Patient Characteristics Associated With Admission to Low-Safety Inpatient Psychiatric Facilities: Evidence for Racial Inequities

Objective: The author examined patient demographic, clinical, payment, and geographic factors associated with admission to low-safety inpatient psychiatric facilities. Methods: Massachusetts all-payer 2017 discharge data (N539, 128 psychiatric patients) were linked to facility-level indicators of safety (N538 facilities). A composite of safety was created by averaging standardized measures of restraint and seclusion as well as 5-year averages of overall, substantiated, and abuse-related (i.e., verbal, physical, or sexual) complaints per 1, 000 discharges (a50.73). This composite informed quintile groups of safety performance. A series of multinomial regression models were fit, with payment and geography added separately. Results: Notable factors independently associated with admission to low-safety facilities were belonging to a racial or ethnic minority group compared with being a White patient (for non-Hispanic Black, relative risk ratio [RRR]51.71, p, 0.01; for non-Hispanic Asian, RRR55.60, p, 0.01; for non-Hispanic “other” race, RRR52.17, p, 0.01; and for Hispanic-Latinx, RRR51.29, p, 0.01) and not having private insurance (for self-pay or uninsured, RRR52.40, p, 0.01; for Medicaid, RRR51.80, p, 0.01; and for Medicare, RRR51.31, p, 0.01). Conclusions: To the best of the author's knowledge, this is the first study to examine differences in admission to low-safety inpatient psychiatric facilities. Even after accounting for potential clinical, geographic, and insurance mediators of structural racism, stark racial and ethnic inequities were found in admission to low-safety inpatient psychiatric facilities. In addition to addressing safety performance, policy makers should invest in gaining a better understanding of how differences in community-based referrals, mode of transport (e.g., police or self), and deliberate or unintentional steering and selection affect admissions and outcomes.