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ORIGINAL ARTICLE |
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| Ahead of print
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| Follow-up attendance of patients with mental disorders and substance use disorders after inpatient treatment in psychiatry ward |
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Abhinav Kapoor1, Parthasarathy Ramamurthy2, Mani Manikandan3, Pradeep Thilakan2
1 Intern, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Associate Professor, Professor and Head, Department of Psychiatry, Pondicherry Institute of Medical Sciences, Puducherry, India
3 Associate Professor Cum Statistician, Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
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| Date of Submission | 25-Dec-2022 |
| Date of Acceptance | 12-Mar-2023 |
| Date of Web Publication | 04-May-2023 |
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Background: The proportion of patients attending the first follow-up appointment as an outpatient after being discharged from the inpatient setting is an outcome indicator of the quality of inpatient services provided. The objectives of this study were to determine the proportion of psychiatric inpatients with mental disorders and substance use disorders attending follow-up appointments after discharge and to determine the factors associated with attending follow-up appointments in these patients.
Materials and Methods: A retrospective chart review (observational study) was conducted among the inpatients of psychiatry ward. The list of patients admitted to the psychiatry ward was obtained from the admission register. The discharge summaries and outpatient records of these patients were reviewed to obtain the following data: sociodemographic details, clinical details, and follow-up visit details. The primary outcome variable was follow-up attendance in the outpatient department within 30 days of discharge.
Results: Ninety-eight patient records were included in the present study. The mean age of the participants was 37.81 (11.03) years and one-third of them were female. The mean duration of hospital stay was 11.32 (8.2) days. Sixty-six (67.35%) patients attended at least one outpatient follow-up visit within 30 days after discharge from the hospital. Patients with mood disorders had 4.25 higher odds of 30-FU when compared to patients with substance use disorders.
Conclusions: Two-thirds of psychiatric inpatients with mental disorders and substance use disorders attended follow-up appointments within 30 days after discharge. Diagnostic category was associated with attending the follow-up appointments in these patients.
Keywords: Dropout rate, follow-up rate, psychiatric inpatients
How to cite this URL:
Kapoor A, Ramamurthy P, Manikandan M, Thilakan P. Follow-up attendance of patients with mental disorders and substance use disorders after inpatient treatment in psychiatry ward. Arch Ment Health [Epub ahead of print] [cited 2023 Jun 5]. Available from: https://www.amhonline.org/preprintarticle.asp?id=375706 |
| Introduction | |  |
Global Burden of Diseases, Injuries, and Risk Factors Study 2019 found that mental disorders ranked among the top ten causes of burden globally.[1] In India, there was a two-fold increase in the contribution of mental disorders to total disease burden and a substantial state-level variation in the burden from different mental disorders.[2] In our country, patients with mental disorders are treated in various settings including outpatient, inpatient, and long-term rehabilitation settings. Despite enormous disease burden, the quality of services provided in these settings has received remarkably little research attention. Several structure, process, and outcome indicators have been proposed as mental health quality measures.[3] Structural components including personnel, training, facilities, and policies provide the framework for providing quality mental health services. Process measures involve operationalizing clinical guidelines and measuring the processes from the reliably obtained data. Outcome measures involve measuring the improvement of 'symptoms, functioning, quality of life, and recovery among others.[3]
Among the various indicators operationalized for ease of implementation, the proportion of patients attending the first follow-up appointment as an outpatient after being discharged from the inpatient setting is an outcome indicator of the quality of inpatient services provided. It is indicative of the patient's co-operation and adherence to treatment and reflects the symptom level at the time of discharge and the therapeutic relationship established during inpatient stay.[4]
Follow-up rate in outpatient psychiatric services has been investigated in various studies in India. About half the patients who visited psychiatric outpatient department in a tertiary care hospital dropped out after the first visit.[5],[6] Similarly, about two-thirds of patients with adjustment disorder evaluated on outpatient basis did not come for a follow-up visit.[7] The proportion of patients who attended follow-up visit after inpatient psychiatric treatment has not been adequately studied in our country. In this context, the present study was conducted with the objectives of determining the proportion of psychiatric inpatients with mental disorders and substance use disorders attending follow-up appointments after discharge and determining the factors associated with attending follow-up appointments in these patients.
| Materials and Methods | | |
A retrospective chart review was conducted among the inpatients of psychiatry ward in a tertiary care teaching hospital in South India. This general hospital psychiatry unit runs outpatient, inpatient, and emergency services which are manned by postgraduate trainees and faculty psychiatrists. Patients requiring inpatient care are usually admitted with their caregiver (usually for a period of few days to few weeks). Detailed psychiatric history, physical examination, mental status examination, and investigations (as indicated) are conducted for these patients. Based on the psychiatric diagnosis, appropriate pharmacological and nonpharmacological treatments are initiated as per standard guidelines. At the time of discharge, the patients are provided with detailed discharge summaries and instructed to review in the outpatient department for continuation of treatment. During the study period, there was no institute policy to contact the patients if they missed the follow-up appointment on the scheduled date.
The study was approved by Institute Ethics Committee (IEC: RC/2022/06). A waiver of consent was obtained from the ethics committee as the data were collected retrospectively from the inpatient and outpatient records. Confidentiality and anonymity of the participants were maintained. Both male and female patients (aged 18 years and above) who were admitted to the psychiatry ward with a diagnosis of substance use disorders, psychotic disorders, and mood disorders (F10-F39) as per the International Classification of Diseases-10 (ICD-10)[8] Classification of Mental and Behavioral disorders were eligible for this study. Patients who were admitted for serum drug level monitoring and patients who were discharged against medical advice were excluded from the study.
The list of patients admitted to the psychiatry ward from September 2021 to March 2022 was obtained from the admission register maintained in the psychiatry ward. The discharge summaries and outpatient records of these patients were accessed through the Hospital Information Management System. The charts of the patients who fulfilled the eligibility criteria were included in the study. The following data were abstracted from the discharge summaries and outpatient records: sociodemographic details, clinical details, and follow-up visit details. The primary outcome variable was follow-up attendance in the outpatient department within 30 days of discharge (30-FU). The data collection was conducted during May 2022.
Assuming that the proportion of patients having a follow-up within 1 month to be 50% as shown by Brown et al.[9] and Benjenk and Chen,[10] 97 patients were required to determine a similar proportion with a precision of 10% at 95% confidence interval. A total of 98 patients were included in the study. Categorical variables were summarized as frequencies and percentages. Continuous variables were summarized as means and standard deviations. The proportion of patients with 30-FU was expressed as frequency and percentage. An exploratory data analysis was conducted with univariate and multivariate logistic regression to determine the predictors (age, gender, years of formal education, duration of inpatient stay, and psychiatric diagnostic category – chosen based on previous literature) of 30-FU. Odds ratio, confidence interval, and P value are reported. P <0.05 was considered as statistically significant.
| Results | | |
A total of 107 patient records were screened and 98 were included in the present study. Nine patient records were excluded as they did not fulfill the eligibility criteria. The mean age of the participants was 37.81 (11.03) years and one-third of them were female. More than one-third of the study participants were unemployed [Table 1]. Majority of the study participants belonged to F20–29 diagnostic category (schizophrenia, schizotypal, and delusional disorders) as per ICD-10 classification. Two-thirds of the study participants came for at least one follow-up visit within 30 days of discharge from the hospital [Table 2]. | Table 1: Sociodemographic details of the patients who underwent inpatient psychiatric treatment
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 | Table 2: Clinical details of the patients who underwent inpatient psychiatric treatment
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An exploratory analysis was conducted with univariate and multivariate logistic regression to identify the predictors of 30-FU. Among the factors evaluated, the diagnostic category was found to be a significant predictor. Patients with mood disorders had 4.25 higher odds of 30-FU when compared to patients with substance use disorders even after controlling for potential confounders. Similarly, patients with psychotic disorders had higher odds of 30-FU compared to patients with substance use disorders but this did not reach statistical significance. Other factors, namely age, gender, years of formal education, and duration of inpatient stay were not associated with 30-FU [Table 3] and [Table 4]. | Table 3: Predictors of follow-up attendance to outpatient department within 30 days of discharge after inpatient psychiatric treatment-univariate logistic regression
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 | Table 4: Predictors of follow-up attendance to outpatient department within 30 days of discharge after inpatient psychiatric treatment-multivariate logistic regression
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| Discussion | | |
The present study found that about 35% of psychiatric inpatients came for a follow-up visit within 7 days of discharge and 67% came within 30 days of discharge. The follow-up rates in our study are broadly similar to the studies conducted in other countries. Benjenk and Chen[10] found that among 1275 inpatient facilities in the United States, the average hospital 30-day follow-up rate was 55.8% with a range from 16% to 95%. An earlier study from the United States among Medicare discharges, 28.7% received follow-up care within 7 days and 53.5% within 30 days.[9] Higher follow-up rates of 85% and 84% after psychiatric hospitalization were reported from Japan[11] and New York.[12] A 30-day follow-up rate of about 65% was reported by two other studies.[13],[14]
A benchmark of 80% follow-up within 1 week after discharge has been suggested as a quality indicator. Since many patients in the present study were advised to visit the outpatient department for follow-up 10–15 days after discharge, this indicator may not be applicable to the present study population. However, the rate of 67% follow-up within 30 days after discharge may be considered satisfactory in the context of findings from similar studies. This sentence can be modified to 'Having said that, there is an untapped opportunity to improve the follow-up rate to the suggested benchmark through implementation of targeted interventions'. Readmission rates have been shown to be higher in patients with no timely follow-up visits.[11],[14]
Follow-up attendance after discharge from the psychiatric ward is considered as an outcome indicator of quality assessment. Several other quality assessment parameters have been proposed. Some of them are number of patients discharged with a discharge note, number of inpatient suicides, number of patients who completed addiction treatment programs, average length of hospitalization, average cost of hospitalization per patient, average bed occupancy, average inflow rate, and number of incidents of violence.[4] A comprehensive assessment of quality of inpatient services requires evaluating several of the above parameters depending on the availability of the data. Such detailed quality assessment measures will help clinicians take corrective steps to improve the quality of mental health-care provided.
The present study was conducted to evaluate follow-up attendance in a naturalistic setting. Awareness of conduct of a prospective study of this nature may influence clinicians' behavior thereby not providing an accurate estimate of follow-up attendance. This may be considered as the strength of this study. The study findings can be generalized to similar psychiatry settings in various medical colleges (general hospital psychiatry units) across India.
The following limitations should be considered when the findings of the present study are interpreted. Since this was a retrospective chart-based review, the diagnosis of the patients could not be confirmed using standard tools. In this inpatient setting, the patients undergo detailed psychiatric evaluation and the diagnosis is made using ICD-10 guidelines. Although the follow-up attendance was evaluated in this study, the reasons for nonattendance could not be evaluated. Similarly, among the patients who attended follow-up, the medication adherence was not evaluated. The study was not powered to detect the factors associated with follow-up attendance. Some relevant factors such as distance from the hospital were not assessed due to the lack of reliable source. The regression analysis reported should be considered exploratory in nature.
In future, prospective studies to evaluate follow-up attendance in various factors associated with it will provide a more detailed and complete picture regarding this important quality parameter. Quality assessments involving various other parameters should be used to complement the data obtained in such studies. Multicentric studies including patients from different settings may improve the generalizability of the findings. Subsequently, low-cost and easily applicable interventions (for instance, mobile phone reminders) should be designed and evaluated to improve the follow-up attendance of psychiatric inpatients.
| Conclusions | | |
Two-thirds of psychiatric inpatients with mental disorders and substance use disorders attended follow-up appointments within 30 days after discharge. Diagnostic category was associated with attending the follow-up appointments in these patients. Interventions to improve follow-up attendance after discharge from inpatient setting should be developed and implemented to improve the quality of care.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | GBD 2019 Mental Disorders Collaborators. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990-2019: A systematic analysis for the global burden of disease study 2019. Lancet Psychiatry 2022;9:137-50.  |
| 2. | Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders across the States of India: The global burden of disease study 1990–2017. Lancet Psychiatry 2020;7:148-61. |
| 3. | Kilbourne AM, Beck K, Spaeth-Rublee B, Ramanuj P, O'Brien RW, Tomoyasu N, et al. Measuring and improving the quality of mental health care: A global perspective. World Psychiatry 2018;17:30-8. |
| 4. | Samartzis L, Talias MA. Assessing and improving the quality in mental health services. Int J Environ Res Public Health 2019;17:249. |
| 5. | Ramamurthy P, Alexander A, Solomon S, Thilakan P. Prescription pattern, follow-up pattern, and medication adherence in psychiatric outpatients. Ann Indian Psychiatry 2021;5:67-73. [Full text] |
| 6. | Singla M, Goyal SK, Sood A, Philips A, Philips S. Profile and pattern of follow-ups of psychiatry outpatients at Christian medical college, Ludhiana. J Ment Health Hum Behav 2015;20:76-9. |
| 7. | Ramamurthy P, Alexander A, Solomon S, Thilakan P. Prescription pattern and follow-up pattern in psychiatric outpatients with adjustment disorder. Indian J Psychol Med 2022;44:530-1. |
| 8. | World Health Organisation. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organisation; 1992. |
| 9. | Brown JD, Blair R, Barry X. Follow-up after discharge from an inpatient psychiatric facility. Psychiatr Serv 2017;68:860-1. |
| 10. | Benjenk I, Chen J. Variation of follow-up rate after psychiatric hospitalization of medicare beneficiaries by hospital characteristics and social determinants of health. Am J Geriatr Psychiatry 2019;27:138-48. |
| 11. | Okumura Y, Sugiyama N, Noda T. Timely follow-up visits after psychiatric hospitalization and readmission in schizophrenia and bipolar disorder in Japan. Psychiatry Res 2018;270:490-5. |
| 12. | Humensky JL, Fattal O, Feit R, Mills SD, Lewis-Fernandez R. Success rate of outpatient follow-up following discharge from inpatient psychiatry in New York City. Psychiatr Serv 2017;68:624-7. |
| 13. | Marcus SC, Chuang CC, Ng-Mak DS, Olfson M. Outpatient follow-up care and risk of hospital readmission in schizophrenia and Bipolar Disorder. Psychiatr Serv 2017;68:1239-46. |
| 14. | Kurdyak P, Vigod SN, Newman A, Giannakeas V, Mulsant BH, Stukel T. Impact of physician follow-up care on psychiatric readmission rates in a population-based sample of patients with schizophrenia. Psychiatr Serv 2018;69:61-8. |
Correspondence Address:
Parthasarathy Ramamurthy,
Department of Psychiatry, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry - 605 014
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/amh.amh_196_22
[Table 1], [Table 2], [Table 3], [Table 4] |
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