As a psychiatry resident at New York University School of Medicine, Dr. Brady G. Case noticed – and heard from older psychiatrists – that inpatient treatment had changed dramatically, especially for children and teenagers, with ever-shorter hospitalizations even for their sickest patients.
Case set out to quantify this trend. He and a team of researchers analyzed federal data on psychiatric patients under 17 discharged from about 1,000 community hospitals across the nation, looking at 1990 and 2000 figures and comparing the diagnoses, lengths of stay and referrals to other facilities.
They reported their findings in this month’s issue of the Archives of General Psychiatry: From 1990 to 2000, the total number of inpatient days and mean charges per visit each fell by about half, and the median length of stay dropped by 63 percent, from 12.2 to 4.5 days, even as the share of patients with psychotic and severe mood disorders increased.
PBN: Was the phenomenon you observed that led you to conduct this study specific to pediatric patients?
CASE: Adult psychiatrists had also experienced changes in how quickly they were expected to discharge patients, and what they were expected to accomplish over the course of an admission. But it seemed to be more marked among the child psychiatrists.
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PBN: And it was not something they did by choice?
CASE: The perception I had from my supervisors and teachers was that it was a fact of life, and they really were being pushed, … I think by the insurance companies, by the hospitals, by the expectations of others. The clinicians were not leading the charge … to try to shorten these lengths of stay. On the other hand, I think a lot of clinicians, especially in child psychiatry, are not excited about admitting kids. They don’t like to split up families, and they see inpatient admissions as disruptive. Most clinicians, I think, try to keep kids out of the hospital when they think it’s safe. So there’s always a balance.
PBN: Lengths of stay have also declined over the decades as psychiatrists decided it really wasn’t good for most kids to be hospitalized for weeks, months or even years. Is that a factor here?
CASE: I think most clinicians I know would say we can’t go any further than we’ve gone. Now maybe they said that five years ago. Maybe they said that 10 years ago. To me, as a clinician, it’s hard for me to imagine doing all that much for seriously ill kids in less time than we currently use. Now Bradley [which wasn’t part of this study] is a little bit different. My experience here has been that the median stay is a little over a week.
PBN: Have the standards for discharging patients changed?
CASE: If you ask clinicians who’ve been working through this period, I think many of them would say they’ve had to readjust their expectations for what can be accomplished during a stay and what they would require to see in terms of changes before making a discharge. This study doesn’t really address that question, though. I don’t have good data in this study about outcomes. … I don’t know how much they’ve improved. I don’t know what they’re being treated with.
PBN: Do most patients now walk out with a prescription?
CASE: In this period there was a really dramatic increase in the use of medications for kids. … We know from other studies that the use of antipsychotics in children has increased something like fivefold. So it’s probably the case that a lot of the kids are leaving with prescriptions. … Also, in 2000, 6.9 percent were transferred to another facility, either another inpatient facility or an intermediate-level facility; 10 years earlier, that number was 11.6 percent. [The rest of the patients] were going home with outpatient services … but we don’t have details on their treatment plans.
PBN: So we don’t know whether they have adequate supports?
CASE: I think that is the question. … To me, the most important aspect of following up on these findings is to ask, are these kids being treated safely once they leave the hospital? … It is true that psychiatry – and child psychiatry in particular – has become more creative in setting up intermediate-level services that address problems that office-based psychiatrists would have trouble handling, … such as Safe Quest [Bradley’s day hospitalization program for teens]. There has been a real blossoming of those types of options. But it’s not clear to me that most communities have access to these types of services, so I am worried.
PBN: You also found a sharp increase in some of the more serious diagnoses.
CASE: With bipolar disorder, 2.9 percent of the admissions were for bipolar in 1990; 15.1 percent were for bipolar in 2000. That’s pretty wild. … One possible reason is that during a period when managed care dominated, it’s not surprising that more severe diagnoses would be more heavily represented among the kids who make it into the hospital, if the standards for admission have gone up. … Also, our field has changed. What used to be seen as depression is now often seen as a mix of manic and depressed states. … And there’s some evidence from my data that people are just calling things differently. Substance use disorders used to be the principal diagnosis in 16 percent of admissions in 1990; that’s fallen to 4.8 percent. However, as a secondary diagnosis, it has gone up, from 9.8 percent to 16.7 percent. So people are shifting the importance of the diagnosis from a major issue to a minor issue, and I think that’s in part because it’s very difficult to admit a kid for a substance use issue, because of insurance issues. So we’ve probably engaged in a process called upcoding, where we slightly alter the diagnosis we present to facilitate the admission of the child.
PBN: Do you have a sense of whether kids really are sicker, though, overall?
CASE: My data doesn’t really indicate one way or the other. What is interesting in my data is that the stated goal of managed care is to adequately match illness severity and treatment, to move kids who didn’t require high-intensity, expensive services out of those services … and free up more resources for appropriate treatment of sicker kids. That would make sense. But in our data, it looks like the lengths of stay fell most for the diagnoses that are most severe. … What’s emerging is a more uniform length of stay for all kids, regardless of diagnosis. That to me is concerning just on its face.
PBN: Going back to the medication issue: The full effects of psychotropic drugs generally don’t kick in for several days. Does this mean kids are being sent home before they know whether their meds work, or whether there are unwanted side effects? Is that safe?
CASE: I think it’s only safe if the follow-up is adequate. The FDA has now indicated that its standard of care for antidepressants in children, for example, is that they must be seen weekly for the first month. As the systems change, I think public health authorities are going to be increasingly interested in how we do business. It may be that requirements or recommendations about frequency of contact and duration of treatment may be increasingly prevalent.
PBN: Do you see a need for legislation that assures kids a certain number of days in the hospital if they need them, just as there are minimums for women giving birth?
CASE: I think it is the case that compared to the rest of medicine as a whole, psychiatry has sustained more significant cuts in the length of stay, … and child psychiatry has sustained even more significant changes. My data doesn’t really tell you whether that is safe or not. Overall, what I can tell you is that inpatient providers are doing more with less. But I do think states should be interested in this question, what the quality of inpatient care is, and whether the dispositions that are being made seem, in general, adequate.
