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Changing Patterns of Psychiatric Inpatient Care in the United States, 1988-1994

David Mechanic, PhD; Donna D. McAlpine, MA; Mark Olfson, MD, MPH
Arch Gen Psychiatry. 1998;55(9):785-791. doi:10.1001/archpsyc.55.9.785.
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Using data from the National Hospital Discharge Survey and the Inventory of Mental Health Organizations, this article examines national trends in psychiatric inpatient care from 1988 to 1994 in general hospitals and mental hospitals. We find that discharges with a primary diagnosis of mental illness in general hospitals increased from 1.4 to 1.9 million during this period. The total increase of 1.2 million days of care in general hospitals was small relative to the reduction of 12.5 million inpatient days in mental hospitals. General hospital discharges increased most in private nonprofit hospitals and declined substantially in public hospitals. Length of stay has fallen most substantially in private nonprofit hospitals. Public programs have increasingly replaced private insurance as the major source of payment. These observations suggest that psychiatric inpatient care in general hospitals can be characterized as a process in which patients who would have been clients of public mental hospitals in a prior period replace privately insured patients who, under managed care, are largely treated in community settings. Private nonprofit general hospitals increasingly treat publicly financed patients with more severe illnesses.

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Figure 1.

Average length of stay in general hospitals for psychiatric discharges by hospital ownership. Lengths of stay of less than 1 day are recoded to equal 1 day. Means (approximate SEs) are presented.

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Figure 2.

Percentage of psychiatric discharges to the community after hospitalization of 5 days or less by hospital ownership. Analysis included only discharges to the community (routine or against medical advice). Percentages (approximate SEs) are presented. Superscripts denote significant differences (P≤.05) between groups: a, different from public; b, different from private nonprofit; and c, different from proprietary. Asterisk indicates relative SE of the numerator greater than 10% (<12.5%).

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Figure 3.

Total psychiatric days of care (in millions) in general hospitals by hospital ownership. Total days (approximate SEs) are presented. Superscripts denote significant differences (P≤.05) between groups: a, different from public; b, different from private nonprofit; and c, different from proprietary.

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Figure 4.

Percentage of psychiatric discharges transferred by hospital ownership. Discharge status was missing for 3.3% of discharges in 1988, 4.9% in 1990, 4.7% in 1992, and 6.5% in 1994. Percentages (approximate SEs) are presented. Superscripts denote significant (P≤.05) differences between groups: a, different from public; b, different from private nonprofit; and c, different from proprietary. Asterisk indicates relative SE of the numerator greater than 10% (<20.0%).

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