Revolving-door patients in a public psychiatric hospital in Israel: Cross sectional study

Aim To study social, demographic, clinical, and forensic profiles of frequently re-hospitalized (revolving-door) psychiatric patients. Methods The study included all patients (n = 183) who were admitted to our hospital 3 or more times during a 2- year period from 1999 through 2000. We compared these patients to 2 control groups of patients who were admitted to our hospital in the same period. For comparison of forensic data, we compared them with all non revolving- door patients (n = 1056) registered in the computerized hospital database and for comparison of medical and clinical data we compared them with a random sample of non revolving-door patients (n = 98). The sample was sufficiently large to yield high statistical power (above 98%). We collected data on the legal status of the hospitalizations (voluntary or involuntary) and social, demographic, clinical, and forensic information from the forensic and medical records of revolving-door and non revolving-door patients. Results In the period 1999-2000, 183 revolving-door patients accounted for 771 (37.8%, 4.2 admissions per patient) and 1056 non revolving-door patients accounted for 1264 (62.5%, 1.2 admissions per patient) of the 2035 admissions to our hospital. Involuntary hospitalizations accounted for 23.9% of revolving-door and 76.0% of non revolvingdoor admissions. Revolving-door patients had significantly shorter mean interval between hospitalizations, showed less violence, and were usually discharged contrary to medical advice. We found no differences in sex, marital status, age, ethnicity, diagnoses, illegal drug and alcohol use, or previous suicide-attempts between the groups. Conclusions Revolving-door patients are not necessarily hospitalized for longer time periods and do not have more involuntarily admissions. The main difference between revolving- door and non revolving-door patients is greater self-management of the hospitalization process by shortening the time between voluntary re-admission and discharge against medical advice. Public mental health systems strive to maintain mentally ill individuals in the community, because hospitalization is the most costly category of care (1,2). Psychiatric patients who are frequently readmitted to hospitals, ie, patients with 3 or more psychiatric admissions in a 2-year period, are referred to as revolving-door patients (3,4). The term "recidivists" is also often used to describe patients who relapse to prior criminal habits and/or are repeatedly psychiatrically hospitalized (5), as well as the term "heavy users," signifying the patients who show an above-average utilization of medical care (6). In the authors' opinion, a more appropriate term for the patients who are admitted to hospital repeatedly and remain well for only short periods of time is "frequent users" or "high frequency users" (7). Service system variables, such as the shift to outpatient care, might influence hospital admission and readmission. Some studies speculate that the revolving-door phenomenon is a byproduct of insufficient social welfare services resulting from deinstitutionalization policies, inadequate rehabilitation facilities, or inadequate continuity of outpatient-treatment (8,9). Others suggest that it is a function of attributes of mental illness (10,11). Most studies suggest that re-hospitalization is not significantly related to housing, family or money problems, but is rather a function of patients' symptoms and lack of adherence to treatment regimens (12,13). Variables repeatedly associated with revolving-door phenomenon have been involuntary first hospitalization (14), alcohol and drug use, medication non-compliance, number of prior hospitalizations (15), and self-harm (16). Attempts to reduce the revolving-door phenomenon include conversion to depot medication before hospital discharge in an effort to facilitate medication adherence during transition to outpatient care. Outpatient civil commitment, when used judiciously, appears to contribute to maintaining hospital recidivists or patients with a history of criminal and/or aggressive behavior in the community (17). Court-mandated outpatient treatment may improve long-term outcomes by stimulating case management efforts, mobilizing supportive resources, improving compliance with treatment in the community, reducing clients' psychiatric symptoms and dangerous behavior, improving their social functioning, and finally by reducing the chance of illness relapse and re-hospitalization (18). An additional cause of revolving-door phenomenon may be related to the fact that between 6% and 35% of psychiatric patients discharge themselves from hospital against medical advice. Premature discharge may prevent patients from deriving the full benefit of hospitalization and may result in rapid re-hospitalization (19). The Mental Health Reform in Israel aims to promote quality of care, efficient use of resources, deinstitutionalization, and community based treatments while reducing the stigma of patients with mild psychiatric conditions. The intention was to create incentives for health service providers to improve continuity and comprehensiveness of care, shift patients from hospital to community care facilities, and negotiate low prices with providers. Use of ambulatory services was expected to increase if health funds were to facilitate access to them or reduce stigma (20). However, though the number of psychiatric hospital beds has been significantly reduced, the number of community-based aftercare clinics has not increased commensurately, thus boosting the revolving-door phenomenon. The revolving-door phenomenon has become a major problem in Israel. Each year, of the 16 000 psychiatric admissions nationwide, 12 000 are readmissions, including 5500 that are at least third readmission in a 2-year period. In terms of patients admitted rather than admissions, almost 15% of patients were hospitalized 3 times or more during a 2-year period (21). The Mental Health Reform in Israel, with the shift of mental health care to the community and reduction of the number of hospital beds, calls for a measurement of performance indicators (eg, length of stay, re-hospitalization after 30 and 180 days) and introduction of fines for excess re-hospitalizations or excess length of hospitalization (20). To achieve this, it is necessary to make an evaluation of risk factors of revolving-door phenomenon. The aim of this study was to assess the social, demographic, clinical and forensic profiles of revolving-door patients in Lev Hasharon Mental Health Center, a public university affiliated hospital in Netanya, Israel.