Brief Reports
Outcomes of Decreased Length of Hospital Stay Among Geriatric Patients With Dementia Mark E. Kunik, M.D. Michelle Edwards Victor A. Molinari, Ph.D. D. Danielle Hale, M.S. Claudia A. Orengo, M.D., Ph.D.
This study examined the outcomes associated with shortening hospital stays for geriatric inpatients with dementia at a Veterans Administration medical center. Thirty-three patients who were admitted after January 1997, when the hospital decided to reduce patients’ lengths of stay, were matched with 33 patients who were admitted before January 1997. Despite significant differences in lengths of stay, no differences were found between the groups on measures of agitation or overall functioning. Despite significantly shorter stays since January 1997, the results of our study indicate that the cognitive and emotional status of patients discharged since that time are equivalent to those of patients discharged after longer hospital stays. (Psychiatric Services 52: 376–378, 2001)
Dr. Kunik and Dr. Orengo are associated with the department of psychiatry and behavioral sciences at Baylor College of Medicine, One Baylor Plaza, Houston, Texas 77030 (e-mail,
[email protected]. edu). Ms. Edwards is a medical student at Baylor College of Medicine. Dr. Kunik is also associated with the Veterans Affairs Medical Center and the Veterans Integrated Service Network in Houston. Dr. Molinari is associated with the Veterans Affairs Medical Center, and Ms. Hale is with the University of Houston. 376
O
ver the past several years, hospitals, insurance companies, and agencies responsible for allocating funds for medical care have mandated increasingly shorter hospital stays for psychiatric patients (1). Whereas formerly these patients were hospitalized for weeks or years, most acutely ill psychiatric patients are now treated with brief inpatient stays or on an outpatient basis (2,3). Some studies suggest that brief inpatient treatment or outpatient treatment is as effective or more effective than long-term inpatient programs for patients with se vere mental illness (4). Other findings indicate that patients with depression who are discharged after a shorter stay are more depressed and are more globally impaired on discharge (2). One study found that psychiatric hospitals are increasingly treating a poorer, sicker group of patients with shorter hospital stays, resulting in poorer long-term outcomes and more readmissions (5). In January 1997 the Houston Veterans Affairs (VA) Medical Center, through a utilization review process, shortened psychiatric lengths of stay. Physicians are now required to report to the chief of service all patients with a length of stay beyond 20 days rather than beyond 30 days, as previously required. In the retrospective case-control study reported here, we examined the outcomes of agitation, cognitive functioning, and readmissions among geriatric patients with dementia after lengths of stay were
administratively decreased. We hypothesized that these patients would be negatively affected by the shortened hospital stay because of problems in providing comprehensive biopsychosocial assessment and treatment in a brief period.
Methods We examined data for all patients who had a primary diagnosis of dementia without delirium and were admitted between October 1993 and November 1997 to the medical center’s geropsychiatric inpatient unit for treatment of behavioral disturbance—physical aggression, verbal threats, wandering, or general confusion. The patients received a comprehensive multidisciplinary evaluation by a geriatric psychiatrist, a geropsychologist, psychiatric nurses, a social worker, and a physician’s assistant. Each patient’s treatment and attending staff remained relatively consistent throughout the course of this study. On admission and discharge, the attending psychiatrist rated each patient on a standardized battery consisting of the Mini Mental State Examination (MMSE) (6) and the Cohen-Mansfield Agitation Inventory (CMAI) (7), which includes subscales of aggressive, nonaggressive, and verbal agitation. Interrater reliability was evaluated every 12 to 18 months, and intraclass correlation coefficients were never less than .76 for the CMAI and .9 for the MMSE.
PSYCHIATRIC SERVICES
♦
March 2001 Vol. 52 No. 3
Axis I psychiatric diagnoses by DSM-III-R criteria, and later DSMIV criteria, were established within two weeks of discharge at a consensus conference attended by two geriatric psychiatrists, and a geropsychologist. All patients received multidisciplinary treatment, including pharmacotherapy, a structured milieu, and family education. Of the 276 patients with dementia consecutively admitted between October 1993 and November 1997, 243 were diagnosed as having dementia without delirium. Thirty-three of these patients were first admitted after January 1997, when the decision was made to reduce length of stay. In order to obtain groups of patients with equivalent baseline psychiatric status, the 33 patients admitted after January 1997 were matched with 33 of the 210 patients admitted before January 1997. Patients were matched on CMAI and MMSE scores at admission and on age. CMAI scores were considered to be equivalent within a range of plus or minus 5 points. MMSE scores were considered to be equivalent within a range of plus or minus 1 point. Age was allowed to vary within a range of plus or minus ten years. In the case of more than one appropriate match, the matching person was randomly selected. We analyzed the data with SPSS for Windows (1995). We used paired t tests to compare the mean scores between the matched groups and to compare the differences be tween admission and discharge scores for all 66 patients. We com pared Global Assessment of Func tioning (GAF) scores at discharge as well as living arrangements—longterm care versus home care—num ber of readmissions per patient per year, and average length of stay during readmission.
Results The final sample of 66 patients included 65 men and one woman. The mean±SD age was 73.6±5.75 years (range=62 to 88 years), and the mean±SD MMSE score at admission was 15.22±8.86. (Scores on the MMSE range from 0 to 30, with higher scores indicating higher cognitive PSYCHIATRIC SERVICES
♦
Table 1
Comparison of Cohen-Mansfield Agitation Inventory (CMAI) and Global Assessment of Functioning (GAF) scores between admission and discharge for 66 geriatric patients with dementia who were treated at a Veterans Affairs medical center At admission
At discharge
Test
Score SD
Range
Score
SD
Range t†
df
CMAI 1 Aggressive agitation Nonaggressive agitation Verbal agitation Total GAF2
14.3 19.0 12.2 56.6 22.3
9–29 6–43 5–33 30–124 10–40
9.9 13.3 7.2 39.9 33.0
2.1 9.2 3.6 12.2 10.3
9–23 7–49 5–22 29–89 10–60
59 60 60 59 65
† 1 2
5.7 10.0 7.0 21.2 9.0
6.09 4.88 5.84 6.34 12.06
p
