When patients decide the admission – a four year pre-post study of changes in admissions and inpatient days following patient controlled admission contracts

Abstract

Background: Mental health professionals usually decide patients' access to inpatient care to ensure the rational and fair distribution of care based on need and prognosis. The purpose of the current study is to investigate the effects of increasing patients' influence on admission by enabling patients to initiate brief inpatient stays of up to five days at a community mental health center. Patients can initiate admission according to their own discretion, outside the existing referral and gatekeeping system. Methods: Patient-controlled admission (PCA) contracts were offered to eligible patients for inpatient stays in four community mental health centers in one health trust in Norway. Data on included patients' inpatient stays at any of the hospitals' mental health or addiction wards were collected by hospital electronic journal data extraction specialists for the two years before PCA contracts were introduced and the first two years after PCA contracts were introduced for the included patients. Results: The included patients (n = 57) had 406 PCAs in the two years following signing PCA contracts. When comparing the periods before and after the introduction of the contracts, the total number of admissions increased from 203 to 498 (p < .001), while the number of inpatient days decreased from 7172 to 3178 (p < .001). No significant change in involuntary care was observed. A comparison of box plots of inpatient day use in the eight half-year periods of the study indicates a gradual increase in median inpatient days up to the signing of a PCA contract for the sample, and an abrupt reduction to a stable median level of inpatient days after signing a contract. Conclusions: The included patients' use of inpatient days changed profoundly after signing PCA contracts, similar to what previous studies of PCAs have indicated. In spite of the marked reductions in inpatient days, the pre-post design makes it impossible to rule out that the reductions were caused by regression toward the mean. No study of PCAs has reported negative effects, indicating that giving patients control over very short admissions is a feasible and potentially positive scheme in mental health care wards.

Patient-controlled admission contracts: a longitudinal study of patient evaluations

“…A small RCT [ 5 ] and a propensity-matched study of PCAs [ 3 ] showed a significant reduction in inpatient days in both controls and PCA patients. In these studies, PCA use was lower or the inpatient days reduction was smaller, indicating differences in service or implementation compared to previous Norwegian studies [ 6 ]. In any case, none of the published studies have yet reported increased use of inpatient days or other important problems for the patients or wards following PCA introduction, thus indicating non-inferiority for PCAs [ 6 ].…”

“…Findings in this study are from the subjective perspective of the patients, and we did not collect family carers or provider evaluations. We have previously reported changes in inpatient day use for a subsample of this study [ 6 ]. We had no control group rating regular admissions, so we could not make comparisons to treatment as usual.…”

“…The study context has been described elsewhere [ 6 ]. In brief, Norwegian mental health services are public, with free inpatient services and 79 mental health beds per 100,000 adult inhabitants in Norway in 2014 [ 10 ].…”

“…Eighty patients gave written consented and were included in the study. A subset of 59 of these patients signed a PCA contract for the first time at inclusion, and sample characteristics and the change in inpatient days for these 59 patients are described in a previous paper [ 6 ]. One of the 80 patients later withdrew consent, and we excluded five patients where there were neither PCAs nor a final evaluation interview.…”

“…The result of the PCA arrangement in pre-post studies (mirror image studies) is typically that patients on contract increase their number of admissions, but the PCAs are so much shorter that the number of inpatient days drops sharply when compared to a similar period before signing the PCA contract [ 4 , 5 ]. However, in these designs, regression to the mean cannot be ruled out as the only cause of the changes [ 6 ]. A small RCT [ 5 ] and a propensity-matched study of PCAs [ 3 ] showed a significant reduction in inpatient days in both controls and PCA patients.…”