Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.
Psychiatr Serv. 2021 Oct 1;72(10):1151-1159. doi: 10.1176/appi.ps.202000657. Epub 2021 May 17.
The author examined patient demographic, clinical, payment, and geographic factors associated with admission to low-safety inpatient psychiatric facilities.
Massachusetts all-payer 2017 discharge data (N=39,128 psychiatric patients) were linked to facility-level indicators of safety (N=38 facilities). A composite of safety was created by averaging standardized measures of restraint and seclusion as well as 5-year averages of overall, substantiated, and abuse-related (i.e., verbal, physical, or sexual) complaints per 1,000 discharges (α=0.73). This composite informed quintile groups of safety performance. A series of multinomial regression models were fit, with payment and geography added separately.
Notable factors independently associated with admission to low-safety facilities were belonging to a racial or ethnic minority group compared with being a White patient (for non-Hispanic Black, relative risk ratio [RRR]=1.71, p<0.01; for non-Hispanic Asian, RRR=5.60, p<0.01; for non-Hispanic "other" race, RRR=2.17, p<0.01; and for Hispanic-Latinx, RRR=1.29, p<0.01) and not having private insurance (for self-pay or uninsured, RRR=2.40, p<0.01; for Medicaid, RRR=1.80, p<0.01; and for Medicare, RRR=1.31, p<0.01).
To the best of the author's knowledge, this is the first study to examine differences in admission to low-safety inpatient psychiatric facilities. Even after accounting for potential clinical, geographic, and insurance mediators of structural racism, stark racial and ethnic inequities were found in admission to low-safety inpatient psychiatric facilities. In addition to addressing safety performance, policy makers should invest in gaining a better understanding of how differences in community-based referrals, mode of transport (e.g., police or self), and deliberate or unintentional steering and selection affect admissions and outcomes.
作者研究了与低安全性住院精神病患者入院相关的患者人口统计学、临床、支付和地理因素。
将马萨诸塞州 2017 年所有支付者的出院数据（N=39128 名精神病患者）与设施安全水平指标（N=38 个设施）相关联。通过平均标准化的约束和隔离措施以及每 1000 名出院患者的五年平均综合、证实和与虐待相关的（即言语、身体或性）投诉来创建安全综合指标（α=0.73）。该综合指标反映了安全绩效的五分位组。拟合了一系列多项回归模型，并分别加入了支付和地理位置。
与被收入低安全性设施相关的显著因素包括属于种族或少数民族群体，而非白人患者（对于非西班牙裔黑人，相对风险比[RRR]=1.71，p<0.01；对于非西班牙裔亚洲人，RRR=5.60，p<0.01；对于非西班牙裔“其他”种族，RRR=2.17，p<0.01；对于西班牙裔拉丁裔，RRR=1.29，p<0.01）和没有私人保险（对于自付或无保险，RRR=2.40，p<0.01；对于医疗补助，RRR=1.80，p<0.01；对于医疗保险，RRR=1.31，p<0.01）。
据作者所知，这是第一项研究低安全性住院精神病患者入院差异的研究。即使在考虑了潜在的临床、地理和保险结构种族主义调解人之后，在低安全性住院精神病患者入院方面仍存在明显的种族和民族不平等。除了解决安全绩效问题外，政策制定者还应投资于更好地了解基于社区的转介、运输方式（如警察或自行）以及故意或无意的引导和选择如何影响入院和结果方面的差异。
