Lee Seung Yup, Kim Kyoung Hoon, Kim Tae, Kim Sun Min, Kim Jong-Woo, Han Changsu, Song Ji Young, Paik Jong-Woo
Department of Neuropsychiatry, College of Medicine, Kyung Hee University, Seoul, Republic of Korea.
Health Insurance Review & Assessment Service, Seoul, Republic of Korea.
Psychiatry Investig. 2015 Oct;12(4):425-33. doi: 10.4306/pi.2015.12.4.425. Epub 2015 Apr 15.
Non-adherence to medication is a recognized problem in psychiatric patients and may be one of the most challenging aspects of treatment for patients with schizophrenia. Failure of follow-up care after discharge greatly increases non-adherence to prescribed medications, relapse and rehospitalization. However, it is still unknown whether and how much outpatient follow-up visits can mitigate the risk of rehospitalization. Therefore we sought to investigate the continuity and effectiveness of outpatient care after inpatient discharge and its effect on rehospitalization of patients with schizophrenia.
Data were extracted from National Health Insurance Claim Database covering the period from 2007 through 2010. We identified 10,246 patients aged 18 years or older who were admitted in psychiatric facilities with the diagnosis of schizophrenia between January 1 and December 31 in 2007. The number of outpatient visits within 60 days after discharge from index admission was defined as the indicator for the continuous care and rehospitalization was inspected during the following 36-month period. Cox's proportional hazard model was used to examine the factors affecting the risk of rehospitalization including the number of outpatient visits, age, sex, comorbidities, antipsychotics, and characteristics of medical institution.
We found that 12.7% (n=1,327) of the patients visited psychiatric outpatient department once within 60 days after hospital discharge, 34.8% (n=3,626) twice, and 27.8% (n=2,900) more than three times. Patients taking atypical antipsychotics showed higher proportion in 2 or more outpatient visits, whereas patients taking typical antipsychotics showed higher proportion in one or no outpatient visits. Cox hazard ratios of rehospitalization for the factor of 3 or more outpatient visits referenced to that of no follow-up visit were 0.567 (0.428-0.750, 95% confidence interval) within 90 days, 0.673 (0.574-0.789) within 180 days, 0.800 (0.713-0.898) within a year, 0.906 (0.824-0.997) within 2 years, and 0.993 (0.910-1.084) within 3 years.
Although continuous outpatient treatment is important for relapse prevention, patients with schizophrenia showed a low rate of outpatient visit as 62.6% of total patients in 2 or more visits within 60 days after discharge. Lack of follow-up treatment might lead to increase psychotic symptoms and raised risk of relapse and rehospitalization. Our data suggest that the number of outpatient visits within 60 days after discharge in patients with schizophrenia is an important indicator of rehospitalization within a year. Therefore, further efforts to examine factors affecting failure of outpatient follow-up after discharge are warranted.
不遵医嘱服药是精神科患者公认的问题，可能是精神分裂症患者治疗中最具挑战性的方面之一。出院后随访护理的缺失会大大增加不遵医嘱服药、复发和再次住院的几率。然而，门诊随访能否以及在多大程度上降低再次住院的风险仍不清楚。因此，我们试图调查住院患者出院后门诊护理的连续性和有效性及其对精神分裂症患者再次住院的影响。
数据取自2007年至2010年期间的国民健康保险索赔数据库。我们确定了10246名18岁及以上的患者，他们于2007年1月1日至12月31日期间在精神科设施住院，诊断为精神分裂症。将首次入院出院后60天内的门诊就诊次数定义为持续护理的指标，并在接下来的36个月内检查再次住院情况。使用Cox比例风险模型来检查影响再次住院风险的因素，包括门诊就诊次数、年龄、性别、合并症、抗精神病药物以及医疗机构的特征。
我们发现，12.7%（n = 1327）的患者在出院后60天内到精神科门诊就诊1次，34.8%（n = 3626）就诊2次，27.8%（n = 2900）就诊超过3次。服用非典型抗精神病药物的患者在2次或更多次门诊就诊中的比例较高，而服用典型抗精神病药物的患者在1次或无门诊就诊中的比例较高。以无随访就诊为参照，3次或更多次门诊就诊因素导致的再次住院的Cox风险比在90天内为0.567（0.428 - 0.750，95%置信区间），180天内为0.673（0.574 - 0.789），1年内为0.800（0.713 - 0.898），2年内为0.906（0.824 - 0.997），3年内为0.993（0.910 - 1.084）。
尽管持续的门诊治疗对预防复发很重要，但精神分裂症患者的门诊就诊率较低，出院后60天内2次或更多次就诊的患者仅占总患者的62.6%。缺乏后续治疗可能会导致精神症状加重，增加复发和再次住院的风险。我们的数据表明，精神分裂症患者出院后60天内的门诊就诊次数是1年内再次住院的重要指标。因此，有必要进一步努力研究影响出院后门诊随访失败的因素。
