High Inpatient Readmission Rates for Persons with Schizophrenia Patients: A Critical Issue in Mental Healthcare

Introduction

Schizophrenia is one of the most common mental health conditions that is associated with various psychological symptoms. Hallucination is an experience involving the perception of something that is not present. Patients with a diagnosis of schizophrenic frequently exhibit a range of delusions accompanied by drastic changes in their behavior (Meehl, 2017). Delusions occur when people cannot distinguish between reality and imaginations. Additionally, symptoms of schizophrenia can be classified into four categories that are; emotional, cognitive, negative and positive symptoms. Emotional symptoms can involve having blunted emotions, cognitive symptoms affect one's though, negative emotions can include lack of motivation or facial expressions while positive symptoms include hallucinations and delusions (Meehl, 2017).

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Despite the psychiatric deinstitutionalization policies being solidified in mental health care (to keep psychiatric patients, like schizophrenic patients away from the hospital), the phenomenon of psychiatric readmission poses challenges to the deinstitutionalization policy (Machado, 2012). Mental health facilities continue to receive high number readmissions of patients with schizophrenia making them strain financially and in terms of human resource (Machado, 2012). Accordingly, the high readmission rates of psychiatric patients/patients with a psychiatric diagnosis in general and schizophrenic patients, in particular, is a huge challenge for mental health professionals. According to Baindera et al. (2003) and Lay et al. (2006), this development is what some call a revolving door, while others have termed these patients to be frequent users. A study by the Agency of Healthcare Research and Quality, and hospital readmissions involving psychiatric disorders found that within 30 days, 15.7 % of initial inpatient stays for patients with a diagnosis of schizophrenic resulted in readmissions with a principal diagnosis of schizophrenia ("Healthcare cost and utilization project" 2015). Of those readmissions, more than 18.6 % were readmitted with a diagnosis of schizophrenia, and 22.4 % were readmitted for other forms of mental health (Kaplan, Casoy, & Zummo, 2013). To portray the extent of hospitalization, there has been the belief that this issue of readmission characterizes a new form of institutionalization. Therefore, one cannot ignore that this issue can pose serious clinical consequences for the patients, who may suffer from a condition of institutionalism. Machado (2012) revealed that patients who are frequently readmitted might suffer from a series of functional, social, and psychological losses. In addition, this situation may be a recurring pattern for patients and can result in the insufficient provision of mental health services. Multiple readmissions to the healthcare facilities may demoralize the health caregivers who provide mental health services.

Burning Clinical Issue

As a psychiatric nurse for almost five years and two years of experience at a city hospital in the North Central US, our hospital has admitted a good number patients with schizophrenia and the number keeps on increasing every year. However, there is no plan to discover why the rate of admission is high. Even so, there is the need to question why there is documentation of the readmission rate, but there is no intervention to manage the high rate of readmission (Das, Malik, & Haddad, 2014). Bringing the issues to the attention of caregivers is of particular importance considering the frequent readmission patterns of these patients can lead to psychological trauma, deterioration of their condition, and lack of mental health services and networks.

Admittedly, it is paramount to address some of the reasons, why providers do not follow the American Psychiatric Association (APA) guidelines for the treatment of schizophrenia, which may contribute to the high admission rates (Viron, Baggett, Hill & Freudenreich, 2012). Kross (2016), revealed that clinician adherence to clinical practice guidelines in schizophrenia remains suboptimal, and uncertainty exists regarding how best to implement guidelines for maximum benefits. According to the American Psychiatric Association (APA) guidelines for schizophrenia, long-acting injectable medications (LAIs) are thought to be especially helpful in the stabilization and stable phase of schizophrenia. The use of long-acting injectable medication helps to improve adherence, which is a critical issue during the stable and stabilization phase (Das, Malik & Haddad, 2014). The APA recommends that patients with recurrent relapses related to nonadherence are candidates for a long-acting injectable antipsychotic medication, as are patients who prefer this mode of administration (APA, 2016). The subject is relevant in current practice as it is vital for positive patient outcomes and is evidence-based. In addition, the practices must be in line with the recommended practice guideline and regulations (Kaplan, Casoy, & Zummo, 2013). Recently, the hospital readmission rate has been used to measure the quality of care provided by hospitals. Medicare reports spending 17.8 billion dollars on readmissions of patients that could have been prevented (Center of Medicare and Medicare, 2012). As a result, Medicare established an admission readmission program that was effective on October 1st, 2012. If it is possible to prevent readmission of schizophrenic patients, it is necessary that practices supporting this should be established.

Already, researchers have identified if schizophrenic patients adhere to LAI medication, the rate of relapse and readmission will decrease. According to Kane et al. (2013), many chronic diseases, such as psychotic disorders like schizophrenia, affect patients who suffer from enormous problems in medication adherence. Such effects lead to countless avoidable emergency room visits and days in the hospital, as well as suboptimal overall outcomes. In addition, Kane et al. (2013) further mentioned that approximately 50% of patients suffering from chronic illnesses are not taking medication as prescribed after six months and about 70% of patients who have schizophrenia will relapse within the year of not taking their medication. Long-acting injectable antipsychotics are theoretically very powerful tools for assuring adherence (Kane et al., 2013). Hence, the formation of this PICOT which proposes the education of providers on the management of schizophrenia with LAIs.

Provider PICOT

For psychiatric providers in a metropolitan hospital in a mid-sized city in North Central US, who provide care for patients with schizophrenia from age 18 and older, (p) will a comprehensive, evidence-based, educational program to address the use of long-acting injectable antipsychotics (I), compared to present practice (c), increase the number of patients offered long-acting injectable medications as noted in a chart review (o) over a six-month period (T)?

It is important to promote changes in a provider's behavior to improve patient outcomes. However, it is also important to look at what patient behaviors could be changed to achieve an improved health outcome (Das, Malik, & Haddad, 2014). An appropriate outcome for patients would include continuing to take medication ordered by the provider, which plays an important role in decreasing rates of readmission.

Patient PICOT

Will patients with a diagnosis of ..... age 18 years or older, who are admitted in a city hospital in North Central US (P), who receive an evidenced-based, educational program from providers and staff on the need to be adherent to medications and the improved health outcomes for patients who use LAIs (I), compared to present practice (c), will accept LAIs in greater numbers and have lower readmission rates over a3 month time period.

Literature Review

Research databases, such as University of Michigan-Flint Summons, CINAHL, PubMed, National Center for Biotechnology Information (NCBI), Biomed Central, and ProQuest were utilized to obtain information about the PICOT questions. The advanced search was utilized to ensure that the search results yielded recent articles with high relevance to the research questions. The keywords searched were long-acting antipsychotic medication, oral antipsychotic medication, schizophrenia medications, readmission rates, education, and quantitative research. The results yielded in CINAHL, PubMed, Biomed Central did not relate to the PICOT question. However, the other databases yielded both primary relevant sources and relevant non-primary sources. The Melnyk & Fineout-Overholt (2011) level of evidence was utilized to assign the level of evidence to the five chosen articles.

Schizophrenia, Non-adherence, and Remission

Barrio et al. (2013) studied readmission of patients with schizophrenia condition and concluded that these people are in great need of quality healthcare. By utilizing the level of evidence developed by Melnyk and Fineout-Overholt (2011), the article discusses the efficacy of LAIs, adherence to medication regimens as a major issue for schizophrenic patients, and the importance of using the long-acting improved injectable Risperidone to counter high readmissions. According to McNally and McCarley (2016), schizophrenia is a severe and chronic psychiatric disorder with a variable course that requires long-term treatment to achieve and maintain remission. One of the major challenges identified by the authors in the treatment of schizophrenia is the issue of medication non-adherence. They stressed that medication adherence had been studied as an issue since the first steps in the pharmacological treatment of the disease were taken. In addition, the authors pointed out that previous studies have shown that 50% of patients with schizophrenia take less/fewer than 70% of their prescribed doses, making medication non-adherence rates in schizophrenia one of the highest compared with other chronic psychiatric conditions (Kross, 2016). This results in a major concern as evidence suggests that nonadherence is the greatest predictor of relapse in first-episode psychosis (Machado et al., 2012). The authors revealed that in line with the above findings, a recent meta-analysis found that nonadherence among those with first-episode psychosis increased the risk of relapse four-fold leading to readmission (Barrio et al., 2013).

Efficacy of LAI in Decreasing Readmission Rates

Furthermore, MacEwan et al. (2016) carried out a research study on patients with schizophrenic conditions in a psychiatric unit from 2004 to 2008 who were on long-acting injectable Risperidone and were followed for two years. After two years the variables related to the efficacy of the antipsychotic treatment were collected. There was no statistically significant difference between the two groups looking at the variable of hospital readmission and illness remission according to the symptom-based criteria, but two times fewer readmissions occurred in the intervention group as the control group.

Schizophrenia, Medication Adherence, Relapse, and Hospitalization Rates

The other article reviewed by Kane et al. (2013) is a systematic review of descriptive and qualitative studies. The authors provided a comprehensive, up-to-date review on long-acting injections of Risperidone on different subjects.

According to Kane et al. (2013), the e-STAR is an international, multicenter, prospective, observational registry that assesses the use of LAIs in patients with schizophrenia or schizoaffective disorder in a clinical practice setting. The study that was completed using1659 patients showed that...