The PROGRES-Acute survey is the first study ever carried in Italy aimed at obtaining comprehensive nationwide data on public and private inpatient facilities and their functioning. It provides valuable information about the phenomenon of long-stay inpatients hospitalized in acute facilities, which represents an important problem for the overall effectiveness of mental health services (also from a financial perspective). The main findings and most important clinical and treatment implications of this study are discussed here below.
Variables associated with hospital long-stay
Several studies have previously reported length-of-stay associations with patient age [9] and gender characteristics [10]. Our results are consistent with these findings in terms of age, but not gender. It is possible that gender per se is not a key long-stay risk factor and that other confounding factors, such as the specific clinical characteristics of study participants and situational variables, have a greater impact on hospital stay duration [11].
Our study also did not replicate previous findings showing an association between long-stay status and diagnosis: based on ICD-10 diagnostic categories, and controlling for other variables, no significant differences between long-stay and short-stay inpatients emerged. We also observed no association with patients' severity in terms of psychopathology. Although severity of psychopathology has been found to influence length of stay [3], the issue of how best to develop valid and reliable ways to measure illness severity has always represented a challenge for the field [12]. Various serious proposals in this regard have emerged in recent years; our study used the 24-item BPRS, an expanded version of the 18-item BPRS, with defined scale points and probe questions, which has shown improved inter-rater reliability over previous versions.
An high percentage of short-stay patients was found among compulsorily admitted subjects. This is consistent with data found by other authors [11], and is probably due to the fact that a "short" duration of admission (up to 90 days in our study) was sufficient for controlling acute psychiatric symptoms, while long-stay status is determined by variables other than symptomatology (as shown also by the results of the multivariate analysis).
The other variables examined herein have also been investigated by other authors, and our finding that unmarried status is associated with long hospital stay is consistent with results from several previous studies [3, 4, 11].
Although we found that poor psychosocial functioning was positively associated with long-stay status, it is generally unclear whether more impaired patients have longer lengths of stay due to difficulties in planning discharges and in community resettlement efforts, or whether hospital stay leads to a loss of basic daily living skills and impairment in ability to function in social environments [13]. Of course, it is possible that both factors influence long-stay: patients with poor psychosocial functioning tend to remain in hospital longer, and this situation in turn facilitates the further loss of daily living skills, increases dependence, and weakens social networks.
An intriguing finding was that patients with higher education level (more than 8 years) were hospitalized for longer than those with lower education level. However, an high school degree (or beyond) was also found in the majority (60%) of long-stay patients in a North-American study [14], while in a German sample of inpatients subjects who had failed to attain a grammar school certificate were more readily discharged as compared to inpatients with an high school degree [11]. An hypothetic explanation may be that treatment psychiatrists had higher expectations of improvement about patients with higher education, and a longer stay of those patients was related to the tendency of these physicians to not discharge patients who still did not show a clinically significant improvement.
Length of stay and hospital setting
The strongest predictor of long hospital stay was admission to a private inpatient facility. It should be noted that this is the first national survey ever conducted in Italy to include patients admitted to private inpatient facilities. Indeed, very few investigations at an international level have examined inpatients admitted to private facilities. It can be argued that the tendency to longer stay in private inpatient facilities is due to specific differences in their functioning and staffing arrangements. In fact, private Italian hospital facilities, vs. public facilities, present several characteristics found to be associated with longer length of stay [5], such as lower staff-patient ratio, poorer coordination with community mental health services (although referral to community services may be associated with higher rehospitalization risk, or does not necessarily reduce the risk of rehospitalization [2, 15]), and a higher number of beds [16].
Risk of violent behavior and long-stay
Our finding that long-stay inpatients were more likely to display violent behaviors during hospitalization has also been reported previously [17]. Various explanations can account for this association: duration of hospital stay may be determined by the violence a patient exhibits. Alternatively, long-term hospitalization itself may contribute to the manifestation of violent behavior – perhaps due to patient frustration about a delayed discharge. Studies conducted in other countries have shown that violent behavior during hospitalization is most likely linked to factors other than long-term hospitalization.
Specifically, acute symptom severity and prior history of dangerousness appear to be the strongest predictors for disruptive behavior in psychiatric units [18, 19]. Patients in the present study frequently had their stay prolonged because they were judged to be at risk of antisocial behavior. Professionals tend to be cautious when placing patients who have exhibited violent behavior in less-supervised settings, in an attempt to avoid triggering events with undesirable consequences. Perhaps the team members in our study tended to carefully weight the risks of discharging patients into family environments, and these patients therefore remain hospitalized for longer periods. This finding has direct implications for the complex ward management of patients showing violent behavior, because they should receive more intensive management during their hospital stay. Yet, as observed elsewhere [20], Italian psychiatric units rarely provide intensive case management and direct behavioural forms of intervention – such as social skills training -which is specific to the post-discharge environment and helps patients better cope with stress and anger. This general scenario persists, in spite of wide-scale acknowledgment of the importance of the inclusion of these programmes in individual inpatient care plans [21].
Treatments and long-stay
The findings about process of care were more complex and difficult to interpret. On one hand, psychotherapies that can require prolonged treatments did not predict prolonged hospital stay. On the other, long-stay inpatients (vs. discharged patients), as expected, were more likely to have received rehabilitative intervention that can require longer hospitalization. In any event, it is worth noting that rehabilitative interventions were delivered to only 24% of these inpatients – a finding that is reason for concern, because 50% of them stayed in hospital for approximately 5 months, and 25% stayed for more than 11 months. Moreover, these findings raise the question of why these patients were not moved from hospital- to community-based settings, including residential facilities.
Staff members noted that many patients continued to occupy acute hospital beds due to the unavailability of appropriate alternative placements – a problem found to be linked to inappropriate bed use in acute settings, in other studies conducted in European countries with similar financing and health care delivery systems. The issue is pressing in the UK, where high proportions of 'new long-stay patients' tend to receive inappropriate, continued acute care, following the country's historical shift to community care [22]. Some of these patients merely require home-based community support, such as group homes. The situation is similar in Italy, where poorly suitable post-discharge accommodation inevitably places greater pressure on acute psychiatric beds. For example, just one out of six residential facilities occasionally admits patients with acute illness episodes [2].
Residential rehabilitative facilities should therefore be made available to patients requiring more intense levels of care. Yet, in Italy, beds in these facilities are not easily made vacant, as shown in a recent nationwide study on Italian psychiatric residential facilities [23], which found that resident turnover was extremely low. These findings point to the need for the development of sufficient and appropriate alternative care settings for patients admitted to acute psychiatric units.
