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The Canadian Journal of Psychiatry /

La Revue Canadienne de Psychiatrie
Thirty-Day and 5-Year Readmissions 2018, Vol. 63(6) 410-415
ª The Author(s) 2018
following First Psychiatric Hospitalization: Reprints and permission:
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DOI: 10.1177/0706743717751667
A System-Level Study of Ontario’s TheCJP.ca | LaRCP.ca

Psychiatric Care
Réhospitalisation dans les 30 jours et les 5 ans par suite d’une
premiére hospitalisation psychiatrique : une étude au niveau du
systéme des soins psychiatriques de l’Ontario

Sheng Chen, PhD1, April Collins, MSW1, and Sean A. Kidd, PhD2

Abstract
Objective: Analyses of representative, system-level data to examine trends in short- and longer-term readmission rates for
psychiatric illnesses are largely absent. The objective of this article is to examine key trends and variables with implications for
inpatient care as indicated by 30-day readmission and outpatient care as reflected by readmission within 5 years.
Methods: Using OMHRS data from 2005 to 2015, patients who had their first inpatient admission were followed for 5 years
to examine their subsequent 30-day and overall admission rates stratified by discharge time and diagnosis.
Results: The study cohort consisted of 42,280 patients. The 30-day and 5-year readmission rates for the entire cohort were
7.2% and 35.1%, respectively. Using a time course analysis of readmission for discharges in different years, both 30-day
readmission and 5-year readmission rates decreased in a linear manner from 2005 to 2010, primarily because of read-
mission patterns for patients diagnosed with mood disorders and schizophrenia/other psychotic disorders. It was also evident
that both demographic considerations such as age and gender and variables reflective of social determinants such as education
level and employment were predictive of rehospitalization risk.
Conclusions: The trends of decreasing readmission rates may be reflective of improvements in the quality of hospital and
community-based outpatient care. Such system-level indicators warrant tracking and may inform more effective tertiary
prevention.

Abrégé
Objectif : Les analyses de données représentatives au niveau du système afin d’examiner les tendances à court et à long terme
des taux de réhospitalisation pour les maladies psychiatriques sont largement absentes. L’objectif de cet article est d’examiner
les principales tendances et variables ainsi que les implications pour les soins des patients hospitalisés comme l’indiquent la
réhospitalisation dans les 30 jours et les soins ambulatoires, que reflète la réhospitalisation dans les 5 ans.
Méthodes : À l’aide des données du Système d’information ontarien sur la santé mentale (SIOSM) de 2005 à 2015, les patients
qui ont été hospitalisés pour la première fois ont été suivis pendant 5 ans afin d’examiner leurs taux d’hospitalisation sub-
séquents dans les 30 jours ou en général, stratifiés selon la date du congé et le diagnostic.

1
Centre for Addiction and Mental Health, Toronto, Ontario, Canada
2
University of Toronto Department of Psychiatry, Toronto, Ontario, Canada

Corresponding Author:
Sean A. Kidd, PhD, Complex Care and Recovery Program & Child, Youth and Emerging Adult Services, Centre for Addiction and Mental Health, 1001 Queen
St. W., Unit 2-1, #161, Toronto, Ontario M6 J 1H1, Canada.
Email: sean_kidd@camh.net
La Revue Canadienne de Psychiatrie 63(6) 411

Résultats : L’étude de cohorte se composait de 42 280 patients. Les taux de réhospitalisation dans les 30 jours et les 5 ans
pour la cohorte en entier étaient de 7,2% et de 35,1% respectivement. À l’aide d’une analyse de série chronologique de la
réhospitalisation pour des congés de différentes années, les taux de réhospitalisation à la fois dans les 30 jours et les 5 ans
diminuaient de manière linéaire de 2005 à 2010, principalement en raison des modèles de réhospitalisation pour les patients
ayant reçu un diagnostic de troubles de l’humeur et de schizophrénie ou d’autres troubles psychotiques. Il était également
évident que les considérations démographiques comme l’âge et le sexe et les variables reflétant les déterminants sociaux
comme le niveau d’instruction et l’emploi prédisaient le risque de réhospitalisation.
Conclusions : Les tendances à la baisse des taux de réhospitalisation peuvent refléter les améliorations de la qualité des soins
ambulatoires en milieu hospitalier et communautaire. Ces indicateurs au niveau du système justifient le suivi et peuvent
éclairer une prévention tertiaire plus efficace.

Keywords
readmission, inpatient psychiatry, health services research

The economic burden of mental health problems in Canada Study Design

is significant, and hospitalization is a primary driver of
expense.1-3 Accordingly, hospital readmission is a pressing
concern to the Canadian health care system. 4,5 Early
readmission, typically benchmarked at 30 days posthospita-
lization,4,6 is associated with inpatient care quality consid-
erations such as premature discharge or a mismatch between
patient needs and the level of outpatient service that was
arranged.4,6,7 Readmission that occurs after 30 days is under-
stood to be more reflective of outpatient care quality.4,8,9
Analyses of representative, system-level data to examine
trends in readmission rates for psychiatric illnesses are lack-
ing. The one prior provincial study in this area used a cir-
cumscribed time frame ending in 2011 that did not allow for
comparison of readmission time frames, 9 and the one
national study in this area is dated.10 In response, this study
examined 30-day and 5-year readmission rates using the
Ontario Mental Health Reporting System (OMHRS) data
from 2005 to 2015. The objective was to document key
trends related to the delivery of inpatient care as reflected
by early 30-day readmission and outpatient care as reflected
by readmission within 5 years.
Methods
Data Source
Data for this study were obtained from OMHRS. Implemen-
ted in October 2005, OMHRS contains information on all
hospital admissions for adults admitted to psychiatric beds in
Ontario. OMHRS data are derived from the Resident
Assessment Instrument–Mental Health (RAI-MH). The
reliability and validity of the RAI-MH have been established
in a number of previous studies. 11,12 The data can be
requested from the Canadian Institute for Health Information
(CIHI) for a fee and with certain restrictions (https://www.ci
hi.ca/en/ontario-mental-health-reporting-system-metadata).
This study received approval from the Research Ethics
Board of the Centre for Addiction and Mental Health (REB
reference No. 093/2015).
OMHRS records were obtained for all patients admitted and
discharged between October 2005 and June 2015 from a
psychiatric bed in Ontario. Discharge records for patients
with the following criteria were extracted from the master
database: (1) admitted on or after 1 October 2005 and dis-
charged before 1 July 2010, (2) first psychiatric admission in
life time to control for the potential confounding effects of
previous psychiatric hospitalization, (3) aged 16 or older at
admission, (4) planned discharge, and (5) length of stay
(LOS) 3 days. Patient unique identification numbers were
then used to retrieve admission records that occurred within
1825 days (5 years) following the discharge from the first
inpatient episode. The primary outcomes of this study were
30-day and 5-year readmission, with readmission rates
stratified by discharge time and Diagnostic and Statistical
Manual of Mental Disorders, fourth edition (DSM-IV), diag-
nostic category (Suppl. Table S1). Data were processed with
Microsoft SQL server and analyzed with SPSS(v21). Multi-
variate logistic regression modeling was used to explore the
significance of sociodemographic and service factors predic-
tive of 30-day or 5-year readmission. The models were devel-
oped with 9 factors, including patients’ gender, age (<35 year,
35-50 years, or >50 years), marital status, language spoken,
education level (<high school or high school), employment
status, Aboriginal status, type of hospital (general or psychia-
tric), and the index admission LOS (14 days or >14 days).
Results
Sample Characteristics
The study cohort consisted of 42,280 patients. By DSM-IV
diagnostic category, 18,876 (44.6%) patients were diagnosed
with mood disorders, 7614 (18.0%) with schizophrenia/other
psychotic disorders, 7355 (17.4%) with substance-related dis-
orders, 2933 (6.9%) with delirium/dementia, and 5502
(13.0%) with other diagnoses. The median age at admission
was 42 years (interquartile range [IQR] 28-54), 42 years for
mood disorders, 35 for schizophrenia/other psychotic
412 The Canadian Journal of Psychiatry 63(6)

Table 1. Thirty-Day and 5-Year Readmission by Diagnostic Category and Discharge Time.

Mood Schizophrenia/Other Substance-Related Delirium/

Disorders Psychotic Disorders Disorders Dementia Other Total

30-day readmission (%)

2005-2010 overall 6.8 10.2 4.3 10.0 6.9 7.2

Discharge time

2005-2006 8.0* 12.5* 4.4 11.5 7.5 8.3*

2006-2007 7.3* 11.5* 4.1 9.8 6.5 7.6*
2007-2008 6.8 8.6 4.1 11.6 7.4 7.1
2008-2009 6.5 10.1 4.6 9.3 6.7 7.0
2009-2010 5.9 8.6 4.5 8.6 6.7 6.5
% Different diagnosis 0.0 0.0 0.0 0.0 0.0 0.0
at readmission

5-year readmission (%)

2005-2010 Overall 34.0 51.3 29.1 25.7 29.5 35.1

Discharge time

2005-2006 39.1* 54.5* 33.5* 27.8 32.4* 39.5*

2006-2007 35.0* 53.1* 31.5* 24.3 30.3 36.5*
2007-2008 33.3* 48.4 27.1 29.0* 30.2 34.0*
2008-2009 33.3* 51.5 28.9* 24.6 28.5 34.3
2009-2010 31.1 49.5 25.5 24.0 27.4 32.4
% Different diagnosis at readmission 3.26 1.79 3.83 1.59 7.02 3.28

Days to readmission, median (IQR) 227 (46-648) 265 (52-674) 252 (66-658) 85 (7-407) 195 (35-588) 229 (45-638)
*P < 0.05, compared with the rate of 2009-2010.

disorders, 40 for substance-related disorders, 78 for delirium/
dementia, and 38 for other diagnoses. Forty-eight percent of
the cohort was female, and 2.8% of the cohort was identified
as Aboriginal. Of the total cohort, 27.9% were admitted to a
psychiatric hospital, and the median LOS was 14 days.
Readmission
The 30-day readmission rate for the cohort was 7.2%, with
6.8% for mood disorders, 10.2% for schizophrenia/other
psychotic disorders, 4.3% for substance-related disorders,
10% for delirium/dementia, and 6.9% for other diagnoses
(Table 1). Thirty-day readmission was stratified by discharge
time. In a time course analysis, the 30-day readmission rate
steadily declined between 2005 and 2010. Compared with the
2009-2010 group, the 30-day readmission rates were signif-
icantly higher in the 2005-2006, 2006-2007, and 2007-2008
groups (P < 0.05; Table 1). This decline was not evident for
substance-related disorders or delirium/dementia.
The 5-year readmission rate for the entire cohort was
35.1%, with 34.0% for mood disorders, 51.3% for schizo-
phrenia/other psychotic disorders, 29.1% for substance-
related disorders, 25.7% for delirium/dementia, and 29.5%
for other diagnoses (Table 1). As with 30-day readmissions,
the rate went down from 2005 to 2010. The rates of 2005-
2006, 2006-2007, and 2008-2009 were significantly higher
than the 2009-2010 group with variability by diagnostic
category (Table 1). This pattern was not evident for
delirium/dementia. It was also found that for all those read-
mitted within 30 days, primary diagnosis at readmission was
the same as the first inpatient episode. Looking at 5-year
readmission, for all but 3.28%, the diagnostic category for
their second admission within 5 years was the same as the
first admission (Table 1).
For 5-year readmission, we also analyzed the time inter-
val between the discharge of the first inpatient stay and the
second admission. The medians were 229 days (IQR 45-638)
for the full cohort, with 227 days (IQR 46-648) for mood
disorders, 265 days (IQR 52-674) for schizophrenia/other
psychotic disorders, 252 days (IQR 66-658) for substance-
related disorders, and 85 days (IQR 7-407) for delirium/
dementia (Table 1).
The association of selected sociodemographic and service
factors with 30-day and 5-year readmission by diagnosis is
found in Table 2, with significant protective and risk con-
siderations highlighted. Details of the regressions analysis
can be found in Supplemental Tables S2 to S6. Since 9
factors were included in each model, the predictive power
of the models, as indicated by the pseudo-R2 ‘s were not
high. Being female was associated with a lower risk for
5-year readmission in schizophrenia/other psychotic disor-
ders and both 30-day and 5-year readmission in delirium/
dementia. Middle age (35-50 years) was protective for
30-day readmission in mood disorders, and both 30-day
and 5-year readmission in schizophrenia/other psychotic
disorders but was a risk factor for 5-year readmission in
 Table 2. Odds Ratio (95% Confidence Interval) Findings of Associations between Demographic, Psychosocial and Service Variables, and 30-Day and 5-Year Inpatient Readmission.
Schizophrenia/Other
Mood Disorders Psychotic Disorders Substance-Related Disorders Delirium/Dementia Other

30-Day 5-Year 30-Day 5-Year 30-Day 5-Year 30-Day 5-Year 30-Day 5-Year
Factor Readmission Readmission Readmission Readmission Readmission Readmission Readmission Readmission Readmission Readmission

Gender (reference: male)

Female 1.05 (0.94-1.18) 1.05 (0.99-1.11) 0.92 (0.19-1.07) 0.87 (0.79-0.95)** 0.99 (0.77-1.26) 1.11 (0.99-1.24) 0.75 (0.58-0.98)* 0.81 (0.68-0.97)* 0.90 (0.73-1.11) 1.07 (0.95-1.20)
Age (reference: <35 years)
35-50 0.77 (0.67-0.88)*** 1.06 (0.98-1.14) 0.80 (0.67-0.96)* 0.72 (0.65-0.81)*** 0.90 (0.69-1.16) 1.17 (1.04-1.32)* 0.73 (0.25-2.15) 1.10 (0.54-2.24) 0.96 (0.74-1.24) 1.15 (0.99-1.33)
>50 0.97 (0.85-1.11) 1.08 (1.00-1.16) * 0.83 (0.68-1.00) 0.55 (0.49-0.62)*** 0.72 (0.52-1.01) 0.92 (0.79-1.06) 0.66 (0.29-1.50) 0.60 (0.34-1.08) 1.02 (0.78-1.35) 1.02 (0.87-1.19)
Marital (reference: married/
partner)
Single/divorced 1.07 (0.95-1.20) 1.22 (1.15-1.30)*** 1.44 (1.18-1.76)*** 1.81 (1.62-2.03)*** 0.99 (0.76-1.29) 1.19 (1.06-1.34)** 0.97 (0.75-1.25) 1.04 (0.87-1.24) 0.89 (0.70-1.12) 1.08 (0.95-1.23)
Language (reference: English)
French 1.01 (0.67-1.52) 0.69 (0.54-0.87)** 1.02 (0.58-1.78) 0.54 (0.38-0.77)** N/A 0.98 (0.54-1.75) 0.76 (0.32-1.80) 0.88 (0.52-1.50) 0.46 (0.15-1.48) 0.81 (0.50-1.30)
Other 1.24 (0.96-1.60) 0.81 (0.70-0.95)** 1.00 (0.75-1.33) 0.61 (0.51-0.72)*** 0.70 (0.30-1.59) 0.61 (0.42-0.87)** 1.17 (0.74-1.83) 1.14 (0.83-1.54) 0.97 (0.55-1.69) 0.78 (0.56-1.09)
Education (reference: <high
school)
High school 0.93 (0.81-1.07) 1.05 (0.98-1.13) 0.70 (0.61-0.83)*** 0.87 (0.78-0.96)*** 1.03 (0.79-1.35) 1.09 (0.96-1.23) 1.39 (1.02-1.89)* 1.26 (1.03-1.54)* 1.03 (0.80-1.32) 1.12 (0.97-1.30)
Unknown 1.19 (0.97-1.47) 1.02 (0.91-1.15) 0.80 (0.63-1.02) 0.77 (0.67-0.90)*** 0.73 (0.41-1.31) 1.15 (0.90-1.47) 1.56 (1.12-2.16)** 1.37 (1.10-1.71)** 1.21 (0.83-1.77) 1.09 (0.87-1.36)
Employment (reference: yes)
No 1.53 (1.35-1.73)*** 1.71 (1.60-1.82)*** 1.21 (1.00-1.47) 1.67 (1.49-1.87)*** 1.60 (1.24-2.06)*** 1.91 (1.71-2.14)*** 1.59 (0.76-3.31) 1.93 (1.16-3.18)* 1.90 (1.47-2.45)*** 2.01 (1.76-2.30)***
Aboriginal (reference: yes)
No 1.15 (0.78-1.71) 0.97 (0.80-1.180) 1.21 (0.81-1.81) 1.63 (1.25-2.13)*** 0.70 (0.38-1.26) 0.84 (0.65-1.09) 1.38 (0.46-4.20) 1.34 (0.61-3.94) 1.29 (0.75-2.23) 0.96 (0.68-1.38)
Hospital type (reference: general)
Psychiatric 2.01 (1.77-2.29)*** 1.38 (1.27-1.49)*** 2.54 (2.16-2.97)*** 1.47 (1.31-1.64)*** 0.99 (0.77-1.28) 1.18 (1.05-1.34)** 4.62 (3.50-6.10)*** 2.11 (1.18-2.54)*** 1.20 (0.94-1.29) 1.00 (0.87-1.15)
Length of stay (reference: 14
days.)
>14 days 1.09 (0.97-1.22) 1.37 (1.29-1.45)*** 0.95 (0.82-1.10) 1.02 (0.94-1.12) 0.45 (0.34-0.58)*** 0.43 (0.38-0.49)*** 0.43 (0.33-0.57)*** 0.53 (0.46-0.67)*** 1.03 (0.82-1.29) 1.35 (1.18-1.15)***

Abbreviation: N/A, not available, due to no French-speaking patient 30-days readmission.

***P < 0.001. **P < 0.01. *P < 0.05.

413
414
substance-related disorders. Being single/divorced/
separated/widowed was a significant risk factor for 5-year
readmission in mood disorders, schizophrenia/other psycho-
tic disorders, and substance-related disorders. Speaking lan-
guages other than English (French or other language) was a
beneficial factor for 5-year readmission in mood disorders,
schizophrenia/other psychotic disorders, and substance-
related disorders. Higher education was beneficial for both
30-day and 5-year readmission in schizophrenia/other psy-
chotic disorders but a risk factor in delirium/dementia. Not
being employed was a significant risk factor for readmission
in almost all diagnoses. Aboriginal origin was a risk factor
for 5-year readmission in schizophrenia/other psychotic dis-
orders. Hospital type (psychiatric hospital) was a significant
risk factor for readmission in all major diagnoses. Longer
LOS (>14 days) was a risk factor for 5-year readmission in
mood disorders but a beneficial factor for readmission in
substance-related disorders and delirium/dementia.
Discussion
This study provides a summary of early and longer-term read-
mission rates using a representative provincial data set. The
30-day readmission rate for the study cohort was 7.2%, which
is lower than the previously reported rate of 9.2% using the
OMHRS 2008-2010 data linked to other data sets such as the
Discharge Abstract Database and the Ontario Health Insur-
ance Program database.9 The lower rate in the present study
might be reflective of the larger cohort, controlling for pre-
vious hospitalization as a risk factor and OMHRS not captur-
ing all psychiatric admission/readmissions. Longer-term
periods of readmission have received less attention. In this
study, the 5-year readmission rate of 35.1% is close to the rate
of 37.9% observed in Taiwan using a similar method.8
In the time course analysis of readmission, both 30-day
readmission and 5-year readmission rates decreased in a
linear manner from 2005 to 2010, primarily because of read-
mission patterns for mood disorders and schizophrenia/other
psychotic disorders. These trends may be reflective of
enhancements in the quality of hospital and community-
based outpatient care or other system-level considerations
such as increasing financial constraints affecting access to
hospital beds.13-15
Most of the risk factors for readmission found in this study
have been consistent with reports from other studies.8,9 It was
clear that acuity and complexity as reflected by length of
initial hospital stay and hospitalization in tertiary facilities had
implications for both short- and longer-term readmission. It
was also evident that both static demographic considerations
such as age and gender as well as variables reflective of social
determinants such as education level and employment also
were predictive of rehospitalization risk. Such patterns have
been observed previously8,9 and have implications for targeted
approaches to reduce readmission risk. We have previously
reported that being unemployed and being single/divorced/
separated/widowed were significant risk factors associated
The Canadian Journal of Psychiatry 63(6)
with longer LOS and less functional improvement in schizo-
phrenia patients.16 It was of interest to note that these factors
were also significant risk factors for readmissions.
With respect to limitations, it is of note that the OMHRS
data set may not capture all psychiatric admissions in
Ontario. Based on unpublished data from the Institute for
Clinical Evaluative Sciences, it has been estimated that
approximately 20% of psychiatric admissions in Ontario
were not captured by OMHRS, including psychiatric admis-
sions to intensive care units after suicide attempts and to
overflow medical beds.9 Death of older patients during the
5-year follow-up, particularly patients with dementia, may
also contribute to an underestimate of the 5-year readmission
rates, and we were unable to exclude planned readmissions.
Such factors might contribute to a margin of systematic error
in our study, but the large sample size offsets the degree of
concern to at least some extent.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
Supplemental Material
Supplementary material for this article is available online.
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