Selective Admission Policies Research Articles

The inverse relationship between cost and survival in the critically ill cancer patient.

The enormous cost of intensive multiple organ system support is apparent from patient or third party charges of $1500--$2000 per day exclusive of physician fees sampled during a retrospective review of 700 consecutive recent admissions to the Critical Care Facility of Memorial Cancer Center. Mortality rates of 49% for general medical, 54% for lymphoma or leukemia, and 20% for surgery patients suggest the need for a selective admission and discharge policy which concentrates financial and personnel resources on those for whom there remains a reasonable chance of worthwhile palliation, if not cure, of their malignancy. An informal policy of this kind may have contributed to a 10% increase in hospital discharges and a reduction of in-unit mortality from 22--18% when compared to 1035 earlier unselected admissions. A modified version of the classification suggested by the Critical Care Committee of the Massachusetts General Hospital has been adopted for use at this institution. A similar approach by other cancer centers is urged so that predictive indices based on prognosis of the underlying disease as well as physiological status may be developed. Otherwise, cost-benefit analysis by third party payers or government will become an unavoidable, and less satisfactory, alternative.

General Policies in the Development of Mental Health Services in the Netherlands

The present situation in the distribution of mental health facilities in the Netherlands shows a high concentration in certain areas whereas others have little or nothing in respect of mental hospital beds. This is illustrated in the accompanying map, which is reproduced from the recent hospital atlas produced by the Dutch National Hospital Institute and gives the position in January 1975. The country is divided into 11 provinces; the population is about 13.5 million, and has been growing only slowly in recent years. Intramural mental health care is provided by 60 institutions, which include 38 mental hospitals, 7 university hospitals, and a number of specialized hospitals. Together they have approximately 29,000 beds, which represents about 2.15 per 1,000 of the general population. However, as mentioned above, these services are by no means equally distributed throughout the country. When most of the mental hospitals were built, it was the policy to isolate the mentally ill, to a large extent, from the general community. Much attention was paid then to having spacious, quiet grounds and possibilities of agricultural work for patients. The latest figures showed 2,068 psychiatric beds in use, in 62 general hospitals, with a maximum of 40 beds in any unit. The number of admissions to these beds is over 13,000 per annum, compared with about 17,000 to mental hospitals. However, generalhospital admissions are of shortstay patients, whereas those to mental hospitals are nonselective. Up to now, generalhospital units have had to have a selective admission policy, are not equipped for the care of longstay patients , do not operate through multidisciplinery collaboration, and have poor facilities for occupational therapy.

The role of the state hospital in the care of the elderly.

Abstract:Advances in psychiatry and new attitudes of society toward the mentally ill have been instrumental in the transformation of the mental hospital from an asylum for deviants into an active therapeutic center for mental illnesses. Also a new approach has crystallized towards the geriatric group who until recently were placed indiscriminantly in mental hospitals.In New York State mental hospitals the new selective admission policy for elderly patients showed in nine months more than a 30 per cent reduction of geriatric admissions and a significantly decreased mortality rate in the geriatric group. The use of newer therapeutic techniques has shown good promise and has changed the outlook for geriatric patients who previously received custodial care only. The release of elderly patients who improved to the extent of being able to live outside the hospital has been rather slow because of shortages in facilities and services in the communities. The Department of Mental Hygiene gives high priority to the funding of community programs for the elderly which will serve as alternatives more desirable than placement in a mental hospital. It is expected that when these programs are fully implemented the release of elderly patients from mental hospitals will be accelerated.