Lower Admission Rates Research Articles

Audit of outpatient laparoscopic cholecystectomy. Universities of Melbourne HPB Group.

Because the postoperative stay after laparoscopic cholecystectomy (LC) has shortened, it seemed that outpatient LC would be feasible. The aim of this study was to prospectively audit initial experience with outpatient LC at the Austin and Repatriation Medical Centre. We aimed to determine appropriate patient selection criteria, to devise anaesthetic and discharge protocols and to assess patient satisfaction at follow up. All patients presenting for LC were assessed for suitability, and those elective cases unlikely to have a duct stone and fulfilling the social criteria were studied. After standard anaesthetic and LC technique, patients recovered in the day surgery unit for up to 8 h and were discharged if stable. The hospital in the home nursing service monitored patients for 48 h and arranged readmission if needed. Patient satisfaction was assessed by independent telephone questionnaire 6 weeks postoperatively. Forty-five patients (median age 43 years) underwent outpatient LC with a discharge rate of 82.3%, resulting in a cost saving of $984 per patient treated. One patient was readmitted, giving an overall success rate of 80%. After stricter implementation of the protocol in the second half of the study, the discharge rate rose to 92%. Patient acceptance of the technique was high at 84.5%. The results of the first 45 patients show that it is possible to safely perform outpatient LC with a low admission rate in fit, elective patients who live close to medical care. Provided a strict anaesthetic protocol is followed, the technique has good patient acceptance and provides some economic benefit to the hospital.

Neonatal Effects of Nifedipine and Ritodrine for Preterm Labor

In Brief Objective We compared nifedipine and ritodrine for treatment of preterm labor with respect to neonatal outcome. Methods We conducted an open randomized multicenter study of neonatal outcome in 185 women who received either oral nifedipine (n = 95) or intravenous (IV) ritodrine (n = 90) for treatment of preterm labor. Secondary outcome measures included neonatal mortality and morbidity, especially neonatal intensive care unit (NICU) admission, respiratory distress syndrome (RDS), and intracranial bleeding. Results There were no significant differences in umbilical artery pH values and Apgar scores between groups. Nifedipine was associated with lower admission rates to the NICU (49% versus 66%; odds ratio 0.51, confidence interval 0.28, 0.93) compared with ritodrine, and lower incidences of RDS (21% versus 37%; 0.46, 0.24, 0.89), intracranial bleeding (18% versus 31%; 0.48, 0.24, 0.96), and neonatal jaundice (52% versus 67%; 0.53, 0.29, 0.97). Logistic regression analysis showed that even after correction for gestational age at birth, newborn risk of RDS, intracranial bleeding, or neonatal jaundice was significantly lower in the nifedipine group than the ritodrine group. Conclusion Nifedipine for treatment of preterm labor was associated with a lower incidence of neonatal morbidity than ritodrine. That difference appeared to be partly because of the higher tocolytic efficacy of nifedipine and partly because of an intrinsic beneficial effect of nifedipine, or the lack of harmful effects when compared with ritodrine. Nifedipine for preterm labor is associated with less frequent neonatal morbidity than ritodrine.

Neonatal effects of nifedipine and ritodrine for preterm labor

Objective: We compared nifedipine and ritodrine for treatment of preterm labor with respect to neonatal outcome. Methods: We conducted an open randomized multicenter study of neonatal outcome in 185 women who received either oral nifedipine ( n = 95) or intravenous (IV) ritodrine ( n = 90) for treatment of preterm labor. Secondary outcome measures included neonatal mortality and morbidity, especially neonatal intensive care unit (NICU) admission, respiratory distress syndrome (RDS), and intracranial bleeding. Results: There were no significant differences in umbilical artery pH values and Apgar scores between groups. Nifedipine was associated with lower admission rates to the NICU (49% versus 66%; odds ratio 0.51, confidence interval 0.28, 0.93) compared with ritodrine, and lower incidences of RDS (21% versus 37%; 0.46, 0.24, 0.89), intracranial bleeding (18% versus 31%; 0.48, 0.24, 0.96), and neonatal jaundice (52% versus 67%; 0.53, 0.29, 0.97). Logistic regression analysis showed that even after correction for gestational age at birth, newborn risk of RDS, intracranial bleeding, or neonatal jaundice was significantly lower in the nifedipine group than the ritodrine group. Conclusion: Nifedipine for treatment of preterm labor was associated with a lower incidence of neonatal morbidity than ritodrine. That difference appeared to be partly because of the higher tocolytic efficacy of nifedipine and partly because of an intrinsic beneficial effect of nifedipine, or the lack of harmful effects when compared with ritodrine.

A prospective audit against national standards of the presentation and management of acute pancreatitis in the South of England

BACKGROUNDThe incidence of acute pancreatitis shows regional variations in the UK.AIMSTo document the incidence and presentation of acute pancreatitis in hospitals in Wessex, and to audit the process and outcome...

Tratamiento de la angina refractaria con electroestimulación medular. Resultados del seguimiento a largo plazo

The quality of life in patients with refractory angina has been shown to improve dramatically with spinal cord stimulation because of its beneficial results. The aim of this study was to assess the long-term morbimortality of this technique of spinal cord stimulation in the long term. 41 patients with refractory angina and treated with spinal cord stimulation were included. Median follow-up was 31.0 [12.0-42.5] months, and total follow-up was 1,236 months. Annual number of admissions per patient year were dramatically reduced after spinal cord stimulation (2.31 vs. 0.28). Patients that died during follow-up had a 3-fold increase rate of admissions than patients that survived (0.37 vs. 0.19). However, patients that died during follow-up also had a lower admission rate after spinal cord stimulation (2.03 vs. 0.37). Overall mortality was 9.7%/year; cardiac mortality was 7.7%/year. Both figures are not different from those of other groups of patients with similar anatomical characteristics of coronary artery disease severity without spinal cord stimulation. Complications of this treatment were minimal (we only observed an early post implantation infection and a battery extrusion, without any complications with electrodes). The outcome was similar in patients with subacute unstable refractory angina or stable angina. Spinal cord stimulation can be considered a safe and effective alternative treatment of refractory angina. Long-term morbidity is low, and mortality is not higher than the expected in this group of patients.

The Ethical Challenge and the Futile Treatment in the Older Population Admitted to the Intensive Care Unit

Projections for the future suggest that the United States population will grow by 10-15% by the year 2000, but the number of people over the age of 80 will increase by 66%. As a result, the increase that has already been observed in the number of elderly patients requiring major medical attention can only be expected to grow. This study reviews the admissions to the intensive care unit (ICU) over the last 5 years by age to analyze whether the ICU admissions are higher for the patients older than 60 years of age. We considered all the admissions to the surgical (SICU) and medical (MICU) intensive care units at Morristown Memorial Hospital from January 1, 1992, to December 31, 1996. Patients were divided into age brackets (0-9 years, 10-19 years, 20-29 years,... > 90 years) and by gender. Medical and surgical admissions were analyzed including the average length of stay in the ICU. Daily charge for bed occupancy was reviewed based on the hospital data reported in 1995. The death rate was also considered. Fisher-corrected chi 2 and a Student t test were used for statistical analysis. A total of 6243 patients (2926 female and 3317 male) were admitted to the ICU over the 5-year period. The ICU admissions rate was higher in patients above 60 years of age compared with those below 60 (60% versus 30%, respectively). The age group with the highest admissions rate was between 70 and 79 years, followed by the 60-69-year group. These two groups had significantly more admission than all other groups (P < 0.001). Medical patients' length of stay was shorter than the surgical group, and they had a lower rate of admission to the ICU. The death rate was higher in the group older than 60 years. They also spent a longer time in ICU compared with the younger group (22 +/- 7 days versus 12 +/- 8 days). The charge per day per bed was $2100 in the ICU, $1600 in a telemetry floor, and $950 in a regular floor. The charge per bed in the group above 60 years old was double compared with the one for the younger group. Older patients were admitted to the ICU with a significantly higher frequency than was the younger group. There were more surgical than medical patients admitted to the ICU. The mortality rate and the daily cost, based on daily bed charge, was significantly higher in the older group. Based on our experience, older people had a more difficult recovery in ICU than did the younger people. In our opinion we should treat acute critical illness but not terminal pathology. A problem exists in educating physicians about which patients will derive no benefit from the ICU. This will determine if we can decrease or avoid the use of the ICU and its accompanying expense, in situations where it does not significantly increase survival and the quality of life.

Utility of Serum Electrolytes in the Management of Dehydration 391

Background: The serum electrolyte panel (SEP) is a frequently ordered laboratory test and of unproved utility in the management of dehydrated pediatric patients. Many clinicians believe that the bicarbonate level may be predictive of patient outcome. Our purpose is to study the incidence of SEP abnormalities and assess their role in management.Methods: Children between the ages of 2 months and 18.8 years receiving intravenous fluids for dehydration were prospectively studied. Historical data, physical examination findings, degree of dehydration and SEP were obtained. Attending physicians documented prior to knowing laboratory results whether they would have ordered a SEP. Outcome measures included changes of management based on SEP, disposition, and return visits within 48 hours. Results: 206 patients were entered with a median age of 19.2 months. 123 patients presented with mild (≤5%), 81 with moderate (6-10%) and 2 with severe dehydration (>10%). The incidence of SEP abnormalities was 46% for one or more abnormal values. 29% had BUN levels > 17mg/dl, 26% had bicarbonate levels 150mmol/L. Considering the 54 patients with bicarbonates <16mmol/L; 27 were discharged home, 22 were placed into observation and 5 were admitted. At 95% significance, bicarbonate was lower in those placed into the observation unit versus those discharged home. There was no correlation between low bicarbonate and admission rates or return visits. The attending thought a SEP was needed in 33% of the cases. Knowing the SEP did not change management in 91%. In 17 patients the SEP changed management; 5 with low glucose values received glucose sooner, 5 with low bicarbonate levels were observed longer, 3 with reassuring values were sent home sooner, and 2 with low potassium levels received potassium. There were 10 return visits requiring IV fluids within 48 hours, 8 (2 with bicarbonates <16) were admitted. Conclusion: Although there were a large number of SEP abnormalities, there was minimal effect on clinical management or patient outcome. Low bicarbonate levels were predictive of observation unit placement but not for need of hospitalization or patient return visits.

ENT day surgery in England and Wales--an audit by the Royal College of Surgeons (Eng.) Comparative Audit Service.

An audit of day surgery was carried out by the Royal College of Surgeons (Eng.) Comparative Audit service. Data from 121 respondents on over 3,962 day cases were analysed from both retrospective information and from prospective individual patient proformas. The day surgery rate is 31 per cent. The variability of facilities for day-surgery, the timing of lists, type of anaesthetic used and case-mix are discussed. Outcome and the reasons for admission to an overnight bed are analysed. The overall admission rate was found to be 2.8 per cent (range 0.6-19.5 per cent between consultants). Seventy per cent of ENT day-surgery was performed on morning lists which have a lower admission rate than afternoon lists. The main reasons for admission are vomiting 30 per cent, haemorrhage 20 per cent and inadequate recovery from anaesthetic 22 per cent. A more detailed analysis of reasons for admission were given for tonsillectomy, adenoidectomy, FESS, and grommets. Recommendations are given which might increase the scope of safe day-surgery and reduce admission rate.

Ampicillin-Metronidazole Treatment in Idiopathic Preterm Labour

Objective To determine whether treatment with ampicillin and metronidazole in women with threatened idiopathic preterm labour will prolong the gestation and reduce maternal and neonatal infectious morbidity. Design Randomised controlled double-blind trial. Setting Six obstetric departments in the Copenhagen area. Population One hundred and twelve women with singleton pregnancies, with threatened idiopathic preterm labour and intact amniotic membranes at 26 to 34 weeks of gestation. Methods Random allocation to eight days intravenous and oral treatment with ampicillin and metronidazole, or placebo. Main outcome measures Number of days from admission to delivery, gestational age at delivery, rates of preterm delivery, low birthweight, maternal infections and neonatal infections. Results Treatment with ampicillin and metronidazole was associated with a significant prolongation of pregnancy (admission to delivery 47.5 days versus 27 days, P < 0.05), higher gestational age at delivery (37 weeks versus 34 weeks, P < 0.05), decreased incidence of preterm birth (42%versus 65%, P < 0.05), and lower rate of admission to neonatal intensive care unit (40%versus 63%, P < 0.05), when compared with placebo treatment. Antibiotic treatment had no significant effects on infectious morbidity. Conclusions Treatment with ampicillin and metronidazole in women with threatened idiopathic preterm labour significantly prolonged the gestation, but had no effects on maternal and neonatal infectious morbidity.

Effectiveness of Selective Use of Intravenous Pyelography in Patients Presenting to the Emergency Department with Ureteral Colic.

To determine whether IV pyelography (IVP) is required routinely for all patients presenting to the ED with ureteral colic. A randomized prospective study was conducted with 2 patient groups-a routine IVP group, in which all patients underwent IVP, and a selective IVP group, in which patients were treated, observed, and released without undergoing IVP unless they experienced continued symptoms. The study was performed in a large university-affiliated, community hospital ED. Participants were patients aged 18-65 years with signs and symptoms consistent with ureteral colic. Among the 40 patients enrolled in the routine IVP group, 26 had positive studies, 8 of which necessitated hospitalization. Among the 41 patients randomized to the selective IVP group, there were only 19 IVPs performed, of which 6 were positive and 4 necessitated hospitalization. Compared with the routine IVP group, there were 54% fewer FVPs performed and a 51 % lower admission rate in the selective IVP group. Despite the fact that fewer IVPs were performed in the selective IVP group, clinical outcomes in the 2 groups were similar, without significant complication in either group. IVPs do not need to be routinely performed for all patients presenting to the ED with ureteral colic. The decision to perform an IVP may be dictated by symptoms that persist after initial evaluation and treatment.

Aspects of psychiatric admissions of migrants to hospitals in Perth, Western Australia.

Recent Australian Government initiatives have emphasised problems with service provision to the ethnic mentally ill. This study aims to address the paucity of contemporary data describing the disposition of the ethnic mentally ill in hospital settings. Patterns of admissions for psychiatric disorders to all hospitals in Perth, Western Australia, for the 3 years from 1990 to 1992, of migrants and the Australian born were compared using data from the Western Australian Mental Health Information System. The overall rates for European migrants showed a 'normalisation' towards those of the Australian-born. There were high rates for the schizophrenic spectrum disorders in Polish and Yugoslavian (old terminology) migrants. There were low admission rates for South-East Asian migrants, predominantly those from Vietnam and Malaysia. Rates for alcoholism were low in Italian and all Asian migrants. There were high rates of organic psychosis, especially in those older than 75 years, among the Italian and Dutch migrants. The relative risk of a first admission in the 3 years being an involuntary admission to a mental hospital was almost twice that of the Australian-born for migrants from Poland, Yugoslavia, Malaysia and Vietnam. The results imply the possibility of significant untreated and/or undiagnosed psychiatric morbidity in the South-East Asian-born. They also indicate a need for further exploration of the unexpectedly high levels of psychiatric morbidity among some ethnic elderly groups, specifically the Dutch- and Italian-born. The findings demonstrate the persistence of high rates of presentation for psychotic disorders among Eastern European-born populations, many years post migration.

Assessing the structure, content, and perceived social climate of residential posttraumatic stress disorder treatment programs

AbstractThis study utilized a comprehensive assessment of program structure, content, and social climate to determine whether specialized residential posttraumatic stress disorder (PTSD) programs (SIPUs, n = 19) can be differentiated from general psychiatric units (GPUs, n = 18) within the Department of Veterans Affairs. Significant differences between program types were found: SIPUs were more clearly differentiated from the larger hospital system, had more strict patient selection criteria and program regulations, longer length of stays and lower admission rates, and spent more program time on PTSD symptoms and war zone experiences than GPUs. Veterans in the SIPUs (n = 453) rated the programs significantly higher on most social climate measures than veterans with PTSD in the GPUs (n = 153), indicating that veterans perceived these programs as more active, supportive, and better structured.

Assessing the structure, content, and perceived social climate of residential posttraumatic stress disorder treatment programs.

This study utilized a comprehensive assessment of program structure, content, and social climate to determine whether specialized residential posttraumatic stress disorder (PTSD) programs (SIPUs, n = 19) can be differentiated from general psychiatric units (GPUs, n = 18) within the Department of Veterans Affairs. Significant differences between program types were found: SIPUs were more clearly differentiated from the larger hospital system, had more strict patient selection criteria and program regulations, longer length of stays and lower admission rates, and spent more program time on PTSD symptoms and war zone experiences than GPUs. Veterans in the SIPUs (n = 453) rated the programs significantly higher on most social climate measures than veterans with PTSD in the GPUs (n = 153), indicating that veterans perceived these programs as more active, supportive, and better structured.

Why don't all general practices offer structured diabetes care?a comparison of practices that do not with those that do

The aim of the study was to examine whether the minority of practices not qualifying for payment for structured diabetes care programmes differ systematically from those that do. Information was collected for all Leicestershire general practices on practice size, population structure, deprivation indices, diabetes related admissions over two years and number of insulin treated patients on the district register. The 21 practices not offering structured diabetes care had a median list size of 3204, compared to 6340 for the other 124 practices (P < 0.001). Jarman and Townsend scores were higher for these practices and estimated prevalence of diabetes was 29% higher (95% CI: 26-32%). Crude admission rates were significantly higher in those practices not offering structured care. However rates adjusted for diabetes prevalence were similar (39.3 vs 39.2 per 100 insulin treated diabetics per year, P = 0.9). These results suggest that some practices face specific problems related both to small practice size and higher prevalence. If these issues are not addressed, inequalities in access to diabetes care between practice populations will persist. There is no evidence that the provision of structured care is associated with lower admission rates in this district. However more information, particularly in relation to prevalence of diabetes, is needed in order to accurately quantify this relationship. Variations in prevalence between practices should be adjusted for in any comparison of admission rates or spurious conclusions may be drawn.

A Cohort Study on Childhood Asthma Admissions and Readmissions

Admissions to hospitals for childhood asthma seem to be increasing, even though admissions for other childhood conditions are decreasing. We studied admissions and readmissions for childhood asthma in Ontario in an attempt to uncover factors relating to the admission patterns. Using the hospital discharge data from the Canadian Institute for Health Information, 28,646 children with diagnoses of asthma were identified from April 1, 1989, to March 31, 1992. The admission rates for asthma among children in Ontario showed a 14.8% decrease from 1987 to 1992. This decline was observed primarily in 5- to 17-year-olds. Younger children had a fourfold risk of hospital admission for asthma. In the 4 years studied, 10,427 children (36.4%) were readmitted at least once, representing 22,114 readmissions, 16,196 (73.2%) of which were for asthma. The 6-month probabilities of readmission for asthma were 20.0% (0- to 4-year-olds) and 11.7% (5- to 17-year-olds). The estimated relative risks (RRs) indicated that younger children had a significantly higher risk of readmission for asthma (RR, 1.38; 95% confidence interval, 1.30 to 1.46) or asthma-related causes (RR, 5.02; 95% confidence interval, 4.16 to 6.05). The observed increasing trend in admissions for asthma among children in the 1970s and 1980s leveled off in the early 1990s. The declining admission rates were largely caused by the lower admission rates among school-aged children from 5 to 17 years. The relatively high admission and readmission rates of preschool children are still a concern. Further research is necessary to examine factors that influence admissions for asthma among young children.

The use of Medicare home health care services.

Medicare's home health care program, consisting primarily of home visits by nurses and health aides, was conceived as a means to facilitate hospital discharge. Because home health care is now one of the fastest-growing categories of Medicare expenditures, we analyzed Medicare claims data to determine current patterns of use. We used 1993 data from Medicare's National Claims History File to examine the temporal relation between home visits and hospital discharge, as well as the number of months Medicare enrollees received home health care. To determine whether home visits replaced hospital services, we calculated population-based utilization rates, adjusted for age and sex, for enrollees living in the 310 U.S. metropolitan statistical areas and determined whether the areas with higher rates of home health care also had lower admission rates or shorter lengths of stay. Finally, we compared the geographic variation in use of home health care with that of other Medicare services. Roughly 3 million Medicare enrollees received over 160 million home health care visits in 1993. Seventy-eight percent of the visits either occurred more than a month after hospital discharge (35 percent) or were not associated with any inpatient care during the previous six months (43%). Home health care often represented a long-term intervention: 61 percent of the visits were to enrollees who received home health care for six months or more. We could find no evidence that home health care was substituted for hospital care; the metropolitan statistical areas with higher rates of home health care did not have fewer hospital admissions or shorter lengths of stay. There was more geographic variation in the use of home health care than in the use of other major categories of Medicare services (e.g., hospital admissions and physicians' services). Five states (all in the South) had more than 9000 visits per 1000 enrollees, and 14 states had fewer than 3000 visits per 1000 enrollees. Home health care visits are used primarily to provide long-term care. There is no evidence that services provided at home replace hospital services, and the dramatic geographic variation in home visits suggests a lack of consensus about their appropriate use.

Triage decisions for emergency department patients with chest pain: do physicians' risk attitudes make the difference?

To determine whether physicians' risk attitudes correlate with their triage decisions for emergency department patients with acute chest pain. Cohort. The emergency department of a university teaching hospital. Patients presenting to the emergency department with a chief complaint of acute chest pain. PHYSICIANS: All physicians who were primarily responsible for the emergency department triage of at least one patient with acute chest pain from July 1990 to July 1991. The physicians' risk attitudes were assessed by two methods: 1) a new, six-question risk-taking scale adapted from the Jackson Personality Index (JPI), and 2) the Stress from Uncertainty Scale (SUS). The physicians who had high risk-taking scores ("risk seekers") admitted only 31% of the patients they evaluated, compared with admission rates of 44% for the medium scores and 53% for the physicians who had low risk-taking scores ("risk avoiders"), p < 0.001. After adjustment for clinical factors, the patients triaged by the risk-seeking physicians had half the odds of admission [odds ratio (OR) 0.51, 95% confidence interval (95% CI) 0.27 to 0.97], and the patients triaged by the risk-avoiding physicians had nearly twice the odds of admission (OR 1.83, 95% CI 1.10 to 3.03) of the patients triaged by the medium-risk scoring physicians. The SUS did not correlate significantly with admission rates. Of the 92 patients released home by the risk-seeking physicians, 91 (99%) were known to be alive four to six weeks afterwards and one was lost to follow-up; among the 66 patients released by the risk-avoiding physicians, 64 (97%) were known to be alive at four to six weeks, one was lost to follow-up, and one died of ischemic heart disease during a subsequent hospitalization (p = NS). The physicians' risk attitudes as measured by a brief risk-taking scale correlated significantly with their rates of admission for emergency department patients with acute chest pain. These data do not suggest that the risk-seeking physicians achieved lower admission rates by releasing more patients who needed to be in the hospital, but an adequate evaluation of the appropriateness of triage decisions of risk-seeking and risk-avoiding physicians will require further study.

The psychiatrist in primary care: let's look before we leap

AbstractObjective: Irish psychiatrists may begin to spend, as their British have counterparts have, at least some of their time delivering a psychiatric service from primary care settings. It was therefore decided to review the origins and development of attitudes towards and outcome this practice in Britain.Method: A literature search and review of relevant papers was undertaken.Results: Collaboration between psychiatrists and general practitioners began to expand significantly in the 1970s and 1980s. Three main models are used, the shifted outpatient model, the selected consultation model and the liaison-attachment team model. The shifted out-patient model is liked by patients whose attendance rate is better at such clinics and in some areas this model has resulted in a fall in hospital admission rates. There is a paucity of papers examining outcome of the other models. Results of the one extensively studied team liaison approach reports higher treated prevalence rates and lower admission rates for those patients referred. There was no effect on detection of illness by GPs and the service was much more costly.Conclusions: While some benefits may result from use of the shifted out-patient approach, they are not compelling enough to enable a firm recommendation for its widespread implementation to be made. The results to date suggest the team-liaison approach does not produce benefits sufficient to outweigh the increased cost. The selected consultation model may hold greater potential but needs to be more extensively researched. Finally the structure of general practice in Ireland, with so few GPs working in multiple partner practices makes it highly unlikely that the widespread introduction of collaboration will be feasible.

A small area analysis of psychiatric hospitalizations to general hospitals: Effects of community mental health centers

Population-based psychiatric admission rates vary across geographic areas, but reasons for this variation are unknown. Insofar as CommunitymMental Health Centers (CMHCs) provide outpatient services that may deter the need for hospitalization, the presence and structural characteristics of CMHCs may have an impact on a population's psychiatric admission rates. This study uses small area analysis to examine how general hospital psychiatric admission rates are associated with CMHC characteristics. Based on a survey of all CMHCs in Iowa and corresponding small area variation data, it was found that population admission rates were higher in areas closer to the CMHC and lower in outlying catchment areas, adjusting for age, sex, and urban/rural differences in populations. There was little evidence that differences in staffing and service variables influenced admission rates, although greater CMHC staff coverage by social workers and psychiatric residents was associated with lower admission rates. The results suggest that CMHCs do not lower an area's hospitalization rate, and in fact, the presence of CMHCs may promote a “supplier-induced demand” phenomenon of higher admissions.

Recruiting subjects for clinical aggression research

The authors discuss the process and problems of recruiting subjects for a study of violent behavior experienced by otherwise normal adults. In a recent study, intensive recruitment efforts generated 443 self-referrals that resulted in the entry of ten percent of the inquirers. Descriptive clinical and demographic profiles of applicants are presented with emphasis on factors associated with noninclusion. Possible explanations for low admission rates are explored. The authors offer three specific recommendations which should help other investigators to recruit suitable subjects for clinical aggression research.