Factors leading to Frequent Readmission Rate in Impatient Psychiatric Wards in the UK

Title:

Factors leading to Frequent Readmission Rate in Impatient Psychiatric Wards in the UK –  A Narrative Review of Literature

Review Question: What factors lead to Frequent Readmission Rate in Impatient Psychiatric wards in the UK.

Introduction and Aim of  the Review

The emphasis of shifting care and support of mental health patients from psychiatric institutions into community based settings has been the focus of  the UK government in recent times. The problem of frequent psychiatric readmission rate or the ‘revolving door’ phenomenon poses significant challenges to the implementation of the psychiatric deinstitutionalization policy,  (Langdon  et a., 2001).

The aim of this narrative literature review is to gather, synthesize and analyse existing literature to find out the factors that lead to frequent  psychiatric readmission rate in the UK. This would help to guide service redesign and development work, as well as stimulate further research and highlight gaps in the literature dedicated to this area. The literature is going to be criticised using the Critical Appraisal Skills Programme (CASP), (CASP, 2018). In line with the Nursing and Midwifery Council code of conduct, Confidentiality about the research participants will be maintained throughout this literature review, (Nursing & Midwifery Council (NMC), 2015).

Ethical Statement

In reviewing the literature, the author has ensured the literature review is unique and no existing literature is copied. The literature used in this review, has been  treated accurately and fairly. The authors of the literature used were not contacted because their literature is already in the public domain. Furthermore, the narrative literature review does not intend to raise any ethical issues or cause harm to any person.

Problem, Context and Background

The UK government has placed much emphasis on psychiatric deinstitutionalization, that is moving care and support to the community. However, the problem of frequent psychiatric readmission poses a significant challenge, as it exposes the fragility of the network of mental health services in the UK, (Langdon  et a., 2001). The implication of frequent psychiatric readmission is that, although patients are not permanently hospitalized, they have developed chronic mental health illnesses which are severe and persistent, these illnesses usually interferes with their interpersonal relationships and social skills which expose them to frequent psychiatric readmissions. The phenomenon of frequent rehospitalisation typifies a new form of  psychiatric institutionalisation. Furthermore, the phenomenon of frequent psychiatric readmissions highlights the limitations of the mental health services network. Even though, currently the mental health services in the UK are undergoing changes, they still bear features of the old models, practices and problems which are yet to be overcome. There has been specific interventions and community based care approaches aimed at reducing the rate of readmissions, (Vigod et al. 2013), thus gaining an understanding of the factors associated with frequent readmission  would help to guide service redesign and development work as well as stimulate further research.

Methodology

Search Strategy and Key Words

The literature search was conducted using Boolean search of the Discover Database. The Discover database was chosen because it has an extensive list of peer reviewed journal articles in subjects of nursing, health, medicine and psychiatry.

Considering the coverage and relevance of the literature review, a Boolean search was conducted using different combinations of Descriptors (DeCS) based on the review question, such as: readmission and mental disorders, readmission and mental health, readmission and psychiatric hospital, recall and mental health,  recall and psychiatric hospital, recall and mental disorder, rehospitalisation and mental health. rehospitalisation and psychiatric hospital, rehospitalization and mental disorder.

Inclusion and Exclusion Criteria

The search was further narrow down using an inclusion and exclusion parameters as describe below. The inclusion criteria were:

(1)articles that addressed the factors associated with psychiatric readmission, as well as studies that evaluated effectiveness of psychiatric patients transitions from in-patient to community care and readmission (2) articles written in English, (3) articles published between January 2009 and January 2019; and (4) articles that presented primary research results or studies; (5) articles mainly on studies from UK and Ireland.

The following exclusion criteria were also established:

(1) articles in the format of a dissertation, thesis, book, book chapter, editorial, comment or critique, proceedings and scientific reports; (2) review or reflective articles on readmission in general terms, that is, not exclusive to psychiatry; (3) articles about psychiatric readmission, which dealt exclusively with children and adolescents; (5) articles that considered only long-term hospitalized patients.

Finally, the author read through the abstracts of the articles that met the inclusion criteria , reviewed and appraised them and 7 of the most suitable articles from the search were selected and gained approval to be used in the literature review.

Data Extraction

Information in the selected articles was analysed, summarised and extracted to a Datasheet to aid the literature review process. The datasheet with the summarised information has the following Headings;

Article (Full reference), Geography, Number of participants, Study Method, Summary of the findings, Conclusions, (See Appendix 2)

Keywords:

Readmission, Readmitted, Recall, Rehospitalisation, Mental Health Hospital, Psychiatric  Hospital,

Literature  Review

Description of studies

The articles selected for the review includes a mixture of both qualitative and quantitative research studies. From the seven articles selected, 4 articles used quantitative method to carry out their research studies (Tulloch et al. 2015; Puntis et al. 2016; Stefan et al. 2009; Attfield et al. 2017) and 2 articles used qualitative design in their research studies, (Daly et al. 2017;  Chiringa et al. 2014). One article used both qualitative and quantitative design in their approach, (O‘Donoghue et al. 2011).

Broadly speaking, research methods are split into quantitative and qualitative research.  Ellis (2013), explained that quantitative research mainly aims to explain phenomena by collecting numerical data that are analysed using mathematically and statistical based methods. Quantitative research studies focus on proof, and cause and effect and the findings are presented in numbers, tables and graphs. Four of the selected articles (Tulloch et al. 2015; Puntis et al. 2016; Stefan et al. 2009; Attfield et al. 2017) employed the quantitative approach.  On the other hand, Ellis (2013) stated that qualitative research focuses on trying to answer questions about why and how people behave in a certain way. It provides in-depth information about human behaviour and phenomenon, two of the selected articles took this approach, (Daly et al. 2017;  Chiringa et al. 2014). In comparison to quantitative research, qualitative research looks to study what people think, believe, feel and understand. Unlike quantitative research, it is not concerned about proving concepts. The greater percentage of the studies took the quantitative methodology, they intended to find out the causes or factors that leads to frequent psychiatric readmissions. Equally, the other studies which took the qualitative approach was able to not only ascertain the causes of psychiatric readmission but also ascertain the views and feelings of patients who have been previously readmitted. 

Reporting the Findings

Three main themes were identified from reviewing the literature articles. The three themes that were identified were, Clinical factors and readmission, Demographic and Socio-Economic factors  and readmission, Continuity of care and readmission. The select literature are going to be reviewed using these themes.

Clinical factors and readmission

The  study established that, a patient mental illness diagnosis is a predicting factor the chances of readmission, The literature studies confirmed that after discharge the chances of readmission goes down quickly, depending on the type of diagnosis. For instance, Tulloch et al. (2015), reported that patients diagnosed with personality disorder are more likely to be readmitted compared to patient with schizophrenia at the time of discharge.

Specifically, the studies pointed out that only a diagnosis of personality disorder had a negative correlation with frequent readmission shortly after discharge, in that patient diagnosed with personality disorder have an increased psychiatric readmission rate compared to patients diagnosed with other mental health disorders shortly after discharge. In line with other research, largely the studies found out that, there is a modest-sized effect of diagnosis on readmission except the diagnosis of personality disorder. However, It was noted form the studies that, although the diagnosis of personality disorder might be a predicting factor for frequent readmission, it is likely that other underlying clinical influences operate before and after discharge which are not measured for this high risk patient group. For instance, most patients diagnosed with personality disorder are known to  express a lower satisfaction level with hospital care with their first admission and have more chances of being readmitted within 1 year after discharge. Also, non-compliance with prescribed medication leads to increased likelihood of readmission irrespective of the type of diagnosis,  (Rittmannsberger et al, 2004)

Demographic and Socio-Economic factors,  and readmission

The importance of social systems (i.e. family, friends, neighbours) as a contributory factor for readmission was strongly highlighted by three studies (Daly et al. 2017; Priebe et al. 2009; O‘Donoghue et al. 2011), and this seems to reflect wider research in this area. The Silva et al. (2009) study for example, stress the need for stronger community psycho-social support services in helping prevent multiple psychiatric readmissions. Additionally, the findings are in line with other studies that have shown that there is a negative correlation between socioeconomic deprivation and readmissions. For instance,  Cotton et al. (2007) found the strongest and most consistent reason for psychiatric readmissions to be social and economic factors. For instance, patients who find it difficult to manage their own home, finances, and are on benefit, most times indicating poor socio-economic status have higher psychiatric readmission rate, (Daly et al. (2017, Priebe et al. 2009).

A demographic factor found in the study that was significantly associated with frequent psychiatric readmissions was people who are from black ethnic background. The study, by Priebe et al (2009), reported that patients of Black African or Black African–Caribbean origin have a higher rate of readmission within a year after discharge than patients of White origin. This may be the case, because of the of socio-economic factors (i.e. being on welfare benefits, lack of family support) which might predispose patient from black African/Caribbean ethnicity to difficulties after discharge, and the subsequent risk of higher readmission rates. This stress the importance of designing social support and inclusion programmes aim at helping patients with mental disorders to not rely on benefits but helped to gain employable skills to mitigate some of the socio-economic factors that predispose them to frequent psychiatric readmissions, (Priebe et al., 2009).

Continuity of care and readmission

Lack of support after discharge into the community has been identified as a significant factor. Three studies (Daly et al. 2017; Puntis et al. 2016; Chiringa et al. 2014), established that, when patients receive efficient and effective support (i.e. medication management, someone to talk to about problems and support to access local community services) from the  Community Mental Health Team (CMHT), frequent readmission is reduced. In Chiringa et al. (2014) article, most of the participants who live in supported accommodation or hostels, stated that, the aftercare support they receive is very poor and ineffective and this leads to frequent readmissions. Also, the studies reported that lack of engagement from the CMHT and other services in informing patient about their care and support available leads to frequent readmission as they are not able to relate with the services and the CMHT when help is needed.

The practice of making available to patient relevant copies of clinical letters and documents can greatly  reduce the likelihood of early readmission. Most patients want information about, their treatment, lack of communication and miscommunication were cited by most studies (Daly et al. 2017; Puntis et al. 2016; Chiringa et al. 2014) as  a contributing factor for frequent recall or readmission.

However, the common perceived assumption that more frequent face-to-face contact would lead to less readmission was in contrast to the findings of the study (Puntis et al. 2016. When readmission and continuity of care was first debated in psychiatry, the consensus was that more frequent and consistent patient face to face contact would result in less readmissions, but the findings from the literature (Puntis et al. (2016) contradicts this commonly held view. This shows that, the evidence for associations between frequent readmission and continuity of care in psychiatry remains limited and requires more research. It was also established in the review that frequent changes in care coordinator leads to frequent readmission rate (Puntis et al. 2016).

Overall, the studies included in the literature review featured a total of 10.296 participants and the sample size range from 7891 to 6 participants (Tulloch et al. 2015; Chiringa et al. 2014). The sample size is very important in research studies as it has an influence on the reliability of the study. For instance,  Tulloch et al. (2015), has a sample size of 7891, thus it could be assumed to be the most reliable study among the selected literature articles. On the other hand, Chiringa et al. (2014), has a total of 6 participants, being the smallest sample size, thus its reliability might be questioned as it might excessively represent a small sub-group from the target population which  could increase the probability of sampling error. However, because it is a qualitative study, it has the advantage of gathering in-depth information on a particular subject and reporting of the findings can be detailed and extensive compare to a small sample size in a quantitative studies. Thus, from the literature articles selected, those with quantitative and qualitative methodology can equally be said to have a high reliability.

Furthermore, the selection methodology of some of the articles (Attfield et al. 2017; Puntis et al. 2016)  are randomised control trials which has an advantage of eliminating selection bias and can be effective in making causal inferences, for instance finding the causes of frequent psychiatric readmission rate. However, in randomised trials informed consent is often impossible to get, and this might raise ethical questions. Also, randomised trials which test for effectiveness might be too large and more expensive to run compare to convenience sampling. On the other hand, a couple of the studies (Chiringa et al. 2014; O‘Donoghue et al. 2011) use convenience or non-probability  sampling which are mainly made of participants who are easy to reach. An advantage of convenience sampling is, it can be conducted easily with much rules governing the sampling or selection process, the cost and time required to carry out a convenience sample is minimal in comparison to random sampling techniques. This allows you to achieve the sample size you want faster and in relatively easy way.  For instance, (Chiringa et al. 2014; O‘Donoghue et al. 2011) research studies would be easy and less costly to conduct, compared to ((Attfield et al. 2017; Puntis et al. 2016) research studies which employed randomised trails,  but both provide useful information in finding out factors that lead to psychiatric readmission. The use of convenience sample may help in collecting useful  information in  a way that might not be possible using random sampling techniques, which may require a formal access to lists of populations. However, convenience sample often suffers from bias. Since the sampling frame is known, and the sample is not chosen at random, it might not be a representative of the entire population being studied. This undermines the ability to make generalisations from the sample to the population that is being studied.

All the studies were conducted in the UK (Tulloch et al. 2015; Puntis et al. 2016; Stefan et al.2009; Attfield et al. 2017; Daly et al. 2017;  Chiringa et al. 2014), with the exception of one study (O‘Donoghue et al. 2011) that was conducted in Ireland. The advantage of this is that, the results can be applied to the UK in helping to find out factors that contribute to frequent  psychiatric readmission in UK. However, the generalisation is decrease in its application to other countries outside UK and also useful information from countries outside UK  which might contribute to knowledge and development are missed. All the same, the study (O‘Donoghue et al. 2011) from Ireland serve to help to make comparison with the UK to gain useful information and facts  to guide service redesign and development work, as well as stimulate further research.

Discussions

It is evident from the literature review  that among the many factors that leads to frequent psychiatric readmission,  clinical, demographic and socio-economic factors as well as efficient and effective continuity of care are the main contributory factors. Both demographic and clinical factors have been demonstrated to be the high risk characteristics in readmission rates in the UK. For instance,  in the UK, mental health patients of African or Caribbean origin are at higher risk of involuntary readmission (Priebe et al., 2009)  and this is mainly due to their socio-economic predispositions. The Silva et al. (2009) study for example, underscore the importance of  providing community psycho-social support services for people with mental health disorders  to reduce frequent psychiatric readmissions. The review established that, although diagnosis is a predictable factor of frequent readmission, notably, only personality disorder was significantly associated with increased readmission, all other mental health diagnosis has modest-sized effect on the rate of readmission (Martinez-Ortega et al., 2012). Furthermore, the literature review illustrates that psychiatric readmission is not only a reflection of the quality of inpatient care but also the continuity of care in the community (Vigod et al., 2013). Effective and efficient support and care in the community reduces frequent readmission. However, it was apparent from the literature review that more frequent face-to-face patient contact does not necessary lead to less readmission and this is at odds with popular held consensus that frequent face to face patient contact reduces psychiatric readmissions. This implies that evidence for associations between continuity of care and readmission remains limited. Furthermore, the literature review suggested that effective continuity of care should include better communication between the CMHT and patients, better support and improvements in the standards of care and a collaborative approach to risk assessment, these would go a long way in reducing the frequency of psychiatric readmission.

Conclusion

The literature review intended to find out the factors that lead to frequent psychiatric readmission or the ‘revolving door’ phenomenon to guide service redesign and development and to stimulate further research.  From the articles reviewed in this narrative literature review, it is evident that the aim of this narrative review has been met with better understanding  of the factors that leads to frequent psychiatric readmission. The correlation between demographic and socio-economic  factors and frequent psychiatric readmission were clearly identified to help inform knowledge and help in future service design and development. Also, the gap in knowledge on continuity of care in relationship to frequent psychiatric was highlighted to pave way for further research as well as recommendation were made for effective aftercare support from the CMHT to help reduce frequent psychiatric readmission.