title: Determinants of hospital length of stay for people with serious mental illness in England and implications for payment systems: a regression analysis.
abstract: BACKGROUND
  Serious mental illness (SMI), which encompasses a set of chronic conditions such as schizophrenia, bipolar disorder and other psychoses, accounts for 3.4 m (7 %) total bed days in the English NHS. The introduction of prospective payment to reimburse hospitals makes an understanding of the key drivers of length of stay (LOS) imperative. Existing evidence, based on mainly small scale and cross-sectional studies, is mixed. Our study is the first to use large-scale national routine data to track English hospitals' LOS for patients with a main diagnosis of SMI over time to examine the patient and local area factors influencing LOS and quantify the provider level effects to draw out the implications for payment systems.
  
  
  METHODS
  We analysed variation in LOS for all SMI admissions to English hospitals from 2006 to 2010 using Hospital Episodes Statistics (HES). We considered patients with a LOS of up to 180 days and estimated Poisson regression models with hospital fixed effects, separately for admissions with one of three main diagnoses: schizophrenia; psychotic and schizoaffective disorder; and bipolar affective disorder. We analysed the independent contribution of potential determinants of LOS including clinical and socioeconomic characteristics of the patient, access to and quality of primary care, and local area characteristics. We examined the degree of unexplained variation in provider LOS.
  
  
  RESULTS
  Most risk factors did not have a differential effect on LOS for different diagnostic sub-groups, however we did find some heterogeneity in the effects. Shorter LOS in the pooled model was associated with co-morbid substance or alcohol misuse (4 days), and personality disorder (8 days). Longer LOS was associated with older age (up to 19 days), black ethnicity (4 days), and formal detention (16 days). Gender was not a significant predictor. Patients who self-discharged had shorter LOS (20 days). No association was found between higher primary care quality and LOS. We found large differences between providers in unexplained variation in LOS.
  
  
  CONCLUSIONS
  By identifying key determinants of LOS our results contribute to a better understanding of the implications of case-mix to ensure prospective payment systems reflect accurately the resource use within sub-groups of patients with SMI.
authors.affiliation: Centre for Health Economics, University of York, Heslington, York, UK. rowena.jacobs@york.ac.uk.
authors.forename: Rowena
authors.initials: R
authors.lastname: Jacobs
authors.affiliation: Centre for Health Economics, University of York, Heslington, York, UK. nils.gutacker@york.ac.uk.
authors.forename: Nils
authors.initials: N
authors.lastname: Gutacker
authors.affiliation: Centre for Health Economics, University of York, Heslington, York, UK. anne.mason@york.ac.uk.
authors.forename: Anne
authors.initials: A
authors.lastname: Mason
authors.affiliation: Centre for Health Economics, University of York, Heslington, York, UK. maria.goddard@york.ac.uk.
authors.forename: Maria
authors.initials: M
authors.lastname: Goddard
authors.affiliation: Centre for Health Economics, University of York, Heslington, York, UK. hugh.gravelle@york.ac.uk.
authors.forename: Hugh
authors.initials: H
authors.lastname: Gravelle
authors.affiliation: Primary Care and Population Sciences, University of Southampton, Southampton, UK. a.r.kendrick@southampton.ac.uk.
authors.forename: Tony
authors.initials: T
authors.lastname: Kendrick
authors.affiliation: Department of Health Sciences, University of York, Heslington, York, UK. simon.gilbody@york.ac.uk.
authors.forename: Simon
authors.initials: S
authors.lastname: Gilbody
mesh_terms: D000328:Adult; D000368:Aged; D003953:Diagnosis-Related Groups; D004469:Economics, Hospital; D004739:England; D004812:Epidemiologic Methods; D005260:Female; D005102:Health Expenditures; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data*; D008297:Male; D001523:Mental Disorders / Q000191:economics / Q000628:therapy*; D008875:Middle Aged; D010351:Patient Discharge / Q000191:economics / Q000706:statistics & numerical data; D011445:Prospective Payment System; D013222:State Medicine / Q000191:economics / Q000706:statistics & numerical data