Comparative Efficiency Ratings Between Public and Private Acute Inpatient Facilities

Abstract

Objectives: The aims of this study are to compare clinical outcomes and efficiency ratings in an acute psychiatric inpatient facility with findings from other studies, and to examine relationships between symptom severity, admission medico-legal status and length of stay.

Method: The Health of the Nation Outcome Scales was administered at admission and discharge and analysed against admission medico-legal status and length of stay. Efficiency ratings were calculated and compared with those from other acute psychiatric inpatient settings.

Results: Clinical outcomes and efficiency ratings were similar to those from other public acute inpatient facilities, with greater admission severities and higher efficiency ratings than those found in private facilities. Involuntary hospitalisation was found to be associated with higher admission severities and longer lengths of stay.

Conclusions: Outcome or effect size is enhanced by higher admission severities, however, mean outcome per 10 days of stay is decreased by involuntary admission legal status. Factors unrelated to admission legal status effect differences in efficiency ratings found between public and private acute psychiatric inpatient facilities.

Mental health services are being subjected to closer economic scrutiny than has previously been the case [1]. An increasing emphasis on resource monitoring and value for money auditing reflects the increasing scarcity of public funding, and places greater pressure on services to produce evidence of efficient management. Recent studies [2,3] have used the Health of the Nation Outcome Scales (HoNOS) [4] to compare patient outcomes and efficiency ratings in public and private acute psychiatric inpatient facilities. The HoNOS has been widely adopted as a routine measure of patient outcome and provides a brief, broad, non-diagnosis-specific rating of patient progress suitable for use in a range of psychiatric settings. Although both hospital settings demonstrated substantial symptom reduction, measures of efficiency, as defined by Boot et al. [3], were found to be higher in public facilities.

There is currently no generally agreed-upon standard of measurement of mental health service efficiency. Andrews [1] defines efficiency in mental health settings as the resources required to produce health gains. An operational definition of efficiency developed by Boot et al. [3] analyses HoNOS and length of hospital stay (LOS) data to compute an outcome or effect size, and a mean outcome per 10 days of stay as an index of efficiency. Using this formula, Boot et al. [3] and Trauer et al. [2] found that admission severities for patients with schizophrenia and major affective disorder tended to be higher in the public settings, but LOS tended to be shorter, resulting in higher efficiency ratings. Trauer et al. [2] showed that the higher outcome or effect size found in public settings was a consequence of higher admission severities. They suggested that the higher mean outcomes per 10 days of stay found in public facilities was due to the greater proportion of involuntary patients. They contended that involuntary patients have higher admission severities, particularly for behavioural problems such as self-harm, which may be more amenable to rapid improvement and require a shorter LOS. Trauer et al. [2] conclude that greater admission symptom severity and possible shorter LOS for involuntary patients combine to create an impression of greater efficiency in public settings.

This study tests this hypothesis by comparing HoNOS and LOS data for voluntary and involuntary patients collected over an 8 month period from an acute psychiatric inpatient unit in a public general hospital in South Australia. Relationships between symptom severity, admission medico-legal status and LOS are reported, and clinical outcomes and efficiency ratings, using Boot et al.'s [3] operational definition, are compared with the results reported by Trauer et al. [2].

Method

Ward 1G is a 20-bed acute psychiatric inpatient unit located at the Lyell McEwen Hospital in northern metropolitan Adelaide. The ward is one of two public acute inpatient units of the North-western Adelaide Mental Health Service, which also provides a range of community mental health services. Both wards provide facilities for involuntary patients requiring more secure accomodation. Public mental health treatment settings differ essentially from private facilities in that they are reliant on government funding and there is no financial cost to patients, whereas private hospitals are largely privately funded and patients require hospital insurance cover for admission. Over an 8-month period hospital clinical staff assessed all patients on admission and discharge using Version 4 of the HoNOS [4].

Of 402 admissions, 138 had a primary diagnosis of schizophrenia or other psychosis, and 162 were diagnosed with a major affective disorder. The present analysis is confined to the two diagnostic categories of schizophrenia and major affective disorder to enable a comparison with data from Trauer et al.'s [2] study. These two diagnostic groups (n = 300) represented 75.8% of total admissions. The mean ages and gender distributions for patients with schizophrenia and major affective disorder were 32.9 years, 70% male and 38.7 years, 62% female respectively. Voluntary or involuntary admission refers to the medico-legal status of patients at admission, and LOS refers to total time spent in hospital regardless of change in medico-legal status during the admission.

Efficiency ratings were calculated using Boot et al. ‘s [3] formula of subtracting discharge total HoNOS score from admission total HoNOS score, divided by the standard deviation of the admission score to compute the outcome or effect size, and dividing this by the mean length of stay multiplied by 10 to obtain the mean outcome per 10 days of stay score. The statistics from Boot et al.'s [3] and Goldney et al.'s [5,6] studies were taken from Trauer et al.'s [2] published article. To compare results total HoNOS scores were computed from only those 11 items common to Version 3 of the HoNOS used in these studies. Voluntary admission data were also analysed separately to provide a more valid comparison with the private hospital data.

Results

Thirty-four per cent (n = 136) of all patients were involuntary admissions. Table 1 shows that 85% of involuntary admissions had a primary diagnosis of schizophrenia (53%) or major affective disorder (32%). Mean LOS for all patients was 13 days, with involuntary patients having a significantly longer LOS (17.5 days) than voluntary patients (10.7 days) (t = 4.54, p < 0.00001). For patients with a primary diagnosis of schizophrenia or major affective disorder the mean LOS was 14.8 days (SD = 14.3), with involuntary patients having a significantly longer LOS (19.4 days) than voluntary patients (12 days) (t = 4.35, p < 0.0001).

Table 1.

Primary diagnosis and length of stay (LOS) for all patients (n = 402), involuntary patients (n = 136) and voluntary patients (n = 266)

Tables 2 and 3 show the comparison in outcome or effect size and mean outcome per 10 days of stay between the Lyell McEwen Hospital and the public and private hospital data reported by Trauer et al. [2]. Patient data from the Lyell McEwen Hospital differentiate between all patients admitted during the study and those admitted voluntarily to provide a more valid comparison with the private hospital data. Table 2 shows that for all patients with schizophrenia, and voluntary admissions only, there was an improvement of approximately seven points which was consistent with findings from other public facilities. The admission symptom severity for all patients was similar to that in other public settings and greater than those found in private facilities, whereas the findings for admission severity for voluntary admissions was similar to private facility findings. The outcome or effect size of 1.73 and mean outcome per 10 days of stay of 1.21 for all patients was greater than Trauer et al.'s [2] calculation of 0.74 and 0.39, respectively, for patients with schizophrenia in private facilities. The outcome or effect size of 1.31 and mean outcome per 10 days of stay of 1.19 found for voluntary patients only was also greater than the scores calculated for the private settings. Table 3 shows the same comparisons for patients with major affective disorder, with admission severity and a level of improvement of approximately seven points for all patients and six points for voluntary patients. The outcome or effect size and mean outcome per 10 days of stay of 1.37 and 0.89 respectively, for all patients, and 1.43 and 1.13 for voluntary patients only, was also greater than Trauer et al. ‘s [2] calculations of 0.96 and 0.45 respectively, for private hospital settings.

Table 2.

Inpatient Health of the Nation Outcome Scales (HoNOS) results for patients with schizophrenia

Table 3.

Inpatient Health of the Nation Outcome Scales (HoNOS) results for patients with major affective disorders

Tables 4 and 5 compare the HoNOS item scores for patients with schizophrenia and major affective disorder respectively with data from Trauer et al. [2] and Goldney et al. [5]. Although differences were not subjected to statistical analysis, scoring trends in this study were similar to the other public facility, with observably higher ratings for aggression and/or agitation and self-harm when compared with private settings. Trauer et al. [2] reported significantly higher admission severities in self-harm for patients with schizophrenia and major affective disorder when compared with Goldney et al.'s [5] results.

Table 4.

Mean Health of the National Outcome Scales (HoNOS) item scores at admission and discharge for patients with schizophrenia in the Lyell McEwen Hospital (n = 136), reported in Trauer et al. (n = 51) and reported in Goldney et al. (n = 97)

Table 5.

Mean Health of the Nation Outcome Scales (HoNOS) item scores at admission and discharge for patients with major affective disorders in the Lyell McEwen Hospital (n = 156), reported in Trauer et al. (n = 42) and reported in Goldney et al. (n = 517)

Table 6 shows the comparison in HoNOS scores between voluntary and involuntary patients with schizophrenia or major affective disorder. Involuntary patients had significantly higher admission severity scores for aggression and/or agitation, drug and alcohol problems, cognitive problems, hallucinations and delusions, activities of daily living problems, accommodation and occupational problems, with a significantly lower mean score for depression. Total HoNOS mean admission score was significantly higher for involuntary patients (t = 5.53, p < 0.00001) when compared with voluntary patients

Table 6.

Mean Health of the Nation Outcome Scales (HoNOS) score for involuntary (n = 113) and voluntary (n = 182) patients with schizophrenia or major affective disorder in the Lyell McEwen Hospital

Correlational analysis of HoNOS items with LOS for all Lyell McEwen patients found that higher admission severity for hallucinations and delusions (r = 0.28, p < 0.000001) and activities of daily living problems (r = 0.20, p < 0.0001) were related to longer LOS, and alcohol and drug problems (r = −0.13, P < 0.05) were associated with shorter LOS. Aggression and/or agitation was associated with higher severity of hallucinations and delusions (r = 0.39, p < 0.000001), activities of daily living (r = 0.21, p < 0.001) and occupational problems (r = 0.14, p < 0.05), and lower severity of depression (r = −0.35, p < 0.000001). Self-harm was related to higher severity of depression (r = 0.57, p < 0.000001), other symptoms (r = 0.23, p < 0.0001) and relationship problems (r = 0.13, p < 0.05), and lower severity of hallucinations and delusions (r = −0.29, p < 0.00001). Correlational analysis of HoNOS items with medicolegal status at admission found that involuntary status was related to higher severities of aggression and/or agitation (r = 0.48, p < 0.000001), hallucinations and delusions (r = 0.42, p < 0.000001), activities of daily living (r = 0.28, p < 0.00001), alcohol and drug problems (r = 0.16, p < 0.01), cognitive problems (r = 0.15, p < 0.05), occupation and activities (r = 0.14, p < 0.05), total HoNOS score (r = 0.31, p < 0.000001) and lower severity of depression (r = −0.30, p < 0.000001). Multiple regression analysis of HoNOS items with medico-legal status (see Table 7) found that aggression and/or agitation, hallucinations and delusions, and activities of daily living problems accounted for 32% of the variance for involuntary status, with aggression and/or agitation accounting for 23%.

Table 7.

Multiple regression analysis of Health of the Nation Outcome Scales (HoNOS) items with medico-legal admission status

Discussion

As with previous studies [2,3], it was found that for the two diagnostic groups, admission severities tended to be higher and lengths of stay were shorter in the public hospital setting.

Using Boot et al.'s [3]. operational definition of efficiency this study has replicated previous findings [2,3] which show greater outcome or effect size and greater mean outcome per 10 days of stay for patients in public mental health settings when compared with private facilities. These differences were maintained when efficiency ratings were calculated for voluntary patients only. As with Trauer et al.'s [2] study, outcome or effect size was shown to be enhanced by higher admission severities in public settings. However, the contention that mean outcome per 10 days of stay was higher in public settings due to their greater proportion of involuntary admissions was not supported. Involuntary patients experienced longer stays in hospital than voluntary patients. This finding is consistent with past studies conducted in similar public acute inpatient settings [7,8]. It is unclear from studies [9,10] which report involuntary hospitalisation related to shorter LOS if comparable methodologies were employed. Okin [9] sampled all admissions to several large, state hospitals, which probably included longer stay as well as acute inpatient facilities. It is unclear from LeWall's [10] study to what extent all involuntary admissions were included in averaging LOS. The reported average appears to exclude the total LOS of 24% of the involuntary sample who became voluntary following admission, and 21% of the sample (those subject to court-ordered treatment) who had a significantly longer average LOS than the voluntary patients.

As with Trauer et al.'s [2] study, patients in this study also had higher admission severities for self-harm than those in private facilities. However, there was no significant difference in self-harm between voluntary and involuntary admissions, and it was not directly related to LOS. The finding that aggression and/or agitation was significantly higher for involuntary admissions may help explain this. Perhaps patients exhibiting the more overt or threatening behavioural disturbances associated with the aggression and/or agitation item are more likely to require forced hospitalisation. This notion is supported by Okin's [9] finding that level of aggression was the most significant preadmission variable differentiating involuntary from voluntary patients. Whether recovery from the behavioural symptoms self-harm and aggression and/or agitation occurs more rapidly than other symptoms was not examined in this study. However, the finding that level of aggression and/or agitation and self-harm were associated with severity of hallucinations and delusions, and depression respectively, suggests that, regardless of recovery rate, these factors are associated with greater overall illness severity.

The significant, but generally weak, associations found between symptom severity and LOS is consistent with past findings. Other patient-related factors such as preadmission quality of life and hospitalisation history have been shown to influence LOS [11,12]. Thomas et al. [13] contend that the focus should be on the characteristics of providers rather than patients to explain LOS. They replicated previous findings in managed-care settings [14,15] to show the single most powerful predictor of LOS was the treating psychiatrists number of inpatients (high-vs low-volume providers). Patients treated by psychiatrists who had higher numbers of inpatients (high-volume providers) had shorter LOS and less readmissions than those treated by low-volume providers. Also, Kirshner and Johnston [7] reported that patients in a public acute inpatient facility who had private hospital insurance cover, and were subsequently treated by private clinicians, had significantly longer inpatient stays, but did not differ in clinical outcomes at discharge. They concluded that there was less incentive to discharge earlier as patient insurance reimbursed all hospitalisations, but limited reimbursement for outpatient treatment. Also, the increasing economic constraints on public hospital services may place greater demands on public inpatient facilities and clinicians may have less say about discharge timing in these settings. However, discharge symptom severity scores suggest that patients are not being discharged when unwell. It is also unclear what constitutes an optimum LOS as outcome measures are conducted at hospital discharge. It may be of benefit to rate clinical change throughout the admission episode in order to identify at what stage patients reach an optimal level of recovery in relation to their LOS. Future work could also examine the effects of change in medico-legal status during the admission. As the current study differentiated patients' medico-legal status based on their status at admission, it is unclear whether duration of involuntary status influences clinical outcomes or LOS.

Boot et al.'s [3] operational definition of efficiency is somewhat limited by its reliance on HoNOS and LOS data alone, particularly for cross-comparative studies. For example, high admission symptom severity may signify service inefficiencies such as delayed intervention or insufficient hospital resources. Future work involving cross-comparisons between mental health settings requires consideration of such external factors for a more comprehensive analysis of service efficiency. However, Boot et al.'s [3] formula does address the importance of including measures of treatment effectiveness in assessing service efficiency. As Andrews [1] stated, evidence of effectiveness (the health benefit that occurs from treatment) is required before one can talk about efficiency (the resources required to produce the health benefit), and only then can one begin to address issues of cost effectiveness. An analysis of cost efficiency and cost effectiveness is beyond the scope of this study, however, the study has shown that involuntary admission status is associated with greater overall symptom severity and longer LOS (or increased resources required to produce the health benefit) in a public acute inpatient facility. Future research could examine the effects of service and care-provider factors on LOS, such as clinical practice patterns and level of demand on resources in different treatment settings.

The notion of applying efficiency ratings to the care of people with severe mental health disorders is contentious. The protracted nature of severe mental illness and the range of associated functional deficits may not fit neatly into models of cost-benefit analyses. However, increasing public funding scarcity and competition for resources has led to a greater emphasis on mental health services requiring to show evidence of cost effectiveness.

Given the strong association between severe mental illness and poverty [16], and the disproportionate number of patients reliant on publicly funded treatment facilities, it is important that public service providers place a greater emphasis on evidence-based practice and routine outcome measurement. Such information will at least provide evidence of health gains from public expenditure.