Systematic review of the effectiveness of planned short hospital stays for mental health care

Introduction

Many countries, including Britain, are reviewing their community care and favouring more hospital care for people with serious mental illness—after 40 years of mental hospital closures.1 Reduced length of stay in hospital is cited as one of the reasons for failure of community care2 and the emergence of “revolving door” and “new long stay” patients. 3 4 Although there is some merit in the argument for closing large institutions and preventing institutionalisation, 5 6 one important questions still remains: how long should a person with serious mental illness stay in hospital for optimum benefit (and least harm) both to the patient and to society? Many researchers have attempted to answer this question, but with observational studies and using outcomes that are irrelevant for today's policy makers.7

We aimed to determine the effectiveness of planned short or brief hospital stays to long hospital stay or standard care for patients with serious mental illness, extracting outcomes data from all relevant randomised controlled trials.

Methods

Results

Results of search

The initial electronic search identified 206 citations. Fourteen studies were identified for assessment, of which four were included because they fulfilled the above criteria. 4 10^–22 Three excluded studies were quasirandomised trials, which were analysed and discussed separately.23^–27 Seven trials were excluded as they were not randomised trials.

Of the four included randomised controlled trials, three were from the United States,4 10^–22 and one from the United Kingdom,18 19 spanning 15 years from 1969 (table). Blinding of raters was not mentioned in any trial. Short hospital stays were planned from 1 week13^–17 to 21-28 days. 4 10^–12 The average length of stay of those patients allocated to short hospital stay ranged from 10.8 days13^–17 to 25.0 days. 4 10^–12 Short stay care included discharge planning and training for crisis resolution. 4 10^–12 No specific community care was described, except for day care by Hirsch et al. 18 19 The duration of long hospital stays before the trial were only clearly reported in one study (90 to 120 days, mean 94 days), 4 10^–12 otherwise professional carers determined length of stay.

Fourteen different outcome scales, some of unknown validity, were used without any reference to SDs, and therefore could not be summated. Only one paper presented data from a continuous measure that could be extracted in dichotomous form, and this was “percentage of people improved.” 4 10^–12 The main drug treatment was with neuroleptics, and all trials reported similar use in patients allocated both long and short hospital stay.

Results of review

Readmissions (fig 1) —All trials reported readmission data (total of 628 patients). No difference was found between short and long hospital stay groups by 1 year (odds ratio 0.93, 95% confidence interval 0.66 to 1.29) and by 2 years (1.06, 0.63 to 1.29), with no heterogeneity between trials (χ²=3.22, df=3, P>0.25 at 1 year). Adding three quasirandomised trials to the sensitivity analysis introduced heterogeneity, due to Burhan's study27 which showed significantly fewer readmissions for those in the short hospital stay group throughout the 2 year period.

Fig 1

Readmissions to hospital at 3 and 6 months and 1 and 2 years

• Download figure
• Open in new tab
• Download powerpoint

Loss to follow up (fig 2) —No differences were found in loss to follow up between short or long hospital stay groups at 1 and 2 years (three trials of 404 patients, 1.09, 0.62 to 1.91 with no heterogeneity at 2 years). At 1 year, just over 5% of people in both groups were lost to follow up and this rose to 14% by 2 years.

Fig 2

Loss to follow up at 6 months and 1 and 2 years

• Download figure
• Open in new tab
• Download powerpoint

Leaving hospital prematurely —Only two trials reported abrupt premature discharge against medical advice4 10^–12 20^–22; no differences were found between the groups for this outcome (0.76, 0.31 to 1.86).

Discharge delayed beyond planned time (fig 3) —In three trials of 404 patients, significantly fewer delayed discharges were found in the short hospital stay groups compared with long hospital stay groups (0.47, 0.27 to 0.85), with no heterogeneity between trials (χ²=0.70, df=2, P> 0.5). Including data from quasirandomised trials, however, reduced this to no effect and introduced significant heterogeneity (χ²=27.45, df=4, P<0.001).

Fig 3

Delayed discharge beyond time planned in study

• Download figure
• Open in new tab
• Download powerpoint

Not improved —Only one trial reported percentages of people “not improved.”4 10^–12 No differences were reported between short and long hospital stay groups as measured by two different scales. This outcome was reported in only the preliminary study, which was a subset of the larger trial.

Deaths (all causes) —Herz et al reported three deaths in the short hospital stay group and four deaths in the long hospital stay group (0.39, 0.08 to 1.86).13^–17

Employment status and independent living —Patients from the short hospital stay groups were less likely to be unemployed at 2 years than those from the long hospital stay groups (0.34, 0.21 to 0.55, reported in two trials with 327 patients). There was, however, heterogeneity between the two trials (χ²=6.01 df=1, P<0.025).

Cost of care —Glick et al reported costs for outpatient services only and suggested that short stay care was slightly more expensive. 4 10^–12

Average length of stay —No SDs were reported for average lengths of hospital stays and therefore these could not be summated. For those allocated short hospital stays, the average length of stay ranged from 10.8 days13^–17 to 25.0 days. 4 10^–12 The average length of long hospital stay ranged from 28 days18 19 to 94 days. 4 10^–12

Discussion

This review provides a timely evaluation of the evidence of effectiveness for hospital care and use of beds when many countries are reassessing their mental health policies. Although inpatient costs use about 80% of mental health resources, this review highlights a longstanding record of poor or inadequate evidence on the organisation and delivery of hospital care (in contrast with some aspects of community care).

Despite this, our review summarises important findings for new policies on modernising mental health services. Planned short hospital stays seemed to be as effective as long hospital stays for several important outcomes. Patients allocated short hospital stay experienced no more readmissions and no more losses to follow up and were more likely to be discharged on time than patients allocated long hospital stay. In addition, those allocated to short stay care had lower rates of unemployment, although these data should be interpreted with caution and warrant further investigation.

Why did short stay care seem as successful as longer stay care? Goffman's theories of institutionalisation may explain why patients allocated long hospital stay had negative results.4 He suggested that longer hospitalisation led to difficulties for patients in re-entering the “real world.” In addition, short stay care with discharge planning and a date for discharge may have provided an impetus for managed care that was both focused and coordinated compared with standard care (similar to the care provided in stroke units). Patients may also prefer short hospital stays (which may help improve engagement in treatment), although this should also be investigated.

Other important outcomes were not assessed in the original trials or could not be summated, including deaths, violence, criminal offence or imprisonment, and continuous data on mental state, social functioning, and family burden. No trial reported patient satisfaction as an outcome, possibly because these views were not considered important in the 1960s and 1970s. Economic information was also very poor and difficult to interpret. If the mean actual length of hospital stay was used as a measure of resources consumed, the average costs for short hospital stay were more than three times cheaper than those for long hospital stay, suggesting that short stay care offered the same or better outcomes for less resources.

We found that adding the three lower quality quasirandomised trials introduced heterogeneity to most outcomes, thus supporting the use of Cochrane criteria for inclusion of methodologically rigorous trials in reviews. One trial merits further discussion.27 We were concerned about the randomisation technique used, which could have led to unequal chances of being randomised into the short hospital stay group from a hospital cohort. The author, however, provided sole aftercare including counselling and continuous personal access via a telephone. Lessons could be learnt from this unusual trial, although it may not be easily replicated in practice.

Finally, planners usually assess the extent of inpatient provisions on the basis of national and international comparisons rather than on their effectiveness. Our review attempts to address this and, on the basis of limited data so far, commissioning short stay policies seem to be an appropriate use of resource irrespective of the quality and quantity of care after discharge and the provision of newer antipsychotics. Further pragmatic trials are needed to fill important gaps in knowledge, strengthen existing evidence, and allow greater generalisability to other care cultures.