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The Readmission Rate and Medical Cost of Patients

with Schizophrenia After First Hospitalization

A 10-Year Follow-up Population-Based Study

Dibawakan oleh :
Zulvikar Umasangadji
Moderator :
dr. Alifiati Fitrikasari, Sp.KJ(K)
Hospital readmissions caused by relapse in patients with schizophrenia are
associated with prognosis.
Identifying individuals at high risk of readmission and providing interventions to
lower the readmission rate are important.

Patients with schizophrenia who were hospitalized for the rst time were recruited
from the National Health Insurance Research Database from 2001 to 2010 (n = 808,
mean age 28.9 years) and compared with matched controls.
Data on the demographics, cost, and utilization of medical resources of patients
who were readmitted were compared with non-readmitted patients.
The readmission time curve was analyzed by the KaplanMeier method.
570 (70.5%) patients were readmitted within 10 years; the median time
between admissions was 1.9 years, and 25% of subjects were readmitted
within 4 months of the rst hospitalization.
There were no signicant differences in age, gender, or length of
hospitalization between the readmission and non-readmission groups.
Taking into account all psychiatric medical services, the readmission group
had a signicantly higher mean frequency of care and a greatermedical cost
than the non-readmission group andmatched controls. However, there were
no signicant differences with regard to non-psychiatric medical services
Schizophrenia has a high rate of readmission and high medical cost in
naturalistic settings.
In addition to the traditional hospital-based treatment model for patients
with schizophrenia, the development of an effective intervention program is
important, especially in the early years of the disease.
The onset of schizophrenia generally occurs during young adulthood. The chronic
and deteriorating course of schizophrenia leads to remarkable impairments in
mental health, cognitive function, and socio-occupational function (Mller and Von
Zerssen, 1995; Liebermanet al., 1996; Wyatt, 1997)
Previous studies showed that more than 80% of patients suffer from a relapse
within ve years of the rst episode of psychosis (Wiersma et al., 1998; Robinson et
al., 1999).
About 20% of those undergoing continuous treatment experience relapse within
one year, but the percent age rises to 6070% in those who are not receiving
continuous treatment (Wunderink et al., 2007; Boonstra et al., 2011).
The risk of relapse is also associated with symptoms, family support and insight,
the patient's baseline adaptation ability and insight, and comorbidities (Miller et
al., 2011; Tiihonen et al., 2011;Alvarez-Jimenez et al., 2012; Emsley et al., 2013a)
A readmission rate within 30 days of 23% was found in schizophrenic
patients taking antipsychotic medications (Boaz et al., 2013)
Similar ndings were reported in a 3 year follow-up study fromTaiwan (Lin
et al., 2006)
However, there is still a lack of information regarding the utilization of
medical services as a whole, and a lack of a comparison between the long-
term utilization of different resources in the real world.
Readmission is an indicator of symptoms relapse. The aims of this study
were to calculate the long-term readmission rate and the utilization of
medical resources in patients with schizophrenia.
In this naturalistic study, the National Health Insurance Research Database
(NHIRD) in Taiwan was used.
We focused on patients with schizophrenia who were hospitalized in an
acute psychiatric ward for the rst time.
The readmission rate and utilization of medical resources in the ten years
after discharge were explored by comparing the demographic
characteristics and lengths of stay in acute wards of readmitted and non-
readmitted patients.
Materials and Methods
Data sources
The data sets used for this study were obtained from the Psychiatric
Inpatients Medical Claims (PIMC) database and the Longitudinal Health
Insurance Database 2000 (LHID2000).
The PIMC contains longitudinal data from January 1, 1996 to December 31,
2010 of a cohort of 91,104 mentally ill patients who were admitted to
hospitals by psychiatry departments with ICD-9-codes 230319 or A-codes
A210A219 between 1996 and 2010.
The LHID2000,which includes a cohort of 1 million beneciaries, comprises
random samples from the year 2000.
Study cohort selection
For the purpose of present study, we drew a sample of schizophrenia
patients who had been hospitalized without previous use of psychiatric
Patients with schizophrenia (ICD-9-CM code 295) were enrolled from the
PIMC. Aged between 20 and 40 years who were admitted to a psychiatry
ward due to schizophrenia during the period 2001.01.012001.12.31 were
eligible for the study.
Study cohort selection
To ensure that these hospitalizations in psychiatric acute wards were rst
hospitalizations, we used the following exclusion criteria:
1. the patient had been a psychiatric ward inpatient during the previous 5
2. the patient had died or escaped from hospital
3. the patient had used a psychiatric outpatient service between 5 years
and 6 months ago
Study cohort selection
In addition, we excluded those whose rst hospitalization involved a longer
hospital stay:
1. the patient was admitted to a chronic ward or daycare unit
2. the patient's acute ward hospitalization duration was greater than 75
3. the patient's acute ward hospitalization was followed by a chronic ward
hospitalization with a duration greater than 120 days
Study cohort selection
To conrm the diagnosis of schizophrenia, we also excluded patients who
had either of the following conditions within 2 years after the rst
Admission :
1. those who had never used an antipsychotic
2. those who had no primary or secondary diagnosis of schizophrenia
Study cohort selection
A comparison cohort was established by matching the schizophrenia cases
at a 3:1 (controls: cases) ratio on the basis of age, gender, level of
urbanization of residential area, and premium ratable wage after excluding
any individuals who fullled any of the following conditions :
1. Hospitalization due to schizophrenia in 2001
2. Aged under 20 years or over 40 years
3. Had been an inpatient in a psychiatric ward during the period
4. Had used a psychiatric outpatient service between 1996.1.1 and
Study cohort selection
Seven levels of urbanization were used as per the National Health
Interviewing Survey 2005, classied according to factors such as population
density, education, and medical delivery level, with a lower urbanization
level score denoting a greater level of urbanization.
Three levels of premium ratable wage were dened: xed rate, under the
mean premium ratable wage of the year 2001 (New Taiwan dollars (NT$)
25,693), and greater than the mean premium ratable wage (NNT$ 25,693).
A total of 36 individuals with schizophrenia were excluded from the analyses
of utilization of healthcare because their urbanization level could not be
The nal control sample contained 2316 individuals.
Fig. 1. Study cohort selection owchart
Denitions of variables
Relapse was dened as the next admission to a psychiatric ward with a
schizophrenia diagnosis after discharge from the rst hospitalization.
Readmission or an emergency room (ER) visit within 14 days of discharge
were considered as the same episode and were not counted as a relapse.
All subjects were followed up to 2010.12.31 or their death date if it occurred
The medical care utilization and cost included outpatient services, inpatient
services, ER visits, day care, home care and rehabilitation in psychiatric
services, and also outpatient visits and hospitalizations in non-psychiatric
Statistical analyses
The relapse time curve was analyzed using the KaplanMeier method.
KruskalWallis tests were performed to compare the differences in medical
care utilization and cost between the relapse, non-relapse, and control
The demographic data of the relapse and non-relapse groups were
compared using the t-test or chi-square test.
All analyses were performed using the SAS software for Windows, version
9.3 (SAS Institute, Cary, NC, USA).
There were 808 patients with schizophrenia eligible for analysis, with a
mean age of 28.9 years, and approximately 40% were female. Of this
cohort, 570 (70.5%) were readmitted by the end of the year 2010 : the
median readmission time was 1.9 years, and 25% of subjects were
readmitted within 4 months of discharge from their rst hospitalization.
A number of patients suffered from multiple readmission during the 10-year
follow-up period: 29.5% had no readmission, 20% had one readmission, 13%
had two, 9.5% had three, 5.6% had four, and 22.4% had ve or more.
The analysis of readmission over time is shown in the KaplanMeier survival curves
presented in Fig. 2.
Table 1 presents a comparison of the demographic characteristics and
duration of rst hospitalization by relapse condition.
There were no signicant differences in age, gender, or length of rst
hospitalization between the subjects who relapsed and those who did not.
Table 2 shows the demographic characteristics of the study cases and the
comparison cohort.
There were no signicant differences in socio-demographic characteristics,
including gender, age, urbanization level, and premium ratable wage,
between the subjects with a rst hospitalization for schizophrenia and the
control cohort at baseline.
Table 3 shows that, for all psychiatric medical services, the relapse group
had a signicantly higher mean frequency of care and cost than the non-
relapse group and matched controls. The relapse group incurred a mean
cost of NT$ 615,269 (1.00 US$ = 31.517 NT$ in 2008), 5.79-fold higher than
the non-relapse group (mean cost of NT$106,281) and 482.19-fold higher
than the controls (mean cost of NT$1276) for all psychiatric medical services
during the period 20012008.
However, there was no signicant difference in terms of utilization of non-
psychiatric medical services.
In this study, we reported the readmission and medical cost of patients with
schizophrenia after their rst hospitalization.
Our results are valuable since they uniquely detail data on medical service
use by schizophrenia patients with a history of hospitalization in early
stages of the disease, and are based on a large database with a ten-year
follow-up period.
Additionally, this naturalistic study could present the clinical course of
patients with schizophrenia in the real world; an important reference for
mental health policy makers.
Treatment for schizophrenia varies throughout the world. In developed
countries with intact medical service systems, the medical costs still vary
depending on the service used.
Using data from the NHIRD, our study focused on the relapse rate and
medical service utilization of Taiwanese patients with schizophrenia during
the 10-year period after their rst hospitalization.
The long follow-up duration is worthy of note. The results showed a high
relapse rate: 70% of patients were re-hospitalized during the 10-year follow-
up period, and one-quarter of re-hospitalizations occurred within only four
This indicates the chronic and uctuating course of schizophrenia and the
high risk of relapse in the early stages of the disease, even under the
nationwide reimbursement program of the health insurance system.
Lin et al. used data from the NHI from 2001 to 2003, and found that 42.5% of
schizophrenia patients were readmitted within 30 days of discharge from
their rst acute ward hospitalization; in addition, a shorter hospitalization
duration was related to a higher relapse rate (Lin et al., 2006; Hui et al.,
There were no signicant differences in age, gender, or length of rst
hospitalization between the relapse and non-relapse groups during the 10-
year follow-up period.
The differences in inclusion criteria between these studies may have led to
the inconsistent results
30% of individuals in our study were not readmitted within 10 years.
Our analysis indicated that sex, age, and length of stay are not predictive of
We speculate that other factors may be associated with relapse, such as the
natural course of the disease, psychopathology, family support and
environmental factors, premorbid social functioning, patients' insight,
quality of medical service, and drug adherence; but this information was not
available in the database used in this study.
In this naturalistic study, the utilization of services by the non-relapse group
was mainly focused on outpatient services, ER visits and acute ward
hospitalizations; while home care and rehabilitation services accounted for
only 10% each.
Since the NHI system offers coverage and regular payment options for
these community-based services, the fees are affordable for most patients.
Studies to explore the effects of other factors on relapse, such as the
patients' psychotic symptoms and cognitive function related to their
understanding and acceptance of rehabilitation, advice from therapists, and
practice organization, are warranted.
High levels of physical comorbidity that begins from an early age are
reported in schizophrenic patients.
This is reected in our, since the utilization and cost of non-psychiatric
medical services by schizophrenic patients were signicantly higher than
those of the controls.
Monitoring of not only psychiatric symptoms but also general physical
condition, in addition to the provision of education to encourage a healthy
lifestyle and prevent the development of somatic comorbidities, and
assistance in seeking help for physical problems in clinical practice are
There are several limitations of this study. First of all, although we found no
signicant differences in basic demographic characteristics such as age and
gender between the relapse and non-relapse subgroups, other factors that
might be related to the relapse rate and medical services utilization, such as
the prole of symptoms, psychosocial factors, and details of interventions,
are not included in the NHIRD
Second, the period covered by the NHIRD,which extends from 1996 to date,
is also a limitation.
Data regarding medical service utilization from earlier than 1996 are absent,
which led to possible missing data and doubt regarding whether the
hospitalization was the rst occurrence in some patients that were
Another limitation was the follow-up period; however, as the relapse rate of
schizophrenic patients is relatively high, the possibility of repeated
hospitalization beyond the study period is low.
Finally, this study only focused on patients with schizophrenia who had
been hospitalized.
Terima Kasih

Mohon Bimbingannya
Banyak metode yang digunakan untuk mengestimasi fungsi survival,
diantaranya Nelson-Aalen estimator, metode life-table (acturial), metode
Kaplan-Meier, AFT, bayessian, counting procces dan lain-lain.
Metode Kaplan Meier (1985) sangat popular untuk analisis survival yang
paling cocok digunakan ketika ukuran sampel kecil. Analisis Kaplan Meier
menggunakan asumsi sebagai berikut :
(1) Subyek yang menarik diri dari penelitian secara rata-rata memiliki nasib
kesudahan variabel hasil (peristiwa) yang sama dengan subyek yang bertahan selama
(2) Perbedaan waktu mulainya masuk dalam pengamatan antar subyek tidak
mempengaruhi risiko (probabilitas) terjadinya variabel hasil (peristiwa). Probabilitas
peristiwa untuk berbagai jangka waktu tersebut dapat digambarkan sebagai kurva
analisis survival. (Murti, 1997)
Kaplan-Meier adalah komputasi untuk menghitung peluang survival.
Metode Kaplan-Meier didasarkan pada waktu kelangsungan hidup individu
dan mengasumsikan bahwa data sensor adalah independen berdasarkan
waktu kelangsungan hidup (yaitu, alasan observasi yang disensor tidak
berhubungan dengan penyebab failure time) (Stevenson, 2009: 6).
Pada penelitian ini ialah penelitian statistik nonparametrik dengan data
tersensor, sehingga penggunaan metode Kaplan-Meier adalah yang paling
Kaplan-Meier estimate is one of the best options to be used to measure the
fraction of subjects living for a certain amount of time after treatment. In clinical
trials or community trials, the effect of an intervention is assessed by measuring
the number of subjects survived or saved after that intervention over a period of
time. The time starting from a defined point to the occurrence of a given event, for
example death is called as survival time and the analysis of group data as survival
analysis. This can be affected by subjects under study that are uncooperative and
refused to be remained in the study or when some of the subjects may not
experience the event or death before the end of the study, although they would
have experienced or died if observation continued, or we lose touch with them
midway in the study.
Uji Kruskal Wallis adalah uji nonparametrik berbasis peringkat yang tujuannya untuk
menentukan adakah perbedaan signifikan secara statistik antara dua atau lebih kelompok
variabel independen pada variabel dependen yang berskala data numerik (interval/rasio)
dan skala ordinal.
Asumsi Kruskall Wallis
Perlu kami tekankan lagi, bahwa syarat atau asumsi uji ini adalah:
1. Variabel independen berskala kategorik lebih dari 2 kategori.
2. Variabel dependen berskala numeric (interval/rasio) atau skala ordinal.
3. Independen artinya sampel ditiap kategori harus bebas satu sama lain, yaitu tidak boleh
ada sampel yang berada pada 2 kategori atau lebih.
4. Tiap kategori memiliki variabilitas yang sama, yaitu bentuk kurve histogram atau sebaran
data yang sama (Lihat Histogram Variabilitas Sama). Apabila bentuk sebaran data sama,
maka uji kruskall wallis dapat digunakan untuk menilai perbedaan Median antar kategori.
Sedangkan jika bentuk sebaran tidak sama (Lihat Histogram Variabilitas Tidak Sama),
maka uji ini tidak dapat digunakan untuk menilai perbedaan Median, jadi hanya
untuk menilai perbedaan peringkat rata-rata.