INTRODUCTION

Within health care discussions are ongoing about the need to develop new methods
for description and analyses of complex patterns of health service delivery. One
concept under discussion is the "total episode of care". In this study the psychiatric
specialist services (in- and outpatient care) in parts of North Halland and South
lvsborg counties have been analysed by construction of total episodes of care using
retrospective encounter data from case registers. The aim has been to illuminate the
benefits of the total episode of care as a tool for better understanding of costs, quality
and distribution of services in the population.
METHOD
The study defines the "total episode of care" as in and outpatient encounters, related
to the management of a specific illness or condition, provided by the psychiatric
services during a time period limited in both ends by an 18-teen month period of
"non-service". The formal definition used was
Episode of care all contacts that a patient has with the health care for a specific
health problem, between a starting and an end point
Four different types of episodes of care where constructed. Type A starts and ends
within the time frame, type B starts before and ends within the selected window, type
C starts within the window and ends later, type D starts before and ends later. Of
these only type A is a true episode of care.
Data about all encounters a patient had during the totality of care were collected
from the case registers kept by the two services (patients encounters in outpatient
care with doctors, nurses, psychologists etc, number of days in inpatient care). A
window was opened towards the database for the years 1995 and 1996. In order to
protect patients integrity, descriptions and analyses were carried out for groups of
patients.
Fig.1. "Episode" types A-D

In this work mainly four different diagnoses were used. These diagnoses were
selected in order to demonstrate the ability of the episode concept in helping
explaining care given for illnesses with different distributions of duration, age and
sex among the patients. Diagnoses used were schizophrenia, mood disorders, chrisis
and anorexia. But, analyses were also made based on the whole database regardless
of diagnoses

In order to test the episodes for epidemiological purposes, episode data were related
to the population in different parts of the catchment areas. Cumulative incidence
were calculated as well as prevalence for different time windows.
As encounter specific cost data were available in the case registers, the total cost for
every single episode could be estimated.
A number of new measures were constructed; total length of episode expressed in
episode days (episode duration); total number of encounters in out- and inpatient
care per episode (one inpatient day was regarded as one encounter); number of
contacts in relation to episode duration (contact intensity); number of outpatient
encounters in relation to the sum of out- and inpatient encounters (outpatient ratio).
As mentioned above the aim of the project was to test usefulness of the episode of
care concept and not to compare the two services. The comparisons were used in
order to validate the power of episodes of care to shed light on actual differences in
how services were performed. These comparisons were made mainly for two
different types of episodes; episode type A which starts and ends within the frame of
the window; episode type D which starts before and ends (if ever) after the window
frame.
RESULTS
The results show that aggregation of encounter data to episodes of care can
illuminate aspects of the care in a way that adds on to knowledge retrieved by
encounter data alone. More clear pictures could be created of the populations mental
health measured in terms of "treated" cumulative incidence and prevalence (as seen
from the perspective of the specialised psychiatry).
Episode analysis also reveals that the two services have systematically different
offers to make their patients when they fall ill. A greater probability for having
inpatient care, longer episode duration, more contacts, high contact intensity and
subsequently higher costs is related to one of the services.
But, the databases do not include data on differences in severity of illness.
Furthermore data on patients outcome is missing. The use of GAF-scoring (Global
Assessment of Psychosocial Functioning) is now under development and future
analyses of total episodes of care could benefit from GAF-data.
Information used to build the episodes of care is based on data that many psychiatric
services in Sweden already can access. The types of descriptions and analyses that
are needed are not especially costly and it does not require more than basic statistical
skills to analyse them.
Working with episodes of care demands special attention to the subject of data
presentation. As episodes of care focuses on services that are given to a certain group
of patients there is a risk that the number of patients can be too low to protect the
integrity for certain patients. Future work in the field of episodes should take on the
need to develop (on consensus basis) recommendations and rules on how data should
be presented in order to protect patients.

The report discusses the problem of different diagnostic cultures and the problem of
defining a health status in a similar way between single doctors and also between the
two psychiatric services. Problems relating the episodes to a specific and welldefined health care problem do exist. This is though not a problem connected solely
to episodes of care. It exists within all types of descriptions and analyses where
information on the patients health situation is needed.
As data on episodes of care relate to consumption of care for specified individuals
for a specific health problem episodes of care give the possibility to describe what
groups or categories of patients that resources are spent on. For example it is
possible to describe how many persons in a selected community, specified for age
and gender, who will turn ill a specific year and hence use the psychiatric services
(ceteris paribus). It will be possible to forecast how many of these that will end their
treatment and also how many that will have an ongoing episode of care. To all these
data it will be possible to connect information about costs.
In the now existing registers there is information about treatments and what different
categories of staff that take part in these. The examination of treatments given to a
certain patient during his episode of care will give a ground for discussing reality in
respect to "best practice" and other guidelines. It will be possible to elucidate when
during a patient episode of care different procedures are initiated and by what kind of
staff. It will also be possible to describe waiting times and other indicators of
availability to care.
One important issue is the exploration of what kind of correlation there is between
patients use of psychiatry and other types (public and private) of care like primary
care, social services, penal system and forensic psychiatry. Such studies are quite
possible to do and they will reveal the role of specialised psychiatry in relation to
other actors in the health care system and other systems closely related to health
care. One important factor to clarify is where referrals have their origin and what are
the future contacts between the system(s) and these patients.
As episodes of care relate to specific individuals, it will also be possible to take into
account how patients social and economic situation influence or will be influenced
by current health status. Episodes of care are probably suitable objects for analysis of
correlation between exposure of risk and later coming use of health services.

Figure 2. Comparisons between South lvsborg and North Halland on

selected variables

Information based on episodes of care can also be used to follow up and evaluate
changes in the health care systems. If capacity within primary care is increased, what
will the results be regarding new patients for psychiatry? If fees for attending
specialist psychiatry are changed, will patients with mental health problems seek
care in other ways within the system?
Furthermore effects of changing medical technologies will be easily recognised, as
they probably will influence the way that episodes are constructed. Introduction of a
new more effective treatment might shorten the episode of care but at the same time
the care may be more intensive and maybe more expensive
Experiences from such studies in combination with information about episode costs
have to be combined with studies of effects and benefits, both for patients and other
parties in the system.
It is also recommendable that the episode concept should be used to analyse in detail
also other types of diagnoses than the four we used. Likewise future developmental
work should adress also comorbidity, such as the psychiatric patients concurrent
somatic health problems.
Of course the results of this project is only the first step in the beginning of
elaboration of the episode of care concept in Sweden. Much work is needed before
episodes of care can serve as one of many information sources for commissioners
and people responsible for running services, in follow up and evaluation. The main
conclusion of this work is that the episode as an analytical concept deserves future
elaboration.
The graph below depicts some of the features of the use of episodes of care. The
main conclusion is that the two services have about the same rates in their
populations regarding incidence and prevalence. After that the similarities end.
CONCLUSIONS
By using episode of care as a tool for description and analyses of the two different
psychiatric services the strength of the episode concept is clear. The results indicate
that several variables can explain the differences in costs such as:
Length of episodes
Number of contacts between patient and services during an episode of care
Mix of in- and outpatient care
Contact intensity (number of contacts per time unit)
The results also indicate that good epidemiological data can be obtained by using
episodes of care (cumulative incidence, prevalence).
The total episode of care is useful for purchasers as well as providers as a tool for
understanding and analysing psychiatric services.

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