Analysis of inpatient cost burden and influencing factors of elderly patients with mental illness in Dalian, China

doi:10.21203/rs.3.rs-3108611/v1

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Research Article

Analysis of inpatient cost burden and influencing factors of elderly patients with mental illness in Dalian, China

https://doi.org/10.21203/rs.3.rs-3108611/v1

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published 14 Nov, 2023

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Background

As China's aging population continues to grow, the prevalence of mental illness among the elderly has been steadily increasing.The aim of this study is to reveal the changing trends and characteristics of economic burden among elderly patients with long-term hospitalization for mental illness, and to analyze the influencing factors.

Methods

In a retrospective analysis, The data for this study was gathered from elderly patients with mental illness who were hospitalized and aged 60 years or older. The patients were admitted to four specialized and general hospitals located in Dalian city between January 2018 and December 2020. Firstly, This study analyzed the basic characteristics of elderly patients with mental illness, with a focus on their personal characteristics. Secondly, the study examined the disease status of elderly patients by analyzing disease-related information of those who were hospitalized for an extended period. Finally, the study analyzed the influencing factors of hospitalization costs for elderly patients with different diseases, based on the differences in hospitalization costs for elderly patients with mental illness among various factors.

Results

Among the 3871 study subjects, the average length of hospital stay was 127.51 days (median 104.00, interquartile range 77.00-154.00).The average hospitalization expenses per case were 33,656.07 yuan (median 27,789.79, interquartile range 19,208.48-38,424.27). Patients were primarily hospitalized in specialized hospitals, and their subaverage hospitalization costs decreased year by year.The primary diagnosis for patient discharge was affective disorders (mood disorders) (ICD-10: F30-F39), and the hospitalization expenses for this disease increased annually over the three-year period.the length of hospital stay was found to be a significant factor affecting all six types of mental illnesses and had the most significant impact on the hospitalization costs of elderly patients with different mental illnesses. Moreover, the hospital category also had a significant impact on the hospitalization costs of elderly patients with all six types of mental illnesses. The payment method of medical insurance had a significant impact on the hospitalization costs of elderly patients with five types of mental illnesses, except for affective disorders. When compared to other types of medical insurance, employee medical insurance had a more significant impact on the hospitalization costs of elderly patients with two types of mental illnesses. Additionally, age only had a significant impact on the hospitalization costs of elderly patients with organic (including symptomatic) mental disorders. The presence of a 31-day readmission plan had a significant impact on the hospitalization costs of elderly patients with four types of mental illnesses. Moreover, the number of physical illnesses had a significant impact on the hospitalization costs of elderly patients with neurotic, stress-related, and somatoform disorders.

Conclusions

Elderly patients with mental illness who receive treatment in specialized hospitals have higher hospitalization costs. Long-term hospitalization increase the total hospitalization costs. Age have an impact on hospitalization costs for patients with organic mental disorders. Patients with two types of mental illnesses who are covered by urban employee medical insurance have higher hospitalization costs.Patients with severe mental illnesses who have a 31-day readmission plan tend to have higher hospitalization costs.Patients with somatic symptom disorders and concurrent physical illnesses often incur higher hospitalization costs.These findings provide a basis for the development of prevention and control measures for elderly mental illness, and offer a reference for the development of health services and security systems for elderly mental illness.

Hospitalization costs

Elderly population

Mental disorder.

The impact of mental illness on health has been increasing year by year. Between 1990 and 2019, the reduction in disability-adjusted life years from the control of communicable diseases, maternal, newborn and nutritional diseases was more than offset by the increased burden of non-communicable diseases such as mental illness^[1][2][3].According to the latest epidemiological survey, the lifetime prevalence of mental disorders (excluding senile dementia) in China is 16.57%, with a 12-month prevalence rate of approximately 9.32%^[4].The economic burden caused by mental illness accounts for a relatively high proportion of the total global economic burden of all diseases^[5].The inpatient costs of patients with mental illness in the UK account for 22% of the total healthcare service costs, highlighting the significant impact of mental illness on healthcare resources^[6].Mental illness is a major component of the healthcare expenditures in the United States, accounting for approximately $201 billion in 2010^[7].For elderly patients, although they have Medicare, Medicaid and employer supplements, they still face the burden of paying out-of-pocket medical expenses^{[8][9][10][11]}.Therefore, researchers believe that individual countries need to place more emphasis on prevention in policy, practice, and research to address the growing burden of mental illness^[12][13].

In recent years, as China's aging population continues to grow^[14], the prevalence of mental illness among the elderly has been steadily increasing. This not only impacts the quality of life for the elderly, but also results in a rise in medical expenses for this demographic. As a result, this places a significant economic burden on both patients and their families, as well as society as a whole.Elderly patients with mental illness typically exhibit symptoms such as memory loss, abnormal mental behavior and a decrease in daily functional ability. Additionally, they are often characterized by a high risk of relapse and are difficult to cure.Prevention and rehabilitation training should be emphasized in elderly patients with mental illness. However, current treatments often rely solely on drug therapy, resulting in longer hospital stays and increased medical costs for this demographic. Hospitalization costs are a significant part of medical expenses for senior patients. Previous studies have identified several factors that affect the cost of hospitalization for elderly patients with mental illness, including length of stay, number of physical illnesses, type of medical insurance, hospital where they are located, age, and gender^[15].

Accurate data on disease costs are crucial for making informed decisions regarding the allocation of resources^[16][17].The majority of low- and middle-income countries allocate less than 1% of their healthcare budget to mental health, primarily because governments do not give enough attention to mental illness and fail to implement policies in place^[18].In China, studies have been conducted to analyze the cost of hospitalization or outpatient treatment for specific mental disorders, such as depression, schizophrenia, and mood disorders, in different regions. However, there is a lack of analysis of hospitalization costs among older adults with various mental disorders, and there is a lack of studies that address the differences in factors influencing hospitalization costs among patients with different disorder types. The case study area has a significant aging population, and as a result, this study collected and analyzed hospitalization cost information of elderly patients with mental illness from multiple medical institutions in Dalian City from 2018 to 2020. The aim of this study is to reveal the changing trends and characteristics of economic burden among elderly patients with long-term hospitalization for mental illness, and to analyze the influencing factors, provide a basis for the development of prevention and control measures for elderly mental illness, and offer a reference for the development of health services and security systems for elderly mental illness.

This study is based on data obtained from the medical record information centers of psychiatric inpatients in four hospitals in Dalian City. The following criteria were used to determine data inclusion and exclusion: (1) The primary diagnosis is a mental disorder (identified by ICD-10 coding for the main diagnosis at discharge); (2) The discharge date falls between January 1, 2018, and December 31, 2020; (3) The actual hospitalization period is 60 days or more; (4) Patients under 60 years old are excluded; (5) Data with missing information are excluded; and (6) Data beyond three standard deviations from the mean are removed using the Z-score method. Ultimately, 3871 patient hospitalization records were included in the study.

According to age classification, developed countries define individuals aged 65 and above as elderly, where as China defines individuals aged 60 and above as elderly. For the purposes of this study, elderly patients refer to individuals aged 60 and above who have been diagnosed with a mental illness and were hospitalized in one of four hospitals in Dalian City. The study focuses specifically on elderly patients with mental illness who were aged 60 and above.

Firstly, this study analyzed the basic characteristics of elderly patients with mental illness, with a focus on their personal characteristics. Secondly, the study examined the disease status of elderly patients by analyzing disease-related information of those who were hospitalized for an extended period. Long-term hospitalization is based on the criteria of health insurance payment, patients are hospitalized within 60 days for DRG payment, and over 60 days as non-acute diagnosis, DRG payment is not used, so this study included hospitalization days of 60 days and above as nodes for long-term hospitalization. Concurrent complications, such as cardiovascular disease and diabetes, were also analyzed as accompanying symptoms of elderly patients with mental illness, based on interviews with clinical psychiatrists. Finally, the study analyzed the influencing factors of hospitalization costs for elderly patients with different diseases, based on the differences in hospitalization costs for elderly patients with mental illness among various factors.

Statistical analysis

Descriptive statistical analyses were performed on factors such as patients' basic conditions and disease types, as well as the three-year average sub-hospitalization costs of different categories of patients for each factor. The dependent variable for this study is the hospitalization expenses of patients, while the independent variables include the personal characteristics of elderly patients with mental illness, disease types and related factors, and insurance types. Variables were selected based on their meanings to analyze the influencing factors, and one-way ANOVA was used to explore the differences in hospitalization expenses among different groups of independent variables for each disease type. For two independent samples that conform to normal distribution but have unequal variances, a corrected t-test was used. For two independent samples that do not conform to normal distribution, the Mann-Whitney U test was used. The Kruskal-Wallis H test was used for three or more groups. Factors that significantly affect hospitalization expenses in the single-factor analysis were included in the multiple linear regression model. The stepwise method was used to analyze the influencing factors of hospitalization expenses for each disease type, and the significance level for entering and excluding variables was set at α= 0.05.

Among the 3871 study subjects, the average length of hospital stay was 127.51 days (median 104.00, interquartile range 77.00-154.00), and the average age was 68.39 years (median 66.00, interquartile range 63.00-73.00). The type of medical insurance of patients was mainly paid by employee medical insurance, followed by new rural cooperative medical insurance payment. Over the three-year period, hospitalization expenses for patients covered by employee medical insurance payment increased annually. Patients were primarily hospitalized in specialized hospitals, and their subaverage hospitalization costs decreased year by year. Conversely, hospitalization expenses for patients hospitalized in comprehensive hospitals increased annually over the three-year period.

Over the three-year period, the average hospitalization expenses of patients who did not plan to be readmitted within 31 days after discharge decreased annually. The primary diagnosis for patient discharge was affective disorders (mood disorders) (ICD-10: F30-F39), and the hospitalization expenses for this disease increased annually over the three-year period, but the increase in 2020 was relatively small compared to the previous year. The second most common diagnosis was schizophrenia, schizotypal and delusional disorders (ICD-10: F20-F29), and the hospitalization expenses for these diseases decreased significantly between 2018 and 2019 but increased again the following year. The number of cases of mental and behavioral disorders caused by psychoactive substances was the smallest, but the average expenses per case increased almost twofold over the three-year period. The average hospitalization expenses per case were 33,656.07 yuan (median 27,789.79, interquartile range 19,208.48-38,424.27). Table 1 displays the basic information of the patients and the variations in hospitalization expenses.

Table 1 The basic information and changes in hospitalization costs of elderly patients with mental disorders from 2018 to 2020

Case situation	Category	Number of cases	Annual average hospitalization cost in 2018 (Yuan)	constituent ratio	Annual average hospitalization cost in 2019 (Yuan)	Constituent ratio	Annual average hospitalization cost in 2020 (Yuan)	Constituent ratio
Age	60~69	2525	35743.72	39.13%	33798.21	32.40%	34322.56	32.47%
	70~79	953	27849.41	30.49%	34249.47	32.83%	33249.67	31.46%
	80~	393	27742.41	30.37%	36277.39	34.77%	38122.61	36.07%
Gender	Male	1759	35047.77	54.21%	36953.69	53.78%	35408.79	51.35%
Gender	Female	2112	29605.10	45.79%	31753.62	46.22%	33549.76	48.65%
Medical insurance type	Employee medical insurance	2050	26679.43	15.94%	29334.72	20.19%	31823.16	21.49%
	Medical insurance for both urban and rural residents	1313	30350.79	18.14%	39222.00	26.99%	34092.91	23.02%
	Settlement is divided into two times	452	72948.22	43.60%	38224.66	26.31%	57091.59	38.56%
	At one's own expense	56	37351.64	22.32%	38512.97	26.51%	25064.83	16.93%
Hospital category	Specialized hospital	2851	30102.84	43.77%	36189.12	56.23%	41144.98	68.96%
Hospital category	General hospital	1020	38666.43	56.23%	28166.63	43.77%	18519.41	31.04%
Have a 31-day readmission is scheduled	Yes	173	18911.31	37.08%	13606.49	28.47%	11228.29	22.92%
Have a 31-day readmission is scheduled	No	3698	32088.25	62.92%	34190.05	71.53%	37769.32	77.08%
Disease	Affective mental disorders (mood disorders)	1624	24028.91	12.55%	29002.68	13.34%	29448.46	11.86%
	Schizophrenia, schizotypal, and delusional disorders	1269	44791.63	23.40%	36113.34	16.62%	40461.98	16.29%
	Organic (including symptomatic) mental disorders	628	33287.73	17.39%	38376.30	17.66%	31663.40	12.75%
	Neurotic, stress-related and somatoform disorders	193	22825.93	11.93%	29835.77	13.73%	41036.79	16.53%
	Mental retardation	80	35743.06	18.68%	41559.57	19.12%	45351.62	18.26%
	Mental and behavioral disorders due to substance use	77	30714.38	16.05%	42445.99	19.53%	60369.29	24.31%
Medical insurance payment method	Pay by bed day	934	26142.4	42.83%	38767.76	54.15%	12523.62	23.94%
Medical insurance payment method	Else	2937	34902.13	57.17%	32832.02	45.85%	39787.03	76.06%
	Total	3871	32088.25	100%	34147.93	100%	34379.41	100%

Based on the results of the single-factor analysis, there were significant differences in the average hospitalization expenses per case among elderly patients with different types of mental illnesses in specialized hospitals and comprehensive hospitals. Patients in most categories of specialized hospitals had higher hospitalization expenses. Table 2 presents the difference in average hospitalization costs per patient between specialized hospitals and general hospitals.

Table 2 Differences in average hospitalization costs per case among patients of different categories in specialized and general hospitals

Variables	Category	Specialized hospital		General hospital		F	P
Variables	Category	Example number	Annual average hospitalization cost (Yuan)	Example number	Annual average hospitalization cost (Yuan)	F	P
Age	60~69	1784	37293.15	741	27701.03	40.985	0.000
	70~79	742	33789.55	211	25410.15
	80~	325	34384.57	68	23776.64
Gender	Male	1182	40774.97	577	25916.73	100.489	0.000
Gender	Female	1669	32703.29	443	28331.53	100.489	0.000
Medical insurance type	Employee medical insurance	1463	29624.57	587	29570.77	172.088	0.000
	Medical insurance for both urban and rural residents	905	40495.43	408	21793.33
	Settlement is divided into two times	452	48726.59
	At one's own expense	31	24654.74	25	50797.31

Table 2(continued)

Variables	Category	Specialized hospital		General hospital		F	P
Variables	Category	Example number	Annual average hospitalization cost (Yuan)	Example number	Annual average hospitalization cost (Yuan)	F	P
Have a 31-day readmission is scheduled	Yes			172	11154.22	203.421	0.000
Have a 31-day readmission is scheduled	No	2851	36051.48	848	30172.51	203.421	0.000
Disease	Affective mental disorders (mood disorders)	1452	28078.88	172	23681.91	76.543	0.000
	Schizophrenia, schizotypal, and delusional disorders	634	49610.63	635	29783.44
	Organic (including symptomatic) mental disorders	459	39912.46	169	21614.80
	Neurotic, stress-related and somatoform disorders	177	35430.21	16	11933.28
	Mental retardation	62	46577.65	18	21140.19
	Mental and behavioral disorders due to substance use	67	46231.14	10	29468.86

Table 2(continued)

Variables	Category	Specialized hospital		General hospital		F	P
		Example number	Annual average hospitalization cost (Yuan)	Example number	Annual average hospitalization cost (Yuan)
Medical insurance payment method	Pay by bed day	649	33293.56	285	11639.88	327.382	0.000
	Else	2202	36862.08	735	32908.10

Results from the regression analyses

Based on the Spearman correlation test, age had a statistically significant impact on the hospitalization expenses of elderly patients with affective disorders, organic mental disorders, neurotic disorders, stress-related disorders, and somatoform disorders. Hospitalization days also had a statistically significant impact on the hospitalization expenses of elderly patients with all six types of mental illnesses. Additionally, the number of physical illnesses had a statistically significant impact on the hospitalization expenses of elderly patients with affective disorders, neurotic disorders, stress-related disorders, and somatoform disorders.

Based on the Mann-Whitney U test or t-test, gender only had a statistically significant impact on the hospitalization expenses of elderly patients with affective disorders (mood disorders) among the six types of mental illnesses. The hospital type had a statistically significant impact on the hospitalization expenses of elderly patients with all six types of mental illnesses. Additionally, whether there was a plan to be readmitted within 31 days had a statistically significant impact on the hospitalization expenses of elderly patients with five types of mental illnesses, except for mental and behavioral disorders caused by psychoactive substances. Moreover, the medical insurance payment method had a statistically significant impact on the hospitalization expenses of elderly patients with five types of mental illnesses, except for affective disorders (mood disorders).

Based on the Kruskal-Wallis H test, the medical insurance type had a statistically significant impact on the hospitalization expenses of elderly patients with five types of mental illnesses, except for mental and behavioral disorders caused by psychoactive substances.

Stepwise multiple linear regression was employed to analyze the factors influencing hospitalization expenses for each of the six types of mental illnesses. The natural logarithm of hospitalization expenses was used as the dependent variable, and factors that had a significant impact on hospitalization expenses in the single-factor analysis were included in the multiple linear regression model as explanatory variables. The table 3 displays the variable assignments.

Table 3 Explanations of the impact factors on hospitalization costs for elderly patients with mental disorders

Variables	Dimension	Code
Hospital day	Actual value (day)	X₁
Age	Actual value (year)	X₂
Number of somatic diseases	Actual value (individual)	X₃
Gender	0= male, 1= female	X₄
Medical insurance type	0= other types of medical insurance 1= employee medical insurance	X₅
Hospital type	0= specialized hospital 1= a general hospital	X₆
Have a 31-day readmission is scheduled	0= Yes, 1= No	X₇
Medical insurance payment method	0= pay per bed day, 1= other	X₈

After verification, the standardized residuals for all six regressions were found to conform to a normal distribution. The results of the regression models confirmed significant influencing factors, with an adjusted r²=0.734 for affective disorders (mood disorders); an adjusted r²=0.886 for schizophrenia, schizotypal, and delusional disorders; an adjusted r²=0.834 for organic (including symptomatic) mental disorders; an adjusted r²=0.855 for neurotic, stress-related, and somatoform disorders; an adjusted r²=0.909 for intellectual disability; and an adjusted r²=0.823 for mental and behavioral disorders due to psychoactive substance use, as shown in Table 4.

Based on the results of the regression analysis, the length of hospital stay was found to be a significant factor affecting all six types of mental illnesses and had the most significant impact on the hospitalization costs of elderly patients with different mental illnesses. Moreover, the hospital category also had a significant impact on the hospitalization costs of elderly patients with all six types of mental illnesses. Additionally, the payment method of medical insurance had a significant impact on the hospitalization costs of elderly patients with five types of mental illnesses, except for affective disorders. When compared to other types of medical insurance, employee medical insurance had a more significant impact on the hospitalization costs of elderly patients with two types of mental illnesses. Additionally, age only had a significant impact on the hospitalization costs of elderly patients with organic (including symptomatic) mental disorders. The presence of a 31-day readmission plan had a significant impact on the hospitalization costs of elderly patients with four types of mental illnesses, excluding neurotic, stress-related, somatoform disorders, and mental and behavioral disorders caused by the use of psychoactive substances. Moreover, the number of physical illnesses had a significant impact on the hospitalization costs of elderly patients with neurotic, stress-related, and somatoform disorders. The gradually multiple regression analysis of hospitalization costs for each type of disease is presented in Table 4.

Table 4 Stepwise multiple regression analysis of hospitalization costs for patients with various diseases

Disease category	Variables	Non-standardized coefficients		Standardized regression coefficient(β)	t	P
Disease category	Variables	B	Std. Error	Standardized regression coefficient(β)	t	P
Affective mental disorders (mood disorders)	Constant	3.865	0.025		153.788	0.000
	Hospital day	0.003	0.000	0.846	63.673	0.000
	Have a 31-day readmission is scheduled	0.181	0.025	0.099	7.172	0.000
	Hospital category	-0.056	0.009	-0.087	-6.448	0.000
	Employee medical insurance	0.019	0.006	-0.042	3.161	0.002
Schizophrenia, schizotypal, and delusional disorders	Constant	3.845	0.024		162.744	0.000
	Hospital day	0.002	0.000	0.723	70.413	0.000
	Medical insurance payment method	0.156	0.007	0.249	21.537	0.000
	Hospital category	-0.110	0.006	-0.210	-17.394	0.000
	Have a 31-day readmission is scheduled	0.129	0.013	0.118	10.216	0.000
Organic (including symptomatic) mental disorders	Constant	4.144	0.051		80.622	0.000
	Hospital day	0.003	0.000	0.762	44.768	0.000
	Medical insurance payment method	0.093	0.010	0.165	9.310	0.000
	Hospital category	-0.108	0.012	-0.174	-8.935	0.000

Table 4(continued)

Disease category	Variables	Non-standardized coefficients		Standardized regression coefficient(β)	t	P
Disease category	Variables	B	Std. Error	Standardized regression coefficient(β)	t	P
	Have a 31-day readmission is scheduled	0.113	0.020	0.117	5.671	0.000
	Age	-0.002	0.001	-0.070	-4.180	0.000
Neurotic, stress-related and somatoform disorders	Constant	3.932	0.022		179.381	0.000
	Hospital day	0.003	0.000	0.723	24.536	0.000
	Medical insurance payment method	0.176	0.027	0.289	6.496	0.000
	Hospital category	-0.163	0.031	-0.165	-5.323	0.000
	Number of somatic diseases	0.019	0.004	0.137	4.763	0.000
	Employee medical insurance	0.051	0.023	0.093	2.246	0.026
Mental retardation	Constant	3.879	0.101		38.580	0.000
	Hospital day	0.002	0.000	0.730	17.775	0.000
	Medical insurance payment method	0.093	0.027	0.140	3.478	0.001
	Hospital category	-0.132	0.042	-0.178	-3.133	0.002
	Have a 31-day readmission is scheduled	0.113	0.052	0.130	2.179	0.032
Mental and behavioral disorders due to substance use	Constant	4.018	0.037		107.348	0.000
	Hospital day	0.003	0.000	0.823	16.929	0.000
	Medical insurance payment method	0.190	0.033	0.281	5.817	0.000
	Hospital category	-0.127	0.041	-0.152	-3.124	0.003

Elderly patients with mental illness who receive treatment in specialized hospitals have higher hospitalization costs. The study found that hospital type significantly impacts six types of mental illness in elderly patients, with specialized hospitals having higher hospitalization costs than general hospitals. Specialized hospitals have a lower self-payment ratio for medical insurance patients compared to general hospitals. Moreover, in China, mental health services are primarily provided by secondary and tertiary hospitals, with over 90% of these services offered by psychiatric hospitals^[19].Specialized hospitals tend to have a higher percentage of out-of-town patients, and elderly out-of-town patients usually have complex medical conditions. They typically seek treatment in specialized hospitals only when they encounter difficulties receiving treatment in their local area^[20].Patients treated in specialized hospitals have more complex medical conditions and longer average hospital stays than those treated in general hospitals,this can result in increased hospitalization costs.Specialized hospitals are increasingly adopting a per-diem payment system. However, under the per-diem payment system for mental illness, hospitals may engage in behaviors that encourage demand for medical insurance outside of coverage, prolong hospitalization days, and increase hospitalization frequency^[21].Similarly, it could lead to higher hospitalization expenses.

Long-term hospitalization has been found to increase the total hospitalization costs. Through the analysis of hospitalization costs for elderly patients with six types of mental illnesses, it was discovered that the length of hospital stay had the greatest impact on hospitalization costs among all influencing factors. The longer the length of hospital stay, the more medical resources the patient consumes, and the higher the hospitalization costs. This result is consistent with previous research on the correlation between length of hospital stay and hospitalization costs for patients with mental illnesses ^[¹⁰^]. Moreover, the impact of length of hospital stay on hospitalization costs did not show any significant change in the elderly patient population or in patients who were hospitalized for a long period of time.

Age has been found to have an impact on hospitalization costs for patients with organic mental disorders. This study specifically focuses on elderly patients with mental illnesses, and the impact of age on hospitalization costs differs from previous studies on elderly patients. The study discovered that age indirectly affects hospitalization costs through the length of hospital stay, and the effect is negative^[⁷^]. However, after conducting multiple factor analysis, this study found that age only had a significant impact on hospitalization costs for patients with organic (including symptomatic) mental disorders. Specifically, the older the patient with this type of disorder, the higher the hospitalization costs. Organic mental disorders are mental disorders that are secondary to other systemic and brain disorders^[22].The older a person is, the higher the likelihood of having coexisting physical illnesses,and the more likely to have organic mental disorders and higher hospitalization costs after co-morbidities. The relationship between age and hospitalization costs for the other five types of mental illnesses was found to be not significant. This could be due to the fact that the study focused on elderly patients who were hospitalized for a long period of time. Elderly patients with long-term mental illnesses and hospitalization tend to have fewer acute illnesses, and their condition is relatively stable with less medication compared to acute patients. The hospital expenses only increase with the extension of hospital stay and are averaged with relatively fewer expenses in other aspects.

Patients with two types of mental illnesses who are covered by urban employee medical insurance have higher hospitalization costs. When compared to the compensation status of medical insurance for different insured and uninsured patients, the reimbursement and compensation ratios of urban employee medical insurance are the highest^[¹¹^].An analysis of hospitalization costs for elderly patients with mental illnesses reveals that the proportion of expenses, such as medication, that may not be covered by medical insurance is relatively low. In this study, the proportion of hospitalization costs paid out-of-pocket by retired employees is lower compared to other medical insurance types. The results of multiple factor analysis indicate that employee medical insurance has a significant impact on hospitalization costs for elderly patients with affective disorders (mood disorders) and neurotic, stress-related, and somatoform disorders, two types of mental illnesses. Patients who participate in employee medical insurance have higher hospitalization costs. When it comes to the unique characteristics of mental illnesses, they are prone to recurrence and have a prolonged course of illness^[23].Patients with these two types of illnesses require more care and long-term treatment compared to other illnesses. The lower the proportion of hospitalization costs paid out-of-pocket by patients, and the more difficult it is to receive home care, the higher the likelihood of family members and patients being hospitalized for long-term treatment and care, resulting in higher hospitalization costs.

Patients with severe mental illnesses who have a 31-day readmission plan tend to have higher hospitalization costs. The study found that the presence of a 31-day readmission plan has a significant impact on hospitalization costs for four types of mental illnesses among elderly patients. These include affective disorders (mood disorders), schizophrenia, schizotypal and delusional disorders, organic (including symptomatic) mental disorders, and intellectual disabilities. Readmission within a month is closely related to hospitalization costs for patients, with the majority being patients with severe mental illnesses such as schizophrenia and bipolar disorder^[¹⁰^].Elderly patients with severe mental illnesses have lower functional abilities compared to patients in other age groups and require care in medical facilities with complete facilities. As a result, they often require readmission after discharge, which affects the length of hospitalization and indirectly affects hospitalization costs.

Patients with somatic symptom disorders and concurrent physical illnesses often incur higher hospitalization costs. Research has found that, after controlling for other variables, comorbidities such as cardiovascular disease, diabetes, and liver disease are significantly linked to increased hospitalization costs for patients^[18].The majority of elderly patients with comorbid physical illnesses in this study had the aforementioned diseases. The research findings revealed a significant correlation between the number of physical illnesses and hospitalization costs for elderly patients with neurotic, stress-related, and somatoform disorders. As the number of physical illnesses increased, so did the hospitalization costs. Moreover, physical illnesses were often the primary symptoms of mental disorders.The study found that 91.9% of patients with somatoform disorders had an average of 2.8 co-occurring mental disorders^[24].Compared to the other five mental disorders, this disease has a higher rate of comorbidity with mental disorders. Additionally, for patients with this disease, the presence of concurrent physical illnesses may result in the emergence of new mental symptoms or worsen pre-existing mental disorders^[25].As a result, this leads to a prolonged hospitalization period, which indirectly results in increased hospitalization costs.

The high cost of hospitalization places a heavy burden on families of elderly patients with mental illness. To address this issue, China has implemented various cost control and protection measures, such as:(1) Legislating to include mental health funding in the budget, establishing psychiatric or psychological outpatient clinics in comprehensive hospitals, and providing appropriate subsidies to mental health workers can strengthen the prevention of mental disorders;(2) China implemented the eliminating drug markups to reduce hospital drug sales, although public hospitals still increase patient medication through prescriptions and additional service fees through clinical pathways; (3) strengthening hospital cost monitoring by strictly controlling cost indicators through monthly and quarterly monitoring; and (4) implementing a tiered diagnosis and treatment policy where common diseases are treated at local community hospitals and transferred to higher-level hospitals if necessary. The tiered diagnosis and treatment system can reduce the pressure and economic burden on patients seeking medical treatment. Currently, China is promoting the implementation of the tiered diagnosis and treatment system through medical security system reforms.

Strengths

This study collected hospitalization cost data of elderly patients with mental illness from multiple medical institutions and effectively utilized the advantages of multi-institutional data to compare and analyze the differences in hospitalization costs between specialized and general hospitals. The study focused on elderly individuals with various mental disorders and conducted a differential analysis of the factors affecting hospitalization costs for patients with different types of diseases.

Limitation

While the data in this study was collected from multiple medical institutions and has a larger sample size and greater representativeness compared to data from a single institution, it still lacks national representativeness. The distribution of resources and service levels for mental health specialty services in China varies greatly, and this study only analyzed hospitals in Dalian. Additionally, although this study maximized the inclusion of information and variables contained in the Homepage of inpatient)medical records, it did not include clinically relevant variables or patient information after discharge. Therefore, the guidance this study provides for clinical practice is relatively limited.

Author’s contributions

Xin Dai was involved in the design of the study and the drafting of the manuscript. Mingcheng Gao was involved in the design of the study and assisted in the drafting of the manuscript. Yue Liu and Run Lv performed the statistical analysis, and assisted in the drafting and reviewing of the manuscript. Huanhong Chen and Huayi Miao was involved in the design of the study and the statistical analysis, and assisted in the drafting of the manuscript. Ying Zhang was involved in the conduct of the study, as a member of the study advisory board, and in the writing and review of the overall manuscript. All authors read and approved the final manuscript.

Consent for publication

Not applicable.

Funding

This work was supported by Liaoning Province social science planning Fund. L20ARK001. The funding body had no role in the design of the study, nor in the data collection, analysis, and interpretation.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Ethics approval and consent to participate

All experiments were performed in accordance with relevant guidelines and regulations.According to Article 32 of Chapter 3 of the Measures for Ethical Review of Life Sciences and Medical Research Involving Human Beings, issued by the Department of Science and Technology Education of the Chinese Health and Health Commission [2023] No.4(http://www.nhc.gov.cn/qjjys/s7946/202302/c3374c180dc5489d85f95df5b46afaf5.shtml), "The use of human information data or biological samples to carry out life science and medical research involving human beings in the following circumstances, does not cause harm to human beings, does not involve sensitive personal information or commercial interests, can be exempted from ethical review, in order to reduce the unnecessary burden on scientific researchers and promote life science and medical research involving human beings:(2) the use of anonymized information data to conduct research.This paper uses anonymized information data to conduct research, which is in accordance with (2), and therefore ethics does not require ethical review.

Acknowledgements

Not applicable.

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Additionaltable1and2.docx
Additional file 1: Table 1. Composition of hospitalization expenses for elderly patients with mental illness from 2018 to 2020. Table 2. Analysis of Factors Influencing Hospitalization Expenses by Disease Type - Single Factor Analysis.
originaldata7.20.xlsx

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Analysis of inpatient cost burden and influencing factors of elderly patients with mental illness in Dalian, China

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