[精神病医院新入院患者的出院动态及相关因素]

[Discharge dynamics and related factors of newly-admitted patients in psychiatric hospitals].

作者信息

Kono Toshiaki, Shiraishi Hiromi, Tachimori Hisateru, Koyamas Asuka, Naganuma Yoichi, Takeshima Tadashi

机构信息

Department of Mental Health Policy and Evaluation, National Institute of Mental Health, National Center of Neurology and Psychiatry.

出版信息

Seishin Shinkeigaku Zasshi. 2012;114(7):764-81.

DOI:
Abstract

The focus of psychiatric services in Japan is being shifted from hospitalization to community care, and the Ministry of Health, Labour and Welfare aims for the prompt discharge of newly-admitted patients. Correspondingly, it set a goal to lower the "mean residual rate (MRR)", which indicates the discharge dynamics of newly-admitted patients, to 24%. As a measure to achieve this goal, the present situation should be investigated in each homogeneous patient group. In this study, we conducted a survey of newly-admitted patients to investigate discharge dynamics and related factors by the diagnosis and type of hospitalization. Out of 1,459 psychiatric hospitals to which we sent questionnaires, 183 (12.5%) replied. Each hospital completed questionnaires regarding a maximum of 5 patients for each type of hospitalization (voluntary hospitalization [VH], hospitalization for medical care and protection [HMCP], and involuntary hospitalization ordered by the prefectural governor [IHOPG]) between October 2005 and January 2006. We weighted the obtained patient data in proportion to the estimated total number of patients, and analyzed valid data on 1,784 patients. The MRR for the whole sample was 29.4%. By diagnosis, dementia showed the highest MRR (45.6%), followed by schizophrenia (34.9%); depression, bipolar disorder, and alcoholism showed the lowest MRRs (20-21%). We calculated MRRs by the type of hospitalization for dementia and the other diagnoses separately, considering confounding effect between the diagnosis and type of hospitalization (markedly high proportion of HMCP observed in dementia). In dementia, HMCP showed a higher MRR (46.8%) than VH (43.7%). In the other diagnoses, IHOPG showed the highest MRR (43.7%), followed by HMCP (34.5%) and VH (25.6%). Dementia differed from the other diagnoses in the distribution of residential settings before admission, with a higher proportion of residential care facilities (25.5%) and hospitalization in other departments (19.3%). In dementia, the residential setting after discharge showed a similar distribution, and death was also frequent (6.6%). Multivariate analyses revealed that a long stay (one year or longer) was significantly associated with a residential setting before admission, the type of ward at admission, a founder (a private hospital or public/university hospital), and symptom severity at admission in schizophrenia; and with the type of ward at admission and hospital founder in dementia. In schizophrenia, the risk of a long stay was higher on hospitalization in other psychiatric hospitals (odds ratio [OR] : 28) and other departments (OR: 18), and living alone (OR: 2.1) than in living with the family by residential setting. The risk was also higher in psychiatric long-term care wards than in general psychiatric wards by the type of ward (OR: 3.0), and in private hospitals than in public/university hospitals by hospital founder (OR: 3.0). Additionally, the higher risk was associated with higher symptom severity assessed using a 6-point scale (OR: 1.3 per point). In dementia, the risk was higher in senile dementia wards than in general psychiatric wards by the type of ward (OR: 2.9), and in private hospitals than in public/university hospitals by hospital founder (OR: 6.8). The most frequently reported direct causes of a long stay were problems regarding a family's acceptance (51.5%), poor improvement of symptoms (48.8%), and poor recovery of daily living abilities (44.0%). In dementia, physical diseases (20.8%) and undecidedness of residence after discharge (29.2%) were also frequent. Considering the elapsed time after survey, the low response rate, and the data analyses with sampling bias adjustment, the results should be interpreted carefully. Nevertheless, the discharge dynamics and related factors in newly-admitted patients varied with the diagnosis and type of hospitalization. Particularly, schizophrenia and dementia, as well as IHOPG and HMCP, showed high MRRs and frequent long stays. Additionally, a long stay was related to patients' demographic and social characteristics. Adopting measures suiting patients' characteristics and arranging treatment and casework for patients at high risk of a long stay are important to facilitate community care.

摘要

日本精神科服务的重点正从住院治疗转向社区护理,厚生劳动省旨在使新入院患者尽快出院。相应地,该部门设定了一个目标,将表明新入院患者出院动态的“平均残留率(MRR)”降至24%。作为实现这一目标的一项措施,应在每个同质患者群体中调查当前状况。在本研究中,我们对新入院患者进行了一项调查,以按诊断和住院类型调查出院动态及相关因素。在我们发送问卷的1459家精神科医院中,183家(12.5%)回复了问卷。每家医院填写了2005年10月至2006年1月期间每种住院类型(自愿住院[VH]、医疗护理和保护住院[HMCP]以及县长下令的非自愿住院[IHOPG])最多5名患者的问卷。我们根据估计的患者总数对获得的患者数据进行加权,并分析了1784名患者的有效数据。整个样本的MRR为29.4%。按诊断来看,痴呆症的MRR最高(45.6%),其次是精神分裂症(34.9%);抑郁症、双相情感障碍和酒精中毒的MRR最低(20 - 21%)。考虑到诊断和住院类型之间的混杂效应(在痴呆症患者中观察到HMCP的比例明显较高),我们分别按痴呆症和其他诊断的住院类型计算了MRR。在痴呆症患者中,HMCP的MRR(46.8%)高于VH(43.7%)。在其他诊断中,IHOPG的MRR最高(43.7%),其次是HMCP(34.5%)和VH(25.6%)。痴呆症在入院前居住环境分布方面与其他诊断不同,居住护理设施的比例较高(25.5%),在其他科室住院的比例也较高(19.3%)。在痴呆症患者中,出院后的居住环境分布相似,死亡情况也很常见(6.6%)。多变量分析显示,长期住院(一年或更长时间)与精神分裂症患者入院前的居住环境、入院时的病房类型、医院创办者(私立医院或公立/大学医院)以及入院时的症状严重程度显著相关;与痴呆症患者入院时的病房类型和医院创办者相关。在精神分裂症患者中,与居住在家属身边相比,在其他精神科医院住院(优势比[OR]:28)和其他科室住院(OR:18)以及独自生活(OR:2.1)的长期住院风险更高。按病房类型来看,在精神科长期护理病房的长期住院风险高于普通精神科病房(OR:3.0),按医院创办者来看,在私立医院的长期住院风险高于公立/大学医院(OR:3.0)。此外,使用6分制评估的较高症状严重程度也与较高风险相关(每增加一分OR:1.3)。在痴呆症患者中,按病房类型来看,在老年痴呆病房的长期住院风险高于普通精神科病房(OR:2.9),按医院创办者来看,在私立医院的长期住院风险高于公立/大学医院(OR:6.8)。长期住院最常报告的直接原因是家庭接纳问题(51.5%)、症状改善不佳(48.8%)以及日常生活能力恢复不佳(44.0%)。在痴呆症患者中,身体疾病(20.8%)和出院后居住地点未确定(29.2%)也很常见。考虑到调查后的时间推移、低回复率以及进行了抽样偏差调整的数据分析,对结果应谨慎解读。尽管如此,新入院患者的出院动态及相关因素因诊断和住院类型而异。特别是,精神分裂症和痴呆症,以及IHOPG和HMCP,显示出较高的MRR和频繁的长期住院情况。此外,长期住院与患者的人口统计学和社会特征相关。采取适合患者特征的措施,并为有长期住院高风险的患者安排治疗和个案工作,对于促进社区护理很重要。

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