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Introduction

Some issues are not easily identified as public health concerns. Among such issues are mental illness and readmission of pediatric patients to psychiatric hospitals. This study serves as an introduction to research that readmission of pediatric psychiatric patients is a public health concern. The central idea in this research is to explore

predictors of readmissions. This work is based on data from an academic psychiatric hospital at the University of Utah. The participants were those who had been admitted as inpatients between 1999 and 2010 to the University Neuropsychiatric Institute (UNI). The participants had to have been no older than 18 years at the time of their admission to UNI and had to be inpatients for less than 365 days.

Specific Aims

In this study, there were three major parts: 1) a description of pediatric patients seen at an academic psychiatric hospital, namely the University Neuropsychiatric Institute. In this part of the study, demographics of these patients were identified and assessed to determine whether there were differences among patients that were

the second part of the study. 2) Part two of this research was to identify predictors of readmission. The goal for this aim was to assess the difference in characteristics

possessed by patients readmitted and those not readmitted. 3) Part three of the study was to do an examination of the relationship between the hospital length of stay in days and readmission of the pediatric patients.

Significance

The limited body of research shows that there is an increase in admissions and readmissions of patients with psychiatric disorders to psychiatric specialty hospitals.1, 2 The increase is seen with increasing age,1 but particularly concerning among children and adolescents.2 These increasing pediatric psychiatric hospital readmissions pose

significant public health concerns.1, 3 _{The public health concern includes a long list of}

reasons resulting from these repeated hospitalizations, for example, interrupted school, family activities, social life,1, 3, 4 and long periods away from parental guidance

responsible for provision of psychological and health needs. A few studies have attempted to study the predictors of psychiatric inpatient readmissions in the United States and reported family and social issues as some of the predictors.2, 3, 5 _However,

many questions remain unanswered. Our retrospective cohort will investigate the answers to the questions expressed in the specific aims. Some research has reported that repeated psychiatric hospitalizations are a concern because the inpatient experience presents with negative effects upon the young such as trauma, posttraumatic stress disorder or learning of self-harm behaviors.6

Main Conclusions and Implications

The general conclusion in these studies is that mental illness or psychiatric disorders are not one unique disease. The study points out that psychiatric disorders are specific diagnoses and efforts to understand them should consider the specific nature of the diagnosis. In the presence of other factors, the specific diagnosis is the main

predictor of whether or not a pediatric patient will be readmitted. This research was started with the main hypothesis that the longer the initial period of hospital length of stay, the less likely that a pediatric patient will be readmitted. The findings of the research, however, are that although hospital length of stay is a vital component of the treatment, it is not generally a predictor of whether a patient will be readmitted. This general conclusion may vary with specific diagnoses such as those within eating disorders.

Public Health Relevance

This research highlights mental health disorders and the repetitive readmission of children with psychiatric illness as a public health problem. With the identification of factors, especially the predictor variables explained above, valuable insights into reducing readmission may be developed. These study results may inform future interventions to minimize such readmissions.

Overall Strengths and Limitations

This study was the first of its kind to utilize the large data set spanning 11 years to investigate readmissions. The use of a number of diagnoses as defined by DSM IV and

ICD 9 codes was unique to this study, as well as a strength. Use of a large data set from a regional psychiatric hospital of the nature of UNI is a big advantage to the study. The many years of clinical data were crucial in exploring change of the hospital length of stay over the years. Data from the same facility provided an additional benefit of uniform data entry.

The study was not designed to investigate available post discharge treatment variables or considerations which may be additional predictor variables. Dual diagnoses or comorbid illnesses, such as diabetes, may interact with psychiatric illness, and may be crucial in the prediction of whether a patient is readmitted or not. These data did not provide information on dual diagnosis or comorbid illness. Presence of such information may have some influence on readmission. This study utilized diagnoses at the time of admission and with psychiatric illness, a change in diagnosis is possible after being an inpatient. It is likely that the results might be different if diagnoses at discharge were available and considered.

While the large data set covering 11 years of clinical data is a strength for the study, there are limitations associated with use of such data from a single facility. It is difficult to generalize findings from this study to all psychiatric academic hospitals. These data were secondary and could have been collected for purposes other than research. The use of secondary data could lead to an overestimation or underestimation of results, even though the data analysis procedures were correct. The findings and descriptions are based on primary diagnosis at the time of admit. It is common, however, to have comorbid disorders in psychiatric illnesses and having comorbid illnesses might have led to different findings. One of the strongest limitations could be that data were

obtained from a regional hospital, and because patients were referred from a distance and from different hospitals, it is possible that those who received readmissions from their home state or region may have been counted as non-readmits at the regional hospital.

Next Steps in Inquiry and Recommendations?

There are other factors that may help to provide insights into readmission patterns such as treatment modalities and costs. Such factors were not part of this study and may be considered for future studies. Prospective research may also help clarify factors that influence readmission such as events following initial discharge.

References

1. James A, Clacey J, Seagroatt V, Goldacre M. Adolescent inpatient psychiatric admission rates and subsequent one-year mortality in England: 1998-2004. J

Child Psychol Psychiatry. 2010;51(12):1395-1404.

2. Romansky JB, Lyons JS, Lehner RK, West CM. Factors related to psychiatric hospital readmission among children and adolescents in state custody. Psychiatr

Serv. 2003;54(3):356-362.

3. Blader JC. Symptom, family, and service predictors of children's psychiatric rehospitalization within one year of discharge. J Am Acad Child Adolesc

Psychiatry. 2004;43(4):440-451.

4. Castro J, Gila A, Puig J, Rodriguez S, Toro J. Predictors of rehospitalization after total weight recovery in adolescents with anorexia nervosa. Int J Eat Disord. 2004;36(1):22-30.

5. Lyons JS, O'Mahoney MT, Miller SI, Neme J, Kabat J, Miller F. Predicting readmission to the psychiatric hospital in a managed care environment: implications for quality indicators. Am J Psychiatry. 1997;154(3):337-340.

6. Barker D, Jairam R, Rocca A, Goddard L, Matthey S. Why do adolescents return to an acute psychiatric unit? Australas Psychiatry. 2010;18(6):551-555.