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Lengthy ER visits for psychiatric patients often result in transfer, not treatment

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PHILADELPHIA — Cutbacks in capacity at state and county mental hospitals have forced more and more psychiatric patients to seek treatment in Emergency Rooms. But a new study led by the Perelman School of Medicine at the University of Pennsylvania, found that people who visit emergency rooms for mental health care were transferred to another facility at six times the rate of people who visit ERs for non-psychiatric conditions, and could wait almost two hours longer. The study is published today in Health Affairs and highlights a persisting shortfall in emergency psychiatric services in the country. "Previous research shows that patients in the ER often experience lengthy wait times, but our new study shows that psychiatric patients wait disproportionately longer than other patients — sometimes for several hours — only to ultimately be discharged or transferred elsewhere," said lead author Jane M. Zhu, MD, MPP, a National Clinician Scholar in the department of General Internal Medicine at the Perelman School of Medicine at the University of Pennsylvania, and a fellow at Penn's Leonard Davis Institute of Health Economics. "Overall, the study highlights the degree to which emergency departments struggle to meet the needs of mental health patients."

The study examined length-of-stay data for more than 200,000 psychiatric and non-psychiatric ER visits during 2002-2011. Length-of-stay is a standard measure of ER crowding and access to services. The dataset came from the National Hospital Ambulatory Medical Care Survey (NHAMCS), an annual survey by the Centers for Disease Control and Prevention that derives national estimates of various measures of health care provision based on visits to sample hospitals.

The analysis showed that for the vast majority of psychiatric patients, the average length-of-stay was significantly longer than for non-psychiatric patients: 355 versus 279 minutes for patients admitted for observation, 312 versus 195 minutes for patients who were transferred to other facilities, and 189 versus 144 minutes for patients who were discharged.

For patients who were eventually admitted to the hospital, the average length-of-stay for psychiatric patients wasn't significantly different than for their non-psychiatric counterparts, but fewer than one-fifth (18 percent) of psychiatric patients fell into this category.

During the period studied, the annual number of visits to ERs by adults in the US rose by 30 percent (from 82.2 million to 106.8 million), but psychiatric visits increased even more dramatically, by about 55 percent (from 4.4 million to 6.8 million). Alcohol-related disorders represented a rising proportion of these visits. Perhaps unsurprisingly, given the increasing pressure on ERs, longer median lengths of stay for psychiatric patients generally persisted throughout this period.

Only in the case of patients admitted for observation – a category that included just 2 percent of psychiatric visits, and had much more variable figures – did the length-of-stay gap appear to close by 2011.

The authors say that on the whole, the findings suggest deficiencies in emergency departments' capacity for psychiatric care. The largest underlying factor, they say, is a shortage of psychiatric inpatient beds, which stems from the "de-institutionalization" of a large portion of the U.S. psychiatric inpatient population, which began in the late 1960s. Between 1970 and 2006, state and county psychiatric inpatient facilities in the country cut capacity from about 400,000 beds to fewer than 50,000. Many psychiatric patients who would otherwise have been receiving long-term care have thus gone relatively untreated and have frequently ended up at ERs, straining their capacities.

Shortages of outpatient mental health facilities and substance abuse treatment programs are also likely factors.

"There has been progress made recently as the number of hospital-based psychiatric ER units has increased, along with regional psychiatric emergency care facilities that can quickly take in patients who visit local ERs," Zhu said. "However, these improvements have yet to offset the overall shortage of psychiatric inpatient resources."

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The co-authors of the study were Astha Singhal, DMD, PhD, of the Henry M. Goldman School of Dental Medicine at Boston University; and Renee Y. Hsia, MD, MSc, of the University of California, San Francisco.

Penn Medicine is one of the world's leading academic medical centers, dedicated to the related missions of medical education, biomedical research, and excellence in patient care. Penn Medicine consists of the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania(founded in 1765 as the nation's first medical school) and the University of Pennsylvania Health System, which together form a $5.3 billion enterprise.

The Perelman School of Medicine has been ranked among the top five medical schools in the United States for the past 18 years, according to U.S. News & World Report's survey of research-oriented medical schools. The School is consistently among the nation's top recipients of funding from the National Institutes of Health, with $373 million awarded in the 2015 fiscal year.

The University of Pennsylvania Health System's patient care facilities include: The Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center — which are recognized as one of the nation's top "Honor Roll" hospitals by U.S. News & World Report — Chester County Hospital; Lancaster General Health; Penn Wissahickon Hospice; and Pennsylvania Hospital — the nation's first hospital, founded in 1751. Additional affiliated inpatient care facilities and services throughout the Philadelphia region include Chestnut Hill Hospital and Good Shepherd Penn Partners, a partnership between Good Shepherd Rehabilitation Network and Penn Medicine.

Penn Medicine is committed to improving lives and health through a variety of community-based programs and activities. In fiscal year 2015, Penn Medicine provided $253.3 million to benefit our community.

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Katie Delach
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