Die Dauer der stationären psychiatrischen Behandlung

D. Richter

doi:10.1055/s-2001-10438

Fortschritte der Neurologie · Psychiatrie, Table of Contents

Fortschr Neurol Psychiatr 2001; 69(1): 19-31
DOI: 10.1055/s-2001-10438

ÜBERSICHT

Georg Thieme Verlag Stuttgart · New York

Die Dauer der stationären psychiatrischen Behandlung

Eine Übersicht über Methodik, Einflussfaktoren und AuswirkungenD. Richter

Westf. Klinik für Psychiatrie und Psychotherapie Münster(Leitung: PD Dr. med. Thomas Reker)

Abstract

Zusammenfassung:

Die Dauer der stationären psychiatrischen Behandlung ist ein umstrittenes Thema zwischen Kliniken und Kostenträgern, das überwiegend unter ökonomischen Fragestellungen diskutiert wird. Diese Arbeit hat das Ziel, die empirischen Befunde über die Behandlungsdauer zu sichten, um neben den ökonomischen Bedingungen auch fachliche Gesichtspunkte berücksichtigen zu können. Zwei zentrale Fragestellungen lassen sich aus der Literatur identifizieren: 1. Welche Faktoren beeinflussen die Dauer der Behandlung? 2. Welche Auswirkungen hat die Dauer der Behandlung auf den Gesundheitsstatus der Patienten? Die Ergebnisse zeigen, dass die Behandlungsdauer weniger durch die Diagnose und durch soziodemographische Merkmale bestimmt wird als vielmehr durch den Behandlungsverlauf und organisatorische Charakteristika der Einrichtungen. Insbesondere jüngere Arbeiten finden positive Effekte längerer Behandlungen für den Gesundheitsstatus der Patienten. Studien über längerfristige Reduktionen der Behandlungsdauer lassen auf einen Zusammenhang zwischen kürzeren Behandlungen und steigenden Wiederaufnahmeraten schließen. Es wird gefolgert, dass die Reduktion der Behandlungsdauer in der stationären Psychiatrie sorgfältig evaluiert werden sollte, um negative Konsequenzen für den Gesundheitsstatus der Patienten auszuschließen.

Psychiatric Inpatient Duration of Stay - A Review of Methods, Influences and Consequences:

Duration of inpatient psychiatric treatment is considerably under discussion between hospitals and payers. This article aims at reviewing the scientific evidence on the topic of psychiatric inpatient duration of stay. Two general research questions can be identified from the literature: 1. Which factors do influence duration of stay? 2. Which consequences does duration of psychiatric treatment have on patients' health status? Results show that duration of stay is less influenced by psychiatric diagnosis and sociodemographic items but more by the process of treatment and by organizational characteristics of the institutions. More recent studies generally find positive effects of longer treatment episodes. Studies about the consequences of duration of stay show a relation between reductions in duration of treatment and increasing readmissions. It is concluded that reductions in duration of inpatient treatment must be carefully evaluated to prevent negative consequences for patients' health status.

Full Text

References

Literatur

1 Robra B, Swart E, Klas P, Leber W D. Zielvereinbarungen zwischen Kostenträgern und Krankenhäusern als Instrument zur Beeinflussung von Krankenhausverweildauer. Gesundheitswesen. 1998; 60 211-216
2 Munk-Jørgensen P. Has deinstitutionalization gone too far?. Eur Arch Psychiatry Clin Neurosci. 1999; 249 136-143
3 Richter D, Eikelmann B. Verweildauerrückgang bei stationären Behandlungen in der Psychiatrie: Positive oder negative Konsequenzen. Spektrum. 2000; 29 67-72
4 Erickson R, Paige A B. Fallacies in using length-of-stay and return rates as measures of success. Hosp Community Psychiatry. 1973; 24 559-561
5 Arnold M, Armann W. Die Verweildauer im Krankenhaus: Ein Kriterium für die Effizienz der stationären Versorgung. Krankenhaus Umschau. 1992; (Heft 11) 801-808
6 Richter D. Krankenhausbetriebsvergleich - Konsequenzen für psychiatrische Kliniken. Das Krankenhaus. 1998; 90 657-660
7 Richter D. Krankenhausbetriebsvergleich für psychiatrische Kliniken - Wie sinnvoll ist ein Vergleich von Verweildauern nach Diagnose und Alter. Gesundheitswesen. 1999; 61 227-233
8 Rössler W, Salize H J. Planungsmaterialien für die psychiatrische Versorgung. Weinheim: Deutscher Studien Verlag 1993
9 Rössler W, Salize H J. Longitudinal statistics of mental health care in Germany. Soc Psychiatry Psychiatr Epidemiol. 1994; 29 112-118
10 Aktion Psychisch Kranke e V. , Deutsche Krankenhausgesellschaft, Spitzenverbände der Krankenkassen e. V. (Hrsg.) .Bundesweite Erhebung zur Evaluation der Psychiatrie-Personalverordnung. Schriftenreihe des Bundesministeriums für Gesundheit. Baden-Baden: Nomos 1998
11 Lebok U, Mey W. Unterschiede der durchschnittlichen Verweildauer in stationären Einrichtungen der alten und neuen Länder. Gesundheitswesen. 1999; 61 280-286
12 Gilbody S, House A. Variations in psychiatric practice: Neither unacceptable nor unavoidable only under-researched. Br J Psychiatry. 1999; 175 303-305
13 Sturm R, Bao Y. Psychiatric care expenditures and length of stay: Trends in industrialized countries. Psychiatr Serv. 2000; 51 295
14 Mechanic D, McAlpine D D, Olfson M. Changing patterns of psychiatric inpatient care in the United States 1988 - 1994. Arch Gen Psychiatry. 1998; 55 785-791
15 Bundesministerium für Gesundheit .Daten des Gesundheitswesens 1997. Schriftenreihe des Bundesministeriums für Gesundheit Bd. 91. Baden-Baden: Nomos 1997
16 Bundesministerium für Gesundheit .Daten des Gesundheitswesens 1999. Schriftenreihe des Bundesministeriums für Gesundheit Bd. 122. Baden-Baden: Nomos 1999
17 Reister M. Die neue Krankenhausdiagnostik: Ergebnisse für 1993. Wirtschaft und Statistik. 1996; (2) 75-85
18 Caton L M, Gralnick A. A review of issues surrounding length of psychiatric hospitalization. Hosp Community Psychiatry. 1987; 38 858-863
19 Reister M. Die Verweildauer im Krankenhaus: Sehr unterschiedliche Werte bestimmen den Durchschnitt. Das Krankenhaus. 1998; 90 82-85
20 Fisher W, Altaffer F B. Inpatient length of stay measures: Statistical and conceptual issues. Admin Policy Mental Health. 1992; 19 311-320
21 Ruffieux C, Marazzi A, Paccaud F. Exploring models for the length of stay distribution. Soz Präventivmed. 1993; 38 77-82
22 Essock-Vitale S. Patient characteristics predictive of treatment costs on inpatient psychiatric wards. Hosp Community Psychiatry. 1987; 38 263-269
23 Scheytt D, Kaiser P, Priebe S. Behandlungsdauer und Fallkosten in unterschiedlichen stationären psychiatrischen Einrichtungen in Berlin. Psychiat Prax. 1996; 23 10-14
24 Boot B, Hall W, Andrews G. Disability outcome and case-mix in acute psychiatric inpatients units. Br J Psychiatry. 1997; 171 242-246
25 Barnow S, Linden M, Schaub R T. The impact of psychosocial and clinical variables on duration of inpatient treatment for depression. Soc Psychiatry Psychiatr Epidemiol. 1997; 32 312-316
26 Øiesvold T, Saarento O, Sytema S, Christiansen L, Göstas G, Lönnerberg O, Muus S, Sandlund M, Hansson L. The nordic comparative study on sectorized psychiatry - length of in-patient stay. Acta Psychiatr Scand. 1999; 100 220-228
27 Aisen P S, Giblin K E, Packer L S, Lawlor B A. Determinants of length of stay in geropsychiatry. Am J Geriat Psychiatry. 1994; 2 165-168
28 Boelhouwer C, Rosenberg M. Length of stay: A retrospective computer analysis. Psychiatr Ann. 1983; 13: 605 609-611
29 Gordon R, Jardiolin P, Gordon K K. Predicting length of hospital stay of psychiatric patients. Am J Psychiatry. 1985; 142 235-237
30 Goldney R, Fisher L J, Walmsley S H. The Health of the Nation Outcome Scales in psychiatric hospitalisation: A multicentre study examining outcome and prediction of length of stay. Aust N Z J Psychiatry. 1998; 32 199-205
31 Saravay S, Lavin M. Psychiatric comorbidity and length of stay in the general hospital: A critical review of outcome studies. Psychosomatics. 1994; 35 233-252
32 Fulop G, Strain J J, Fahs M C, Schmeidler J, Snyder S. A prospective study of the impact of psychiatric comorbidity on length of hospital stays of elderly medical-surgical inpatients. Psychosomatics. 1998; 39 273-280
33 Sloan D, Yokley J, Gottesman H, Schubert D SP. A five-year study on the interactive effects of depression and physical illness on psychiatric unit length of stay. Psychosom Med. 1991; 61 21-25
34 Wilson K, Kraitberg N J, Brown J H, Bergman J N. Electroconvulsive therapy in the treatment of depression: The impact on length of stay. Compr Psychiatry. 1991; 23 345-354
35 Hoff R, Rosenheck R A. The cost of treating substance abuse patients with and without comorbid psychiatric disorders. Psychiatr Serv. 1999; 50 1309-1315
36 Lyons J, O'Mahoney M T, Doheny K M, Dworkin L N, Miller S I. The prediction of short-stay psychiatric inpatients. Admin Policy Mental Health. 1995; 23 17-25
37 Yohanna D, Christopher N J, Lyons J S, Miller S I, Slomowitz M, Bultema J K. Characteristics of short-stay admissions to a psychiatric inpatient service. J Behav Health Serv Res. 1998; 25 337-345
38 Herr B, Abraham H D, Anderson W. Length of stay in a general hospital psychiatric unit. Gen Hosp Psychiatry. 1991; 13 68-70
39 Mai F, Gosselin J Y, Varan L, Bourgon L, Ruiz Navarro J. Effects of Treatment and alternative care on length of stay on a general hospital psychiatric unit - Results of an Audit. Can J Psychiatry. 1993; 38 39-45
40 Richter D, Berger K, Eikelmann B. Was kennzeichnet den psychiatrischen Problempatienten? Ergebnisse einer Untersuchung zur Patienteneinstufung in der Psychiatrie-Personalverordnung. Fortschr Neurol Psychiat. 1999; 67 21-28
41 Marshall M, Gray A, Lockwood A, Green R. Case management for people with severe mental disorders (Cochrane Review). Oxford: Update Software 1999
42 Marshall M, Lockwood A. Assertive community treatment for people with severe mental disorders (Cochrane Review). Oxford: Update Software 1999
43 Bortz J. Statistik für Sozialwissenschaftler Berlin: Springer 1993
44 Shwartz M, Ash A S. Evaluating the performance of risk-adjustment methods: Continuous Outcomes. In: Iezzoni L (Hrsg.). Risk Adjustment for measuring healthcare outcomes Chicago: Health Administration Press 1997: 391-426
45 Mezzich J, Coffman G A. Factors influencing length of hospital stay. Hosp Community Psychiatry. 1985; 36 1262-1264
46 Allen J G, Coyne L, Beasly C, Spohn H E. A conceptual model for research on required length of psychiatric hospital stay. Compr Psychiatry. 1987; 28 131-140
47 Horgan C, Jencks S F. Research on psychiatric classification and payment systems. Med Care. 1987; 25(Suppl) S22-S36
48 Chang G, Brenner L, Bryant K. Factors predicting inpatient lenght of stay in a CMHC. Hosp Community Psychiatry. 1991; 42 853-855
49 Draper B, Luscombe G. Quantification of factors contributing to length of stay in an acute psychogeriatric ward. Int J Geriat Psychiatry. 1998; 13 1-7
50 Brock I P, Brown G R. Psychiatric length of stay determinants in a military medical center. Gen Hosp Psychiatry. 1993; 15 392-398
51 Taube C, Lee E S, Forthofer R N. Diagnosis-Related Groups for mental disorders, alcoholism and drug abuse: Evaluation and alternatives. Hosp Community Psychiatry. 1984a; 35 452-455
52 Kiesler C, Simpkins C, Morton T. Predicting length of hospital stay for psychiatric inpatients. Hosp Community Psychiatry. 1990; 41 149-154
53 Horn S, Chambers A F, Sharkey P D, Horn R A. Psychiatric severity of illness: A case mix study. Med Care. 1989; 27 69-84
54 Russo J, Roy-Byrne P, Jaffe C, Ries R, Dagadakis C, Avery D. Psychiatric status quality of life and level of care as predictors of outcomes of acute inpatient treatment. Psychiatr Serv. 1993; 48 1427-1434
55 Creed F, Tomenson B, Anthony P, Tramner M. Predicting length of stay in psychiatry. Psychol Med. 1997; 27 961-966
56 Frick U, Rehm J, Krischker S, Cording C. Length of stay in a German psychiatric hospital as a function of patient and organizational characteristics - a multilevel analysis. Int J Meth Psychiatr Res. 1999; 8 146-191
57 Richter D, Eikelmann B, Reker T. Das biopsychosoziale Modell psychischer Krankheiten - Versuch einer Standortbestimmung. Nervenheilkunde. 1999; 18 434-441
58 Johnstone P, Zolese G. Systematic review of the effectiveness of planned short hospital stays for mental health care. Br Med J. 1999; 318 1387-1390
59 Pfeiffer S, O'Malley D S, Shott S. Factors associated with the outcome of adults treated in psychiatric hospitals: A synthesis of findings. Psychiatr Serv. 1996; 47 263-269
60 Lyons J, O'Mahoney M T, Miller S I, Neme J, Kabat J, Miller F. Predicting Readmission to the psychiatric hospital in a Managed Care environment: Implications for quality indicators. Am J Psychiatry. 1997; 154 337-340
61 Appleby L, Desai P N, Luchins D J, Gibbons R D, Hedeker D R. Length of stay and recidivism in schizophrenia: a study of public hospital patients. Am J Psychiatry. 1993; 150 72-76
62 Appleby L, Luchins D J, Desai P N, Gibbons R D, Janicak R G, Marks R. Length of stay and recidivism among patients with schizophrenia. Psychiatr Serv. 1996; 47 985-990
63 Castaneda R, Lifshutz H, Galanter M, Medalia A, Franco H. Treatment compliance after detoxification among highly disadvantaged alcoholics. Am J Drug Alcohol Abuse. 1992; 18 223-234
64 Driessen M, Veltrup C, Junghanns K, Przywara A, Dilling H. Kosten-Nutzen-Analyse klinisch-evaluierter Behandlungsprogramme: Erweiterte Entzugstherapie bei Alkoholabhängigkeit. Nervenarzt. 1999; 70 463-470
65 Gottheil E, McLellan A T, Druley K A. Length of stay, patient severity and treatment outcome: Sample data from the field of alcoholism. J Stud Alcohol. 1992; 53 69-75
66 Moos R, Pettit B, Gruber V. Longer episodes of community residential care reduce substance abuse patients' readmission rates. J Stud Alcohol. 1995; 46 433-443
67 Nosper M. Der Erfolg psychosomatischer Rehabilitation in Abhängigkeit von der Behandlungsdauer. Psychother Psychosom med Psychol. 1999; 49 354-360
68 Druss B, Rosenheck R A, Stolar M. Patient satisfaction and administrative measures as indicators of the quality of mental health care. Psychiatr Serv. 1990; 50 1053-1058
69 Rosenheck R, Massari L. Psychiatric inpatient care in the VA: Before during and after DRG-based budgeting. Am J Psychiatry. 1991; 148 888-891
70 Rosenheck R, Massari L, Astrachan B M. The impact of DRG-based budgeting on inpatient psychiatric care in Veterans Administration Medical Centers. Med Care. 1990; 28 124-134
71 Menke T, Ashton C M, Petersen N J, Wolinsky F D. Impact of an all-inclusive Diagnosis Related Group payment system on inpatient utilization. Med Care. 1998; 36 1126-1137
72 Goldstein G, Shemansky W J. Length and number of hospitalization on two cohorts of veterans with chronic schizophrenia. Psychiatr Serv. 2000; 51 245-247
73 Wickizer T, Lesser D, Travis K M. Controlling inpatient psychiatric utilization through managed care. Am J Psychiatry. 1996; 153 339-345
74 Dickey B, Normand S LT, Norton E C, Azeni H, Fisher W, Altaffer F. Managing the care of schizophrenia: Lessons from a 4-year Massachusetts Medicaid study. Arch Gen Psychiatry. 1996; 53 945-952
75 Wickizer T, Lessler D. Do treatment restrictions imposed by Utilization Management increase the likelihood of readmission for psychiatric patients?. Med Care. 1998; 36 844-850
76 Piersma H, Boes J L. The relationship of length of stay to MCMI-II and MCMI-III change scores. J Clin Psychol. 1997; 53 535-542
77 Lieberman P, Wiitala S A, Elliott B, Mc Cormick S, Goyett S B. Decreasing length of stay: Are there effects on outcomes of psychiatric hospitalization. Am J Psychiatry. 1998; 155 905-909
78 Thomas M, Kassner C T, Fryer G E, Giese A A, Rosenberg S A, Dubovsky S L. Impact of shorter lengths of stay on status at discharge in bipolar mania. Ann Clin Psychiatry. 1996; 9 139-143
79 Thomas M, Rosenberg S A, Giese A A, Fryer G E, Dubovsky S L, Shore J H. Shortening length of stay without increasing redicivism on a university-affiliated inpatient unit. Psychiatr Serv. 1997; 47 996-998
80 Iezzoni L. (Hrsg): Risk adjustment for measuring healthcare outcomes. Chicago: Health Administration Press 1997
81 Becker H C. The alcohol withdrawal „kindling” phenomenon: clinical and experimental findings. Alcohol Clin Exp Res. 1996; 20(Suppl) 121A-124A
82 Becker H C. Kindling in alcohol withdrawal. Alcohol Health Res World. 1998; 22 25-33
83 Appleby L, Shaw J, Amos T, McDonell R, Harris C, McKann K, Kiernan K, Davies S, Bickley H, Parsons R. Suicide within 12 months of contact with mental health services: national clinical survey. Br Med J. 1999; 318 1235-1239
84 Mason J, Louks J, Backus F. Patient-predicted length of stay and Diagnosis-Related-Group reimbursement. Am J Psychiatry. 1985; 142 369-371
85 Michalon M, Richman A. Factors influencing length of stay in a psychiatric intensive care unit. Gen Hosp Psychiatry. 1990; 12 303-308
86 Tucker P, Brems C. Variables affecting length of psychiatric inpatient treatment. J Ment Health Admin. 1993; 20 58-65
87 McCrone P, Phelan M. Diagnosis and length of psychiatric in-patient stay. Psychol Med. 1994; 24 1025-1030
88 Taube C, Lee E S, Forthofer R N. DRGs in psychiatry: An empirical evaluation. Med Care. 1984b; 22 567-610
89 Parks E, Josef N. A retrospective study of determinants of length of stay in a geropsychiatric state hospital. Psychiatr Quarterly. 1997; 68 91-99
90 Zwanziger J, Davis L, Bamezai A, Hosek S D. Using DRGs to pay for inpatient substance abuse services: An assessment of the CHAMPUS reimbursement system. Med Care. 1991; 29 565-577
91 McCrone P, Lorusso P. A comparison of psychiatric casemix in the UK and Italy. Soc Psychiatry Psychiatr Epidemiol. 1999; 34 432-436
92 Mitchell J, Dickey B, Liptzin B, Sederer L I. Bringing psychiatric patients into Medicare prospective payment system: alternatives to DRGs. Am J Psychiatry. 1987; 144 610-615
93 Wellock C. Is a diagnosis-based classification system appropriate for funding psychiatric care in Alberta. Can J Psychiatry. 1995; 40 507-513
94 English J, Sharfstein S S, Scherl D J, Astrachan B, Muszynski I L. Diagnosis-Related Groups and general hospital psychiatry: The APA study. Am J Psychiatry. 1986; 143 131-139
95 Ashcraft M LF, Fries B E, Nerenz D R, Falcon S P, Srivastava S V, Lee C Z, Berki S E, Errera P. A psychiatric patient classification system: An alternative to Diagnosis-Related Groups. Med Care. 1989; 27 543-557
96 Schumacher D, Namerow M J, Parker B, Fox P, Kofie V. Prospective payment for psychiatry - Feasibility and impact. N Engl J Med. 1986; 315 1331-1336
97 Lyons J, O'Mahoney M T, Larson D B. The attending psychiatrist as a predictor of length of stay. Hosp Community Psychiatry. 1991; 42 1064-1066
98 Stoskopf C, Horn S D. The Computerized Psychiatric Severity Index as a predictor of inpatient length of stay for psychoses. Med Care. 1991; 29 179-195
99 Fortney J, Booth B, Smith G. Variation among VA hospitals in length of stay for treatment of depression. Psychiatr Serv. 1996; 47 608-613
100 Frank R, Lave J R. The impact of Medicaid benefit design on length of hospital stay and patient transfers. Hosp Community Psychiatry. 1985; 36 749-753
101 Huntley D, Cho D W, Christman J, Csernansky J G. Predicting length of stay in an acute psychiatric hospital. Psychiatr Serv. 1998; 49 1049-1053
102 Munley P, Devone N, Einhorn C, Gash I, Hyer L, Kuhn K. Demographic and clinical characteristics as predictors of length of hospitalization and readmission. J Clin Psychol. 1977; 33 1093-1099
103 De Francisco D, Anderson D, Pantano R, Kline F. The relationship between length of stay and rapid-readmission rates. Hosp Community Psychiatry. 1980; 31 196-197

Dr. phil D Richter

Westf. Klinik für Psychiatrie und Psychotherapie Münster

Postfach 862048046 Münster

Email: E-mail: d.richter@wkp-muenster.de