Argo Daniel, Barash Igor, Lubin Gadi, Abramowitz Moshe Z
Jerusalem Mental Health Center, Eitanim Psychiatric Hospital, Jerusalem, Israel.
Jerusalem Mental Health Center, Jerusalem, Israel.
Isr J Health Policy Res. 2017 Oct 26;6(1):57. doi: 10.1186/s13584-017-0178-8.
The Israel Mental Health Act of 1991 stipulates a process for involuntary psychiatric hospitalization (IPH). A patient thus hospitalized may be discharged by either the treating psychiatrist (TP) or the district psychiatric committee (DPC). The decision rendered by the DPC is often at odds with the recommendation of the TP. Although much has been written about the ethical issues of restricting patients' rights and limiting their freedom, far less attention has been devoted to the psychiatric, medical, and social outcome of legal patient discharge against the doctor's recommendation.
In our study we examined the outcomes of the decisions made by the DPC using readmission data, an internationally recognized indicator of the quality of hospital care, and compared them to the outcomes of patients discharged by the TP. All IPH discharges resulting from the DPC's determination for the year 2013 (N = 972) were extracted from the Israel national register. We also collected all IPH discharges owing to the TP's decision for 2013 (N = 5788). We defined "failure" as readmission in less than 30 days, involuntary civil readmission in less than 180 days, and involuntary readmission under court order in less than 1 year.
The rehospitalization pattern was compared in the two groups of patients discharged from their psychiatric hospitalization during 2013 (index discharges) and followed up individually for a year. We found a statistically significant difference between the DPC and the TP group for each of the time frames, with the DPC group returning to IPH much more frequently than the TP group. Using cross-sectional comparison with logistic regression adjusted for age, gender, diagnosis and length of hospitalization, we found the probability of a decision failure in the TP group was significantly less with an OR of 0.7 (95% CI .586-.863), representing a 30% adjusted decrease in the probability for failure in the TP group.
The results we present show that the probability of decision "failure" (readmission) was found to be significantly higher in the DPC group than in the TP group. It is often assumed that IPH patients will fare better at home in their communities than in a protracted hospitalization. This is frequently the rationale for early discharge by the DPC (30.1 days vs. 75.9 DPC and TP groups, respectively). Our results demonstrate that this rationale may well be a faulty generalization.
1991年的以色列《精神卫生法》规定了非自愿精神科住院治疗（IPH）的流程。如此住院的患者可由主治精神科医生（TP）或地区精神科委员会（DPC）批准出院。DPC做出的决定往往与TP的建议不一致。尽管已有大量关于限制患者权利和自由的伦理问题的著述，但对于违背医生建议让患者合法出院的精神科、医学和社会后果却鲜有关注。
在我们的研究中，我们使用再入院数据（一种国际认可的医院护理质量指标）来检查DPC做出的决定的结果，并将其与TP批准出院的患者的结果进行比较。2013年因DPC决定而导致的所有IPH出院病例（N = 972）均从以色列国家登记册中提取。我们还收集了2013年因TP决定而导致的所有IPH出院病例（N = 5788）。我们将“失败”定义为在30天内再次入院、在180天内非自愿再次民事入院以及在1年内根据法院命令非自愿再次入院。
对2013年从精神科住院治疗中出院（索引出院）并分别随访一年的两组患者的再住院模式进行了比较。我们发现在每个时间框架内，DPC组和TP组之间存在统计学上的显著差异，DPC组比TP组更频繁地再次接受IPH治疗。通过对年龄、性别、诊断和住院时间进行逻辑回归调整后的横断面比较，我们发现TP组决策失败的概率显著更低，比值比为0.7（95%置信区间为0.586 - 0.863），这表明TP组失败概率经调整后降低了30%。
我们呈现的结果表明，DPC组中决策“失败”（再次入院）的概率明显高于TP组。人们通常认为，IPH患者在社区家中的情况会比长期住院更好。这常常是DPC提前出院的理由（DPC组和TP组分别为30.1天和75.9天）。我们的结果表明，这个理由很可能是一个错误的概括。
