Predicting psychiatric admission rates.

OBJECTIVE--To determine the numbers of actual and expected psychiatric admissions for the residents of the district health authorities of England and to develop a model to indicate which social, health status, and service provision factors best explain the variation of the actual from the expected psychiatric admissions; to use this model to predict psychiatric admission for district health authorities as an aid to resource allocation. DESIGN--The actual psychiatric admission for district health authority residents were extracted from data of the 1986 Mental Health Enquiry. Expected admissions were calculated using the age, sex, and marital status structure of each district health authority and the national psychiatric admission rates related to age, sex, and marital status. Standardised psychiatric admission ratios were calculated as the ratios of the numbers of actual to expected psychiatric admissions. A wide range of social, health status, and service provision data were used as the explanatory variables in regression analyses to determine which combination of factors best explained the variation between districts of standardised psychiatric admission ratios. SETTING--The 168,652 psychiatric admissions recorded for the 1986 Mental Health Enquiry, after exclusion of mental handicap and psychogeriatric admissions. RESULTS--The actual number of psychiatric admissions varied from 79% above to 54% below the expected number of admissions from age, sex, and marital status for the districts of England. The most powerful variables to explain this variation were the rate of notification of drug misusers, standardised mortality ratios, and levels of illegitimacy in each district. A complex model was developed which could be used to predict district psychiatric admissions as an aid to resource allocation. A simpler model was also developed (which was less powerful than the more complex model) based on the underprivileged area score. One advantage of this model was that it could be used at the level of electoral wards as well as district health authorities.     

Deprivation and general practitioner workload.

OBJECTIVES--To examine general practitioner consultations by demographic and socioeconomic variables and to derive a method of measuring the impact of relative deprivation on general practitioner workload. DESIGN--The study was based on general practitioner consultations reported in the general household surveys of 1983-7, covering a sample of 129,987 individuals in Great Britain. Odds ratios for general practitioner consultations were obtained for selected variables among children (0-15 years), men (16-64), women (16-64), and elderly people (greater than or equal to 65). These were then used to derive deprivation indices specific to electoral wards for use in general practice. SETTING--Great Britain, with particular findings illustrated by English electoral wards and the conurbations of London, Manchester, Merseyside, and the West Midlands. RESULTS--Council tenure increased the likelihood of consultation significantly in all four groups. Odds ratios were raised in children, men, and women with no access to a car. Birth in the New Commonwealth or Pakistan yielded high odds ratios in men, women, and elderly people but not in children. Marginally increased consultation rates were evident in the manual socioeconomic groups in women, elderly people, and children with a single parent mother. The deprivation indices for general practice derived using these odds ratios varied substantially among English electoral wards with, for example, anticipated general practitioner consultations in the electoral ward of Hulme, Manchester, being 24% higher than the average ward in England as a result of local attributes, and consultations in the Cheam South ward of Sutton, London, 11% lower than average. CONCLUSION--This deprivation index for general practice overcomes several shortcomings expressed about the underprivileged area score, which has been adopted in the 1990 contract as a basis for allocating deprivation supplements to general practitioners. The proposed index can be applied nationwide.     

Integrated hospital and community psychiatric services and use of inpatient beds.

The impact of introducing a divisional psychiatric service based in the community in Nottingham in 1981 on adult psychiatric admissions (patients aged 15-65) was examined with data from the Nottingham case register. During 1980-5 the number of psychiatric admissions fell significantly (4.5% a year) compared with the national figures (0.46% a year). Admissions were reduced most for the diagnoses of affective psychosis and neurotic and personality disorders. The average duration of admission fell by 3.6% a year, and use of inpatient beds fell by 37.5%. Integrating hospital and community psychiatric services by creating sectors is a viable and economically feasible way of improving psychiatric services.     

Unemployment rates: an alternative to the Jarman index?

OBJECTIVE--To compare the Jarman index with alternative deprivation measures with regard to its usefulness to district health authorities as an indicator of need at small area level. DESIGN--The Jarman index (UPA (8)), Townsend''s index of material deprivation, the Scottish Development Department''s index, the Department of the Environment''s basic index, and unemployment rates were compared in respect of their correlation with measures of morbidity by electoral ward in a typical English district health authority. Measures of morbidity comprised standardised mortality ratios, admission rates (standardised and non-standardised), and permanent sickness rates. Spearman rank correlation coefficients were calculated for each combination of measures and were then ranked for each of the deprivation indices. SETTING--The 59 electoral wards of the Central Nottinghamshire Health Authority. RESULTS--The Jarman index consistently ranked lower in respect of its correlation with measures of morbidity than did the other deprivation measures. Current unemployment rates correlated well with morbidity measures, in particular with hospital admission rates, with correlations ranging from 0.669 to 0.830 for average and standardised all age admission rates. CONCLUSIONS--The Jarman index seems to be the least appropriate of these indices for health authority use. Unemployment rate merits further consideration as a simple, up to date marker for deprivation and consequent need for health service provision.     

Comparison of community based service with hospital based service for people with acute,severe psychiatric illness.

OBJECTIVE--To compare the burden on relatives and outcome of people treated for severe acute psychiatric illness by a community service and a traditional hospital based service. DESIGN--Follow up of patients aged 16-65 who required admission to hospital or home treatment for psychiatric illness during January 1990 to February 1991. SETTING--Two Birmingham electoral wards, Sparkbrook and Small Heath; Sparkbrook has a community based service and Small Heath a traditional hospital based service. SUBJECTS--69 patients from Sparkbrook and 55 from Small Health. MAIN OUTCOME MEASURES--Scores on present state examination, social behaviour assessment schedule, and general health questionnaire. RESULTS--24 (35%) of Sparkbrook patients received some treatment in hospital during the initial episodes. Relatives of Sparkbrook patients were less distressed by their burden at the initial assessment than relatives of Small Health patients (mean score 0.11 v 0.29, p < 0.01). Relatives were also more satisfied with the support they received and the treatment received by patients. More patients from Sparkbrook than Small Health were in contact with a psychiatrist (81% (95% confidence interval 71% to 91%) v 62% (44% to 68%)) and community nurse (56% (44% to 68%) v 14% (13% to 24%)) one year after the initial episode. Sparkbrook patients spent significantly fewer days in hospital during the initial episode (8 days v 59 days) and the first year (20.6 v 67.9 days). CONCLUSION--The community based service is as effective as the hospital based service and is preferred by relatives. It is more effective in keeping people in long term contact with psychiatrists.     

Mental capacity to make decisions on treatment in people admitted to psychiatric hospitals: cross sectional study

Objective To estimate the prevalence of mental capacity to make decisions on treatment in people from different diagnostic and legal groups admitted to psychiatric hospital.Design Cross sectional study.Setting General adult acute psychiatric inpatient units.Participants 350 consecutive people admitted to psychiatric wards from the community over 16 months.Main outcome measure Mental capacity assessed by clinical interview and the MacArthur competence assessment tool for treatment.Results Estimates of mental capacity were obtained on 97% (n=338) of the 350 people admitted. Of those an estimated 60% (95% confidence interval 55% to 65%) lacked mental capacity to make decisions on treatment. This proportion varied according to diagnosis, ranging from 97% (n=36) in people with mania to 4% (n=24) in people with personality disorder. Mental incapacity was common in patients admitted informally to the psychiatric wards (n=188; 39%, 32% to 46%). Incapacity and detention are closely associated under non-capacity based mental health law.Conclusions Mental incapacity to make decisions on treatment is common in people admitted to psychiatric wards from the community but cannot be presumed. It is usual in those detained under the Mental Health Act and common in those admitted voluntarily.     

Mortality in elderly patients admitted for respite care.

OBJECTIVE--To determine whether admitting elderly patients to hospital to give temporary relief to their carers is associated with increased mortality. DESIGN--Prospective multicentre study comparing the mortality of patients admitted on a one off or rotational basis with that experienced while they were awaiting admission. SETTING--A wide range of urban and rural district general, geriatric or long stay, and general practitioner hospitals. PATIENTS--474 Patients aged 70 or over who had 601 admissions. MAIN OUTCOME MEASURE--Death. RESULTS--16 (3.4%) Of the 474 patients (2.7% of all 601 admissions) died while in hospital during an average stay of 15.7 days whereas 23 (4.9%) patients died while awaiting admission (average waiting time was 34.2 days). The 16 deaths in hospital and the 23 deaths during the longer waiting period correspond to death rates of 19.9 and 12.5 per 10,000 person days respectively. The difference between these of 7.4 is not statistically significant (95% confidence interval -3.6 to 18.3). The estimated relative risk of dying in hospital is 1.59 but the 95% confidence interval is wide (0.84 to 3.01). CONCLUSION--Although the death rates are slightly higher in those admitted to hospital for relief care than in those awaiting admission, the difference was not significant, and the death rate in both groups was reassuringly small.     

Depression and other psychiatric morbidity in carers of elderly people living at home.

OBJECTIVE--To describe the mental health of a community sample of carers of elderly people with dementia, depression, or physical disability and to compare that with the mental health of other adults living in the household and of those living alone. DESIGN--Assessment of psychiatric morbidity and physical disability with standardised questionnaire in randomly selected enumeration districts; subjects were interviewed at home. SETTING--London Borough of Islington. SUBJECTS--700 people aged > or = 65 and other coresidents. MAIN OUTCOME MEASURE--Depression measured with standardised interview. RESULTS--The prevalence of depression was not significantly higher in carers overall (15%) than in coresidents (11%). Being a woman carer was a significant predictor of psychiatric illness. Depression was more common in the carers of people with a psychiatric disorder than in coresidents (24% v 11%, P < 0.05) and in those living alone (19%). Depression was most common (47%) in women carers of people with dementia. CONCLUSION--The increase in psychiatric morbidity reported in carers of people with psychiatric disorders may reflect the lack of a confiding relationship.     

Relation between night visit rates and deprivation measures in one general practice.

OBJECTIVE--To compare night visit rates in different electoral wards of one general practice with the Jarman and Townsend deprivation scores and unemployment rates. DESIGN--Analysis of computerised workload data. SETTING--General practice in centre of Mansfield, Nottinghamshire. OUTCOME MEASURE--Visits made in 588 nights to the 11,998 patients on the practice list. RESULTS--Night visit rates in 15 electoral wards varied from 19.6 to 55.3 visits per 1000 patients per year. The rates showed a significant association with the Townsend score (p = 0.004) and the unemployment rate (p = 0.03) but not with the Jarman score (p = 0.3). The Townsend score explained 49% of the variability; unemployment explained 31% and the Jarman score explained 9%. CONCLUSIONS--Even in a general practice not eligible for deprivation payments there was a 2.8-fold variation in night visit rates between wards. In this practice the Townsend score was significantly better at predicting night visit rates than the Jarman score. This method of looking at internal variation in workloads in computerised practices could give more direct data on the relation between deprivation and general practice workload than has previously been available.     

Home treatment for acute psychiatric illness.

OBJECTIVE--To determine the factors influencing the successful outcome of community treatment for severe acute psychiatric illnesses that are traditionally treated in hospital. DESIGN--All patients from a single electoral ward who were either admitted to hospital or treated at home over a two year period (1 October 1987 to 30 September 1989) were included in the study and their case notes audited. The second year of the study is reported. SETTING--Electoral ward of Sparkbrook, Birmingham. SUBJECTS--99 Patients aged 16-65 with severe acute psychiatric illness. RESULTS--65 Patients were managed by home treatment alone; 34 required admission to hospital. The location of treatment was significantly (all p less than 0.05) influenced by social characteristics of the patients (marital state, age (in men), ethnicity, and living alone) and by characteristics of the referral (occurring out of hours; assessment taking place at hospital or police station). DSM-III-R diagnosis was more weakly associated with outcome. Violence during the episode was significantly related to admission, although deliberate self harm was not. CONCLUSIONS--Home treatment is feasible for most patients with acute psychiatric illness. A 24 hour on call assessment service increases the likelihood of success because admission is determined more strongly by social characteristics of the patient and the referral than by illness factors. Admission will still be required for some patients. A locally based mental health resource centre, a 24 hour on call service, an open referral system, and an active follow up policy increase the effectiveness of a home treatment service.     

Childhood leukaemia in the West Berkshire and Basingstoke and North Hampshire District Health Authorities in relation to nuclear establishments in the vicinity.

During the years 1972-85, 89 children aged 0-14 were registered with leukaemia in the West Berkshire and Basingstoke and North Hampshire District Health Authorities. Two nuclear establishments are located within the health authorities, and a third is situated nearby. Fifty of the 143 electoral wards in the two district health authorities lie wholly within, or have at least half their area lying within, a circle of radius 10 km around the establishments. In those 50 electoral wards 41 children aged 0-14 were registered with leukaemia, 28.6 registrations being expected on the basis of leukaemia registration rates in England and Wales (incidence ratio = 1.4, p less than 0.05). This excess was confined to children aged 0-4, among whom there were 29 registrations of leukaemia, 14.4 being expected (incidence ratio = 2.0, p less than 0.001). In the remaining 93 electoral wards there was a small and non-significant increase in the number of registrations of leukaemia at age 0-14 (48 observed, 40.8 expected; incidence ratio = 1.2). There was no obvious trend in the incidence of childhood leukaemia over the 14 years and the overall occurrence of the malignancy in the 143 electoral wards was consistent with a random distribution. In the surrounding Oxford and Wessex Regional Health Authorities the number of registrations of leukaemia at age 0-14 was virtually identical with that expected on the basis of registration rates in England and Wales (362 observed, 372.5 expected; incidence ratio = 1.0). These data indicate that in the two district health authorities studied there was an excess incidence of childhood leukaemia during 1972-85 in the vicinity of the nuclear establishments. In the West Berkshire and Basingstoke and North Hampshire District Health Authorities an average of 60,000 children aged 0-14 lived within a 10 km radius of a nuclear establishment each year. The normal expectation of leukaemia in these children was two cases a year, whereas the recorded incidence was three cases per year, representing one extra case of leukaemia each year among these 60,000 children.     

Higher mortality in deprived areas: community or personal disadvantage?

OBJECTIVE--To investigate the association between level of social deprivation in electoral wards and premature mortality among residents, before and after allowing for levels of personal deprivation. DESIGN--Longitudinal study of the Office of Population Censuses and Surveys. SETTING--England. SUBJECTS--Random sample of nearly 300,000 people aged between 16 and 65 at the 1981 census and followed up for nearly nine years. MAIN OUTCOME MEASURE--Death from all causes between ages of 16 and 70. RESULTS--Without allowance for personal disadvantage, both sexes showed a clear, significant, and roughly linear positive relation between degree of deprivation of the ward of residence in 1981 and premature death before 1990. For men, this association was effectively explained away once allowance was made for individual socioeconomic circumstances. For women living in wards of above average deprivation, the association was also effectively removed, but the situation for other women was less clear. CONCLUSION--The excess mortality associated with residence in areas designated as deprived by census based indicators is wholly explained by the concentration in those areas of people with adverse personal or household socioeconomic factors. Health policy needs to target people as well as places.     

Contribution from geriatric medicine within acute medical wards.

In 1977 a scheme of attachment to acute medical wards of consultants in geriatric medicine and associated junior medical staff was instituted in a large Edinburgh teaching hospital. The effect on admissions of patients aged 65 and over was examined for comparable periods before and during this arrangement. Mean and median stays were reduced for both sexes but more noticeably for women. The mean stay for all women aged over 65 was reduced from 25 to 16 days and for women aged over 85 from 50 to 19 days. The proportion staying under two weeks was significantly increased in both sexes, and the proportion discharged home also increased, correspondingly fewer patients being transferred to convalescent wards. These changes were not accompanied by increased transfers to the geriatric department, and probably the skills and extra resources available to the geriatric service were the factors mainly responsible for the changes in performance.     

Accidents in the home among children under 5: ethnic differences or social disadvantage?

Accidents in the home to children under 5 in a multiracial population with a high level of social disadvantage were studied by interviewing at home the parents of 402 children attending the accident department of a west London hospital during one year. The parents'' country of birth, whether they were employed, and their housing conditions were recorded using the definitions of the 1981 census. Four ethnic groups (British (183 children), Asian (127), Caribbean (61), and other (31)) were identified. Though attendance rates based on the populations of electoral wards at the census and standardised for distance from the hospital showed no significant differences among the ethnic groups, there was a strong gradient by social class and strong associations with unemployment of the mother (although not of the father), overcrowding, and tenure of housing.Social disadvantage seems to be more important than ethnicity as a determinant of accidents to children in the home.     

Cross sectional survey of socioeconomic variations in severity and mechanism of childhood injuries in Trent 1992-7

ObjectiveTo determine the relation between morbidity from injury and deprivation for different levels of injury severity and for different injury mechanisms for children aged 0-14 years.DesignCross sectional survey of routinely collected hospital admission data for injury 1992-7.Setting862 electoral wards in Trent Region.Subjects21 587 injury related hospital admissions for children aged 0-4 years and 35 042 admissions for children aged 5-14.ResultsBoth total number of admissions for injury and admissions for injuries of higher severity increased with increasing socioeconomic deprivation. These gradients were more marked for 0-4 year old children than 5-14 year olds. In terms of injury mechanisms, the steepest socioeconomic gradients (where the rate for the fifth of electoral wards with the highest deprivation scores was ⩾3 times that of the fifth with the lowest scores) were for pedestrian injuries (adjusted rate ratio 3.65 (95% confidence interval 2.94 to 4.54)), burns and scalds (adjusted rate ratio 3.49 (2.81 to 4.34)), and poisoning (adjusted rate ratio 2.98 (2.65 to 3.34)).ConclusionThere are steep socioeconomic gradients for injury morbidity including the most common mechanisms of injury. This has implications for targeting injury prevention interventions and resources.

What is already known on this topic?

There is a steep socioeconomic gradient for injury related mortalityThere is conflicting evidence regarding the socioeconomic gradient for injury morbidity, particularly with respect to different injury severity and injury mechanisms

What this study adds

A socioeconomic gradient for injury morbidity exists in children aged <15 years, particularly in those aged <5, which persist for different measures of injury severityThe socioeconomic gradient for injury mechanisms is steepest for pedestrian injuries, burns and scalds, and poisoning, which has implications for targeting injury prevention strategies     

Childhood antecedents of schizophrenia and affective illness: social adjustment at ages 7 and 11.

OBJECTIVE--To investigate the social adjustment in childhood of people who as adults have psychiatric disorders. DESIGN--Subjects in a prospectively followed up cohort (the national child development study) who had been admitted as adults to psychiatric hospitals were compared with the rest of the cohort on ratings of social behaviour made by teachers at the ages of 7 and 11 years. SUBJECTS--40 adult patients with schizophrenic illnesses, 35 with affective psychoses, and 79 with neurotic illness who had been admitted for psychiatric reasons by the age of 28. 1914 randomly selected members of the cohort who had never been admitted for psychiatric treatment. MAIN OUTCOME MEASURES--Overall scores and scores for overreaction (externalising behaviour) and underreaction (internalising behaviour) with the Bristol social adjustment guide at ages 7 and 11. RESULTS--At the age of 7 children who developed schizophrenia were rated by their teachers as manifesting more social maladjustment than controls (overall score 4.3 (SD 2.4) v 3.1 (2.0); P < 0.01). This was more apparent in the boys (5 (2.6)) than the girls (3.4 (1.8)) and related to overreactive rather than underreactive behaviour. At both ages prepsychotic (affective) children differed little from normal controls. By the age of 11 preneurotic children, particularly the girls, had an increased rating of maladjustment (including overreactions and underreactions). CONCLUSION--Abnormalities of social adjustment are detectable in childhood in some people who develop psychotic illness. Sex and the rate of development of different components of the capacity for social interaction are important determinants of the risk of psychosis and other psychiatric disorders in adulthood.     

Time trends and demography of mortality after fractured neck of femur in an English population, 1968-98: database study

Objectives To investigate time trends in mortality after admission to hospital for fractured neck of femur from 1968 to 1998, and to report on the effects of demographic factors on mortality.Design Analysis of hospital inpatient statistics for fractured neck of femur, incorporating linkage to death certificates.Setting Four counties in southern England.Subjects 32 590 people aged 65 years or over admitted to hospital with fractured neck of femur between 1968 and 1998.Main outcome measures Case fatality rates at 30, 90, and 365 days after admission, and standardised mortality ratios at monthly intervals up to one year after admission.Results Case fatality rates declined between the 1960s and the early 1980s, but there was no appreciable fall thereafter. They increased sharply with increasing age: for example, fatality rates at 30 days in 1984-98 increased from 4% in men aged 64-69 years to 31% in those aged ≥ 90. They were higher in men than women, and in social classes IV and V than in classes I and II. In the first month after fracture, standardised mortality ratios in women were 16 times higher, and those in men 12 times higher, than mortality in the same age group in the general population.Conclusions The high mortality rates, and the fact that they have not fallen over the past 20 years, reinforce the need for measures to prevent osteoporosis and falls and their consequences in elderly people. Whether post-fracture mortality has fallen to an irreducible minimum, or whether further decline is possible, is unclear.     

Increasing Short-Stay Unplanned Hospital Admissions among Children in England; Time Trends Analysis ’97–‘06

Background

Timely care by general practitioners in the community keeps children out of hospital and provides better continuity of care. Yet in the UK, access to primary care has diminished since 2004 when changes in general practitioners'' contracts enabled them to ‘opt out’ of providing out-of-hours care and since then unplanned pediatric hospital admission rates have escalated, particularly through emergency departments. We hypothesised that any increase in isolated short stay admissions for childhood illness might reflect failure to manage these cases in the community over a 10 year period spanning these changes.

Methods and Findings

We conducted a population based time trends study of major causes of hospital admission in children <10 years using the Hospital Episode Statistics database, which records all admissions to all NHS hospitals in England using ICD10 codes. Outcomes measures were total and isolated short stay unplanned hospital admissions (lasting less than 2 days without readmission within 28 days) from 1997 to 2006. Over the period annual unplanned admission rates in children aged <10 years rose by 22% (from 73.6/1000 to 89.5/1000 child years) with larger increases of 41% in isolated short stay admissions (from 42.7/1000 to 60.2/1000 child years). There was a smaller fall of 12% in admissions with length of stay of >2 days. By 2006, 67.3% of all unplanned admissions were isolated short stays <2 days. The increases in admission rates were greater for common non-infectious than infectious causes of admissions.

Conclusions

Short stay unplanned hospital admission rates in young children in England have increased substantially in recent years and are not accounted for by reductions in length of in-hospital stay. The majority are isolated short stay admissions for minor illness episodes that could be better managed by primary care in the community and may be evidence of a failure of primary care services.     

Impact of a province-wide nurses' strike on medical care in a regional referral centre.

A 4-week, province-wide nurses'' strike in Alberta in 1982 caused the closure of 57% of the acute care beds, including 47% of the intensive care beds, in Calgary. The effects of the strike on patient care at Foothills Provincial General Hospital, where nurses did not strike, were assessed. The number of emergency admissions, severity of illness and rate of death in the intensive care unit increased. On the other hand, the rate of death, length of stay and number of unexpected deaths on the medical wards were similar to those in the control periods before and after the strike. A subjective perception by hospital personnel of deteriorating patient care caused much anxiety; however, the results of analysis of measurable aspects of care suggested that the patients admitted to hospital received care during the strike that was comparable to care given before or after the strike. The inconvenience and potential harm to the patients not admitted because they had less severe illness were not measured.     

Widening inequality of health in northern England, 1981-91.

OBJECTIVE--To identify relative and absolute changes in mortality in the Northern region of England between 1981 and 1991. DESIGN--1981 and 1991 census data were used to rank 678 wards on an index of material deprivation composed of four variables (unemployment, car ownership, housing tenure, household overcrowding). Standardised mortality ratios (all causes) were calculated for various periods between 1981 and 1991 and for different age categories. SETTING--Counties of Cleveland, Cumbria, Durham, Northumberland, and Tyne and Wear. RESULTS--During 1981-91 mortality differentials widened between the most affluent and deprived fifths of wards in all age categories under 75 years. The decline in the relative position of the poorest areas was particularly great, and there was no narrowing of inequalities across the remainder of the socioeconomic spectrum. In absolute terms, there were improvements in mortality in all age categories in the most affluent areas. In the poorest areas improvements in the 55-64 age group were balanced by increased mortality among men aged 15-44, a slight rise among women aged 65-74, and static rates among men aged 45-54. CONCLUSIONS--These results re-emphasise the case for linking mortality patterns with material conditions rather than individual behaviour.