The Readmission Rate and Medical

Cost of Patients with Schizophrenia

After First Hospitalization
A 10-Year Follow-up PopulationBased Study
Dibawakan oleh :
Zulvikar Umasangadji
Moderator :
dr. Alifiati Fitrikasari, Sp.KJ(K)

Abstract
Background:
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.
Methods:
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.

Abstract
Result:
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 nonreadmission 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

Abstract
Conclusion:
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.

Introduction
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)

Introduction

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.

Introduction

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 services.
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 years
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 days
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 1996.1.12000.12.31
4. Had used a psychiatric outpatient service between
1996.1.1 and 2000.6.30

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 identied.
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 earlier.
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 services

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 groups.
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).

Results
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.

Results

The analysis of readmission over time is shown in the KaplanMeier

survival curves presented in Fig. 2.

Results
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.

Results
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.

Results
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 2001
2008.
However, there was no signicant difference in terms of
utilization of non-psychiatric medical services.

Discussion
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.

Discussion

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 rehospitalized during the 10-year follow-up period, and onequarter of re-hospitalizations occurred within only four
months.
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.

Discussion
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., 2013).
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

Discussion
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 non-readmission.
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 nonrelapse group was mainly focused on outpatient services, ER visits
and acute ward hospitalizations; while home care and rehabilitation
services accounted for only 10% each.

Discussion
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 nonpsychiatric medical services by schizophrenic patients were
signicantly higher than those of the controls.

Discussion
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 important.
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

Discussion
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 recruited.
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

Discussion
Kaplan-Meier
Banyak metode yang digunakan untuk mengestimasi fungsi survival,
diantaranya Nelson-Aalen estimator, metode life-table (acturial),
metode Kaplan-Meier, AFT, bayessian, counting procces dan lainlain.
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 pengamatan;

(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)

Discussion
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 baik.

 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 dened 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 signikan secara statistik antara dua

atau lebih kelompok variabel independen pada variabel dependen yang
berskaladatanumerik (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(LihatHistogramVariabilitas Tidak Sama), maka uji ini tidak dapat
digunakan untuk menilai perbedaan Median, jadi hanya untukmenilai
perbedaan peringkat rata-rata.