT published in English between Jan 1, 1806, and Jan 4, 2018. We included both randomised and non-randomised designs that compared CCT with no CCT, and pre-post designs that compared patients before and after CCT. Studies were eligible if they had been peer-reviewed, if 50% or more of patients had severe mental illness, and if CCT was the intervention. Trials in which CCT was used in response to a criminal offence were excluded. We extracted data on study characteristics and length of follow-up, patient-level data on diagnosis, age, sex, race, and admission history, and outcomes of interest (readmission to hospital, inpatient bed-days, community service use, and treatment adherence) for meta-analysis, for which we extracted summary estimates. We used a random-effects model to compare disparate outcome measures and convert effect size statistics into standardised mean differences. This systematic review is registered with PROSPERO, number CRD42018086232.FindingsOf 1931 studies identified, 41 (2%) met inclusion criteria and had sufficient data for analysis. Before and after CCT comparisons showed significant large effects on readmission to hospital (standardised mean difference 0·80, 95% CI 0·53–1·08; I2=94·74), use of community services (0·83, 0·46–1·21; I2=87·26), and treatment adherence (2·12, 1·69–2·55; I2=0), and a medium effect on inpatient bed-days (0·66, 0·46–0·85; I2=94·12). Contemporaneous controlled comparison studies (randomised and non-randomised) showed no significant effect on readmission, inpatient bed-days, or treatment adherence, but a moderate effect on use of community services (0·38, 0·19–0·58; I2=96·92). A high degree of variability in study quality was found, with observational study ratings ranging from three to nine. Bias most frequently centred on poor comparability between CCT and control participants.InterpretationWe found no consistent evidence that CCT reduces readmission or length of inpatient stay, although it might have some benefit in enforcing use of outpatient treatment or increasing service provision, or both. Future research should focus on why some people do not engage with treatment offered and on enhancing quality of the community care available. Shortcomings of this study include high levels of variability between studies and variation in study quality.FundingNational Institute for Health Research.