Examining Intensive Outpatient Programs as a Potential Mechanism to Reduce Suicide Risk During the Post-Hospitalization Period Among Medicaid Recipients

摘要 自杀是美国十大死亡原因之一，年自杀率急剧上升。 近几十年最近的一项荟萃分析显示，从精神病医院出院后的自杀率 每100 000人-年有2 078例设施感染（一般人群为14.0例）。大约一个- 四分之一的自杀死亡发生在从精神病院出院后的3个月内， 风险极高 随着20世纪90年代管理式医疗的出现， 住院期间，制定了强化门诊计划/部分住院计划（IOP/PHPs），以管理 高危病人在医院病房外如今，IOP/PHP服务在某些领域中被频繁使用 作为患者出院时的主要出院计划。然而，几乎没有证据表明 研究他们在这一时期对自杀风险的临床影响。虽然这些IOP/PHP服务很容易获得， 在该国的某些地区，其他地区几乎不存在这种机构。如果IOP/PHP服务具有 预防出院后自杀有显著效果 在全国范围内提供这些服务可以作为一种弯曲自杀曲线的方法。 我们假设IOP/PHPs强烈的社会和心理支持将反映在一个 通过这些方案接受治疗的患者的自杀风险降低。我们将测试这个 通过对接受治疗的患者进行倾向评分匹配的观察性研究， 出院后IOP/PHP服务与接受非强化门诊随访的患者相比。 这些组的队列将足够大（每组超过100，000人），以检测即使很小的差异， 干预组之间的自杀率（最低检出率比范围为0.82至0.95，见表 4）。该项目的数据将来自医疗补助数据库，并将与国家死亡数据库相关联。 该指数是美国最权威的死亡率数据来源。 此外，我们将对IOP/PHP服务的临床主任进行全国调查，以确定和 描述临床护理过程。调查结果将与基于索赔的分析相结合， 了解哪些护理流程可以有效降低出院后的自杀风险 以了解IOP/PHP服务在全国范围内的护理质量差异。 该项目的结果将对政策和排放规划模式产生重要影响 在住院期间。今后的方向将包括传播和执行倡议 使出院计划模式与临床证据相一致。将在2010年12月25日至26日期间成立一个利益攸关方理事会， 项目，以帮助执行战略，以提高这些服务的地点， 不是很容易接触到

ABSTRACT Suicide is a top ten cause of mortality in the United States, and suicide rates have increased dramatically in recent decades. A recent meta-analysis showed that the suicide rate following discharge from a psychiatric facility was 2,078 per 100,000 person-years (versus 14.0 for the general population). Approximately one- quarter of all suicide deaths occur within 3 months of discharge from a psychiatric facility, making this a period of extremely high risk. With the advent of managed care in the 1990s and the concomitant decrease in hospital lengths of stay, Intensive Outpatient Programs/Partial Hospitalization Programs (IOP/PHPs) were instituted to manage high-risk patients outside of a locked hospital unit. Today, IOP/PHP services are frequently used in some areas as the principal discharge plan for patients upon leaving the hospital. However, there is virtually no evidence examining their clinical effects on suicide risk in this period. While these IOP/PHP services are readily available in some areas of the country, they are virtually non-existent in other regions. If IOP/PHP services have a significant protective effect against suicide following hospital discharge, implementation initiatives to broaden the availability of these services nationwide could be undertaken as a way to bend the curve against suicide. We hypothesize that the intense social and psychological support of IOP/PHPs will be reflected in a reduction in suicide risk among patients who receive treatment through these programs. We will test this hypothesis by conducting a propensity score matched observational study of patients who receive treatment at IOP/PHP services following discharge compared to patients who receive non-intensive outpatient follow-up. Cohorts for these groups will be sufficiently large (over 100,000 per group) to detect even small differences in suicide rates between intervention groups (minimum detectable rate ratio ranging from 0.82 to 0.95, see Table 4). The data for this project will be drawn from Medicaid databases and will be linked with the National Death Index, the most authoritative data source for mortality in the United States. Additionally, we will conduct a national survey of clinical directors of IOP/PHP services to identify and characterize clinical care processes. Survey results will be integrated with claims-based analyses to better understand what care processes may be effective in reducing suicide risk following hospital discharge as well as to understand the variations in quality of care throughout the country among IOP/PHP services. Results from this project would have important implications for policy and discharge planning patterns in the post-hospitalization period. Future directions would include dissemination and implementation initiatives to align discharge planning patterns with clinical evidence. A stakeholder council will be formed during the project to help implement strategies to enhance the availability of these services in locations where they are not widely accessible.