Increased Risk of Avoidable Hospitalization among Patients with Schizophrenia

Article excerpt

Objective: Some studies suggest that hospitalizations for certain conditions, called ambulatory care sensitive conditions (ACSCs), are potentially avoidable. However, almost no study has addressed the risk of ACSC hospitalizations specifically for patients with severe mental illness. Our study examines the risk of ACSC hospitalizations among patients with schizophrenia in Taiwan, using a 5-year, nationwide, population-based database.

Methods: Our study included 2503 patients with schizophrenia and 20 024 matched patients without schizophrenia. Poisson regression analysis was then performed in which the number of ACSC hospitalizations from 2002 to 2006 (including ruptured appendix, asthma, cellulitis, congestive heart failure, diabetes, gangrene, hypokalemia, immunizable conditions, malignant hypertension, pneumonia, pyelonephritis, and perforated or bleeding ulcer) was regressed against the independent variable of whether or not a patient had a schizophrenia diagnosis in 2001.

Results: Results show that 9.83% of patients with schizophrenia and 4.71% of patients in the comparison group experienced ACSC hospitalizations from 2002 to 2006. After adjusting for each patient's sex, age, level of urbanization, geographic location of residence within a community, and monthly income, patients with schizophrenia had a 3.26-fold higher (95% CI 3.00 to 3.54, P < 0.001) risk of experiencing ACSC hospitalizations than the comparison participants. After excluding the conditions of diabetes, hypertension, and asthma, patients with schizophrenia independently had a 2.46-fold higher risk of ACSC hospitalizations (95% CI 2.12 to 2.86, P < 0.001), compared with participants in the comparison group.

Conclusions: We conclude that schizophrenia patients are at a higher risk for hospitalizations owing to ACSCs, despite a national health insurance system providing universal coverage to citizens.

Can J Psychiatry. 2011;56(3):171-178.

Clinical Implications

* Schizophrenia patients are at a higher risk for hospitalization owing to ACSCs, despite a national health insurance system providing universal coverage to citizens.

* Even under the universal national health insurance program, patients with schizophrenia continue to have reduced access to physical health care, and the quality of care they receive is lower than that of the general population.

* The development and implementation of a set of guidelines on how to manage somatic morbidity in patients with schizophrenia may improve the quality of care, if these guidelines addressed the deficiencies in physicians for these patients.


* We identified patients diagnosed with schizophrenia from administrative claims data by International Classification of Diseases, Tenth Revision, Clinical Modification code, potentially compromising the validity of diagnoses.

* Our study was unable to examine the effects of potential confounders such as the highest educational level, marital status, social support, local health infrastructure, and family cohesion in the regression model, which could compromise our findings.

Key Words: schizophrenia, ambulatory care sensitive conditions, cellulitis, diabetes, pneumonia


ACSC ambulatory care sensitive conditions

ICD International Classification of Diseases

LHID Longitudinal Health Insurance Database

NHI National Health Insurance

Many hospitalizations may be considered unavoidable, because the situation requiring hospitalization developed acutely and was unanticipated. However, some studies suggest that hospitalizations for certain conditions, called ACSCs, are potentially avoidable.13 ACSC hospitalizations are defined as admissions for indications that could have been prevented by prompt and appropriate outpatient health care services. In 1992, a study by Weissman et al4 identified 12 avoidable hospital conditions, which have become an established tool for assessing primary care access and effectiveness, especially for vulnerable population groups. …


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