Health-economic outcomes in hospital patients with medical-psychiatric comorbidity: A systematic review and meta-analysis

Factors predicting discharge after two years for inpatients in the psychiatric long-term care wards who can walk independently

[Purpose] The purpose of this study was to investigate the factors that affected the discharge of walkable patients admitted to psychiatric long-term care wards. [Participants and Methods] The participants were walkable patients admitted to psychiatric long-term care wards at three different hospitals in Japan. The baseline assessments of all 73 patients were conducted between September and December 2018. During the 2 year follow-up period, five patients died, while 68 were included in the analysis. The baseline assessment includes the basic information of the participants and the risk of locomotive syndrome. [Results] In the comparisons between the discharged (n=12) and hospitalizing groups (n=56), the age, length of stay, and two-step and stand-up test scores at the baseline assessment were significantly different. The multiple logistic regression analysis, which discriminates between the two groups, adopted age as a significant variable in the baseline assessment as a predictor of dischargeability (odds ratio: 1.08; 95% confidence interval: 1.01, 1.16). [Conclusion] Age was considered to be a discharge likelihood predictor, as it affects the decline in motor function, such as locomotive syndrome, as well as the social resources that would be needed after discharge, such as family support.

Acceptance and commitment-based therapy for patients with psychiatric and physical health conditions in routine general hospital care - Development, implementation and outcomes

OBJECTIVE

Transdiagnostic approaches are needed to effectively treat patients with a broad range of diagnoses and comorbidities in routine general hospital care. Yet the evidence for the effectiveness of treatments beyond Cognitive Behavioral Therapy (CBT) is largely lacking. We describe the process of implementing an interdisciplinary multi-professional Acceptance and Commitment Therapy (ACT)-based treatment for patients with psychiatric and physical health conditions and present outcomes before and after implementation.

METHOD

The present investigation was a naturalistic comparative study comparing ACT-based (n = 126) vs. CBT-based (n = 127) treatments in a psychiatric day hospital in Berlin, Germany. Within- and between-group changes (pre- to post-treatment) in everyday functioning and health-related quality of life (primary outcomes; assessed by the Short Form 36 (SF-36)), as well as anxiety and depressive symptoms (secondary outcomes; assessed by the Hospital Anxiety and Depression Scale (HADS) and Beck Depression Inventory-II (BDI-II)), were analyzed with Generalized Linear Models, and Wilcoxon signed-rank tests and effect size r.

RESULTS

Data analysis showed statistically significant improvements from pre- to post-treatment (r ranging from 0.27 to 0.61, p < 0.001) for most SF-36 scales as well as for all HADS and BDI-II scores (r ranging from 0.38 to 0.60, p < 0.001) for both the ACT and CBT groups. ACT and CBT showed comparable effects in relation to clinical outcomes.

CONCLUSION

An interdisciplinary multi-professional ACT-based group treatment is a valuable approach for patients with psychiatric and physical health conditions in real-life hospital settings, with effects equivalent to CBT interventions.

The impact of mental and physical multimorbidity on healthcare utilization and health spending in China: A nationwide longitudinal population-based study

BACKGROUND

In China, little evidence exists on the effect of mental and physical multimorbidity on individuals and the health system. This study aims to examine the prevalence of mental-physical multimorbidity and its impact on health service utilization and health expenditures.

METHODS

We conducted a panel study using two waves of data (in 2011 and 2015) from the China Health and Retirement Longitudinal Study, including 10,181 participants aged 45 years and older. Generalized linear regression models were used to assess the association of multimorbidity with total health expenditure and out-of-pocket expenditure (OOPE) on outpatient and inpatient care. Random-effects logistic regression models were used to examine the impact of multimorbidity on outpatient visits, admission to hospital and incidence of catastrophic health expenditure (CHE).

RESULTS

Overall, 3210 participants (31.53% of 10,181) had mental-physical multimorbidity in 2015 in China. Compared to patients with a single physical disease, individuals with physical-mental multimorbidity had over 150% of the increase in the number of outpatient visits and days of hospitalization. The percentage change of OOPE for outpatient and inpatient care was 156.8% and 163.6%, respectively. Mental-physical multimorbidity was associated with an increased likelihood of experiencing CHE (OR = 2.205, 95% CI = 2.048, 2.051).

CONCLUSION

Multimorbidity, particularly mental-physical multimorbidity, is associated with higher levels of health service use and a greater financial burden to individuals in China. Healthcare system needs to shift from single-disease models to new financing and service delivery models to more effectively manage mental-physical multimorbidity.

Association Between Comorbid Psychiatric Disorders and Hospital Resource Use in Physically Ill Pediatric Inpatients: A Case-Matched Analysis

OBJECTIVE

To understand differences in hospital length of stay and costs associated with the presence of a comorbid psychiatric disorder among physically ill inpatients within a publicly funded pediatric hospital.

METHOD

This was a retrospective observational design using administrative data on physically ill inpatients 2 to 18 years old who were admitted over a 5-year period (n = 54,316 admissions). Records with (n = 4,953) and without (n = 49,363) documented comorbid psychiatric disorder were compared for differences in baseline characteristics. To optimize the balance of measured covariates, individuals with comorbid psychiatric disorders were matched on propensity score, case mix group, and Elixhauser comorbidities, resulting in 4,371 pairs of inpatients with and without a comorbid psychiatric disorder. Differences in length of stay and total hospital costs were assessed using generalized estimating equation models on matched patients.

RESULTS

Unmatched analyses demonstrated that inpatient admissions with comorbid psychiatric disorders were associated with higher occurrence of previous hospitalizations (69.2% versus 55.0%), unscheduled admissions (66.9% versus 60.9%), medical admissions (75.6% versus 52.7%), urgent admissions (62.5% versus 56.2%), and Elixhauser comorbidities (69.0% versus 39.0%), with standardized differences > |0.1|. Matched analyses demonstrated a 9.6% longer length of stay (95% CI = 5.7-13.7; p < .001) and 9.6% higher costs per admission (95% CI = 5.9-13.4; p < .001) in inpatients with comorbid psychiatric disorders compared to those without.

CONCLUSION

The complexity of inpatients with a comorbid psychiatric disorder, in conjunction with the approximate 10% increase in hospital resource use, highlights the need for innovative models of clinical care and research directed at improving patient outcomes and reducing hospital costs.

The prevalence of depression, anxiety, and sleep disturbances in COVID-19 patients: a meta-analysis

Evidence from previous coronavirus outbreaks has shown that infected patients are at risk for developing psychiatric and mental health disorders, such as depression, anxiety, and sleep disturbances. To construct a comprehensive picture of the mental health status in COVID-19 patients, we conducted a systematic review and random-effects meta-analysis to assess the prevalence of depression, anxiety, and sleep disturbances in this population. We searched MEDLINE, EMBASE, PubMed, Web of Science, CINAHL, Wanfang Data, Wangfang Med Online, CNKI, and CQVIP for relevant articles, and we included 31 studies (n = 5153) in our analyses. We found that the pooled prevalence of depression was 45% (95% CI: 37-54%, I2  = 96%), the pooled prevalence of anxiety was 47% (95% CI: 37-57%, I2  = 97%), and the pooled prevalence of sleeping disturbances was 34% (95% CI: 19-50%, I2  = 98%). We did not find any significant differences in the prevalence estimates between different genders; however, the depression and anxiety prevalence estimates varied based on different screening tools. More observational studies assessing the mental wellness of COVID-19 outpatients and COVID-19 patients from countries other than China are needed to further examine the psychological implications of COVID-19 infections.

Proactive Consultation-Liaison Psychiatry: American Psychiatric Association Resource Document

In 2019, the American Psychiatric Association Council on Consultation-Liaison (C-L) Psychiatry convened a work group to develop a resource document on proactive C-L psychiatry. A draft of this document was reviewed by the Council in July 2020, and a revised version was approved by this Council in September 2020. The accepted version was subsequently reviewed by the American Psychiatric Association Council on Health Care Systems and Financing in November 2020. The final version was approved by the Joint Reference Committee on November 24, 2020, and received approval for publication by the Board of Trustees on December 12, 2020. This resource document describes the historical context and modern trends that have given rise to the model of proactive C-L psychiatry. Styled as an inpatient corollary to outpatient collaborative care models, proactive C-L provides a framework of mental health care delivery in the general hospital designed to enhance mental health services to a broad range of patients. Its 4 elements include systematic screening for active mental health concerns, proactive interventions tailored to individual patients, team-based care delivery, and care integration with primary teams and services. Studies have found that proactive C-L psychiatry is associated with reduced hospital length of stay, enhanced psychiatric service utilization, reduced time to psychiatric consultation, and improved provider and nurse satisfaction. These favorable results encourage further studies that replicate and build upon these findings. Additional outcomes such as patient experience, health outcomes, and readmission rates deserve investigation. Further studies are also needed to examine a broader array of team compositions and the potential value of proactive C-L psychiatry to different hospital settings such as community hospitals, surgery, and critical care.

Analysis of the Care Provided Over a Six-Month Period by the Liaison Psychiatry Unit at a General Hospital in Lima, Peru

INTRODUCTION

Consultation-liaison psychiatry is a branch of clinical psychiatry that enables psychiatrists to carry out a series of activities within a general hospital. The number of liaison psychiatry units around the world has increased significantly, and Peru is no exception. However, this development is heterogeneous and unknown, so recent study reports are required to reveal the characteristics and details of the clinical care services provided by these units.

AIM

To describe and report the socio-demographic and clinical characteristics of patients evaluated in the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital in Lima, Peru, and to analyse the symptomatic and syndromic nature of the identified conditions.

METHODS

Cross-sectional descriptive study. Referrals to the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital between May and October 2019 were studied, and a factor analysis of the symptoms was conducted.

RESULTS

In a total of 400 referrals evaluated, the average age was 58±17.09 years and 61.5% of the patients were women. The rate of psychiatric consultation was 2.73%. Internal medicine (13.9%) was the service that most frequently requested a psychiatric consultation. The disorder most frequently diagnosed was anxiety (44%), and the symptoms most frequently found were depression (45.3%), insomnia (44.5%), and anxiety (41.3%). The most used treatments were antidepressants (44.3%). The exploratory factor analysis of the symptoms showed three syndromic components: delirium, depression, and anxiety.

CONCLUSIONS

The typical patient of this sample is a woman in her late 50s, suffering from a non-psychiatric medical illness, and with anxiety disorders as the main diagnosis resulting from the psychiatric consultation.

Relationship between whether the planned discharge destination is decided and locomotive syndrome for admitted patients in psychiatric long-term care wards

OBJECTIVE

We focused on locomotive syndrome as a low physical function factor that may prevent patients with psychiatric disease from being discharged. The purpose of this study is to clarify the factors, including locomotive syndrome, that prevent discharge from psychiatric long-term care wards.

METHOD

We enrolled 74 patients who were admitted to psychiatric long-term care wards at three different hospitals in Japan. Nurses or medical social workers in the ward were asked whether the planned discharge destination had been decided, and patients were categorized into a decided group and an undecided group. Outcome measures were age, sex, F code in the ICD-10 Classification of Mental and Behavioral Disorders, length of stay, chlorpromazine equivalent dose of antipsychotics, locomotive syndrome test scores (25-question GLFS, two-step test, stand-up test), and Barthel Index.

RESULTS

Based on the multivariate logistic regression analysis results, the length of stay and the two-step test score significantly explained the difference between the two groups. The odds ratio of a length of stay greater than 10 years was 8.42 times that of a length of stay less than 2 years (P=0.012, 95% CI=1.59, 44.53). Regarding the twostep test, the odds ratio for obtaining stage 2 was 10.62 times that for obtaining stage 0 (P=0.013, 95% CI=1.65, 68.23).

CONCLUSION

Those who with longer length of stays and lower two-step test scores tended not to be decided the planned discharge destination.

Diagnostic Agreement between Physicians and a Consultation-Liaison Psychiatry Team at a General Hospital: An Exploratory Study across 20 Years of Referrals

Consultation-liaison psychiatry (CLP) manages psychiatric care for patients admitted to a general hospital (GH) for somatic reasons. We evaluated patterns in psychiatric morbidity, reasons for referral and diagnostic concordance between referring doctors and CL psychiatrists. Referrals over the course of 20 years (2000-2019) made by the CLP Service at Modena GH (Italy) were retrospectively analyzed. Cohen's kappa statistics were used to estimate the agreement between the diagnoses made by CL psychiatrist and the diagnoses considered by the referring doctors. The analyses covered 18,888 referrals. The most common referral reason was suspicion of depression (n = 4937; 32.3%), followed by agitation (n = 1534; 10.0%). Psychiatric diagnoses were established for 13,883 (73.8%) referrals. Fair agreement was found for depressive disorders (kappa = 0.281) and for delirium (kappa = 0.342), which increased for anxiety comorbid depression (kappa = 0.305) and hyperkinetic delirium (kappa = 0.504). Moderate agreement was found for alcohol or substance abuse (kappa = 0.574). Referring doctors correctly recognized psychiatric conditions due to their exogenous etiology or clear clinical signs; in addition, the presence of positive symptoms (such as panic or agitation) increased diagnostic concordance. Close daily collaboration between CL psychiatrists and GH doctors lead to improvements in the ability to properly detect comorbid psychiatric conditions.

Self-reported PTSD is associated with increased use of MDMA in adolescents with substance use disorders

BACKGROUND

Adolescent patients with a substance use disorder (SUD) often fulfil the criteria for a co-occurring post-traumatic stress disorder (PTSD). However, it is not clear if these dual-diagnosed adolescents present with unique levels of substance use and how their substance use relates to PTSD symptom clusters.

OBJECTIVE

To investigate substance use in adolescents with co-occurring PTSD and SUD. Additionally, we explored how the use of specific substances is related to specific PTSD symptom clusters.

METHOD

We recruited n = 121 German adolescent SUD patients, in three groups: no history of traumatic events (TEs) (n = 35), TEs but not PTSD (n = 48), probable PTSD (n = 38). All groups were administered a trauma questionnaire and were asked to report their past-month substance use.

RESULTS

Adolescents with probable PTSD and SUD report a higher frequency of MDMA use than adolescents with no PTSD and no TE (PTSD vs. noTE: U = 510.5, p = .016; PTSD vs. TE: U = 710.0, p = .010). The use of MDMA was more frequent in adolescents with avoidance symptoms (X² (1) = 6.0, p = .014). Participants report using substances at a younger age (PTSD vs. noTE: U = 372.0, p = .001; PTSD vs. TE: U = 653.5, p = .022) and PTSD symptom onset was on average 2.2 years earlier than first MDMA use (t (26) = -2.89, p = .008).

CONCLUSIONS

Adolescent SUD patients with probable PTSD are more likely to use MDMA than SUD patients without PTSD. The use of MDMA was associated with reported avoidance symptoms. The first age of MDMA use is initiated after PTSD onset. It is unclear whether the association of MDMA use with avoidance symptoms is due to efforts to reduce these symptoms or a result of regular MDMA use.

Mental Health Costs of Inflammatory Bowel Diseases

BACKGROUND

Mental health diagnoses (MHDs) were identified as significant drivers of inflammatory bowel disease (IBD)-related costs in an analysis titled "Cost of Care Initiative" supported by the Crohn's & Colitis Foundation. In this subanalysis, we sought to characterize and compare IBD patients with and without MHDs based on insurance claims data in terms of demographic traits, medical utilization, and annualized costs of care.

METHODS

We analyzed the Optum Research Database of administrative claims from years 2007 to 2016 representing commercially insured and Medicare Advantage insured IBD patients in the United States. Inflammatory bowel disease patients with and without an MHD were compared in terms of demographics (age, gender, race), insurance type, IBD-related medical utilization (ambulatory visits, emergency department [ED] visits, and inpatient hospitalizations), and total IBD-related costs. Only patients with costs >$0 in each of the utilization categories were included in the cost estimates.

RESULTS

Of the total IBD study cohort of 52,782 patients representing 179,314 person-years of data, 22,483 (42.6%) patients had at least 1 MHD coded in their claims data with a total of 46,510 person-years in which a patient had a coded MHD. The most commonly coded diagnostic categories were depressive disorders, anxiety disorders, adjustment disorders, substance use disorders, and bipolar and related disorders. Compared with patients without an MHD, a significantly greater percentage of IBD patients with MHDs were female (61.59% vs 48.63%), older than 75 years of age (9.59% vs 6.32%), white (73.80% vs 70.17%), and significantly less likely to be younger than 25 years of age (9.18% vs 11.39%) compared with those without mental illness (P < 0.001). Patients with MHDs had significantly more ED visits (14.34% vs 7.62%, P < 0.001) and inpatient stays (19.65% vs 8.63%, P < 0.001) compared with those without an MHD. Concomitantly, patients with MHDs had significantly higher ED costs ($970 vs $754, P < 0.001) and inpatient costs ($39,205 vs $29,550, P < 0.001) compared with IBD patients without MHDs. Patients with MHDs also had significantly higher total annual IBD-related surgical costs ($55,693 vs $40,486, P < 0.001) and nonsurgical costs (medical and pharmacy) ($17,220 vs $11,073, P < 0.001), and paid a larger portion of the total out-of-pocket cost for IBD services ($1017 vs $905, P < 0.001).

CONCLUSION

Patients whose claims data contained both IBD-related and MHD-related diagnoses generated significantly higher costs compared with IBD patients without an MHD diagnosis. Based on these data, we speculate that health care costs might be reduced and the course of patients IBD might be improved if the IBD-treating provider recognized this link and implemented effective behavioral health screening and intervention as soon as an MHD was suspected during management of IBD patients. Studies investigating best screening and intervention strategies for MHDs are needed.

The Impact of Psychiatric Comorbidity on Health Care Utilization in Inflammatory Bowel Disease: A Population-based Study

BACKGROUND

Inflammatory bowel disease (IBD) is associated with an increase in psychiatric comorbidity (PC) compared with the general population. We aimed to determine the impact of PC on health care utilization in persons with IBD.

METHODS

We applied a validated administrative definition of IBD to identify all Manitobans with IBD from April 1, 2006, to March 31, 2016, and a matched cohort without IBD. A validated definition for PC in IBD population was applied to both cohorts; active PC status meant ≥2 visits for psychiatric diagnoses within a given year. We examined the association of active PC with physician visits, inpatient hospital days, proportion with inpatient hospitalization, and use of prescription IBD medications in the following year. We tested for the presence of a 2-way interaction between cohort and PC status.

RESULTS

Our study matched 8459 persons with IBD to 40,375 controls. On crude analysis, IBD subjects had ≥3.7 additional physician visits, had >1.5 extra hospital days, and used 2.1 more drug types annually than controls. Subjects with active PC had >10 more physician visits, had 3.1 more hospital days, and used >6.3 more drugs. There was a synergistic effect of IBD (vs no IBD) and PC (vs no PC) across psychiatric disorders of around 4%. This synergistic effect was greatest for anxiety (6% [2%, 9%]). After excluding psychiatry-related visits and psychiatry-related hospital stays, there remained an excess health care utilization in persons with IBD and PC.

CONCLUSION

Inflammatory bowel disease with PC increases health care utilization compared with matched controls and compared with persons with IBD without PC. Active PC further increases health care utilization.

Machine-learning prediction of unplanned 30-day rehospitalization using the French hospital medico-administrative database

Predicting unplanned rehospitalizations has traditionally employed logistic regression models. Machine learning (ML) methods have been introduced in health service research and may improve the prediction of health outcomes. The objective of this work was to develop a ML model to predict 30-day all-cause rehospitalizations based on the French hospital medico-administrative database.This was a retrospective cohort study of all discharges in the year 2015 from acute-care inpatient hospitalizations in a tertiary-care university center comprising 4 French hospitals. The study endpoint was unplanned 30-day all-cause rehospitalization. Logistic regression (LR), classification and regression trees (CART), random forest (RF), gradient boosting (GB), and neural networks (NN) were applied to the collected data. The predictive performance of the models was evaluated using the H-measure and the area under the ROC curve (AUC).Our analysis included 118,650 hospitalizations, of which 4127 (3.5%) led to rehospitalizations via emergency departments. The RF model was the most performant model according to the H-measure (0.29) and the AUC (0.79). The performances of the RF, GB and NN models (H-measures ranged from 0.18 to 0. 29, AUC ranged from 0.74 to 0.79) were better than those of the LR model (H-measure = 0.18, AUC = 0.74); all P values <.001. In contrast, LR was superior to CART (H-measure = 0.16, AUC = 0.70), P < .0001.The use of ML may be an alternative to regression models to predict health outcomes. The integration of ML, particularly the RF algorithm, in the prediction of unplanned rehospitalization may help health service providers target patients at high risk of rehospitalizations and propose effective interventions at the hospital level.

A psychoeducational intervention increases use of a delirium protocol by Neurologists and Neurosurgeons in patients with brain disorders

OBJECTIVES

Over 50% of inpatients with neurological disorders may present with a co-morbid psychiatric illness. Delirium has a reported point prevalence of 20% in hospital inpatients and is frequently undetected. We aimed to (1) examine inpatient referrals to a Liaison Neuropsychiatry service and (2) review the diagnosis and management of delirium before and after an educational intervention.

METHODS

An initial 6-month audit of referrals to the inpatient Liaison Neuropsychiatry service was conducted in 2018. We then undertook a psychoeducational intervention to raise awareness of the diagnosis and management of delirium. We conducted a re-audit of referrals to the service in 2019.

RESULTS

On initial audit, of 84 referrals, the most common referral was for mood (38%; n = 32). Just 4% (n = 3) had a specific delirium query. Following assessment by Neuropsychiatry, organic disorders (43%; n = 32), including delirium (33%; n = 25), were the most common diagnoses. On re-audit, of 86 referrals, mood assessment remained the most common reason for referral (38%; n = 33) and 2% (n = 2) were referred for possible delirium. Organic disorders remained the most common diagnoses (53%; n = 45) including delirium (38%; n = 32). We found a significant increase in the use of the delirium protocol from 12% (n = 3) on initial audit to 47% (n = 15); p < 0.01 on re-audit despite no increase in the number of specific delirium queries.

CONCLUSIONS

A psychoeducational intervention improves the management of delirium by Neurologists and Neurosurgeons in patients with brain disorders.

Predictors of civil and forensic inpatient psychiatric readmissions at a Public Mental Health Hospital

Inpatient psychiatric readmissions are increasingly prevalent and associated with worse prognostic outcomes and high economic costs, regardless of the medicolegal ramifications that necessitate them. Unlike most general medical readmissions, psychiatric readmissions are commonly warranted for both medical and legal purposes. However, studies focusing on analyzing the predictors of inpatient psychiatric readmission and their relationship to civil versus forensic readmission are limited. The purpose of this study was to examine the predictors of psychiatric readmission among civil and forensic patients admitted to a psychiatric hospital. In this retrospective chart review, we extrapolated data from medical records of 741 patients admitted from 2012 to 2017 with follow up until 2019. Analyses involved chi-square tests for comparing the distribution of demographic and clinical variables between forensic and civil readmission, and Cox regression to determine predictors of time to first readmission. Our results show that race, diagnosis, restraint/seclusion, type of admission, and disposition are significantly associated with an increased risk of psychiatric readmission. This study has important implications for healthcare providers and policy makers in revising mental health policies and improving systems-based practices for the mental health system. Future efforts in improving community psychiatric services and enhancing inpatient therapeutic environment may reduce psychiatric readmissions.

Added Cost and Time Spent by Patients With History of Abuse in Florida Emergency Departments

Interpersonal violence is known to lead to both short- and long-term health effects. Victims of sexual abuse tend to have higher healthcare costs and higher rates of physical and mental health issues than nonvictims. In this study, we investigate whether the comorbidity of mental illness and a personal history of adult physical and sexual abuse (HAPSA) results in higher healthcare costs and length of emergency department (ED) stay among Florida residents. A Negative Binomial and Log-Linear Regression Analysis suggest increased ED visit duration for those with a history of abuse, Hispanics, the uninsured, and those with multiple comorbidities. In addition, increased costs were found to be associated with White race, the uninsured, those with multiple comorbidities, and the facility type (for-profit hospitals).

Severe mental illness and health service utilisation for nonpsychiatric medical disorders: A systematic review and meta-analysis

BACKGROUND

Psychiatric comorbidity is known to impact upon use of nonpsychiatric health services. The aim of this systematic review and meta-analysis was to assess the specific impact of severe mental illness (SMI) on the use of inpatient, emergency, and primary care services for nonpsychiatric medical disorders.

METHODS AND FINDINGS

PubMed, Web of Science, PsychINFO, EMBASE, and The Cochrane Library were searched for relevant studies up to October 2018. An updated search was carried out up to the end of February 2020. Studies were included if they assessed the impact of SMI on nonpsychiatric inpatient, emergency, and primary care service use in adults. Study designs eligible for review included observational cohort and case-control studies and randomised controlled trials. Random-effects meta-analyses of the effect of SMI on inpatient admissions, length of hospital stay, 30-day hospital readmission rates, and emergency department use were performed. This review protocol is registered in PROSPERO (CRD42019119516). Seventy-four studies were eligible for review. All were observational cohort or case-control studies carried out in high-income countries. Sample sizes ranged from 27 to 10,777,210. Study quality was assessed using the Newcastle-Ottawa Scale for observational studies. The majority of studies (n = 45) were deemed to be of good quality. Narrative analysis showed that SMI led to increases in use of inpatient, emergency, and primary care services. Meta-analyses revealed that patients with SMI were more likely to be admitted as nonpsychiatric inpatients (pooled odds ratio [OR] = 1.84, 95% confidence interval [CI] 1.21-2.80, p = 0.005, I2 = 100%), had hospital stays that were increased by 0.59 days (pooled standardised mean difference = 0.59 days, 95% CI 0.36-0.83, p < 0.001, I2 = 100%), were more likely to be readmitted to hospital within 30 days (pooled OR = 1.37, 95% CI 1.28-1.47, p < 0.001, I2 = 83%), and were more likely to attend the emergency department (pooled OR = 1.97, 95% CI 1.41-2.76, p < 0.001, I2 = 99%) compared to patients without SMI. Study limitations include considerable heterogeneity across studies, meaning that results of meta-analyses should be interpreted with caution, and the fact that it was not always possible to determine whether service use outcomes definitively excluded mental health treatment.

CONCLUSIONS

In this study, we found that SMI impacts significantly upon the use of nonpsychiatric health services. Illustrating and quantifying this helps to build a case for and guide the delivery of system-wide integration of mental and physical health services.

The impact of increasing general hospital admissions on Consultation-Liaison Psychiatry

OBJECTIVE

The objective of this study was to identify changes in patients referred to CLP at a typical inner urban teaching hospital over two decades in the context of increased hospital admissions.

METHOD

Multivariate analyses were conducted on data collected for all referrals to CLP at Royal Melbourne Hospital between 1998 and 2017. Analyses were conducted with reason for referral, current psychiatric contact, psychiatric diagnosis, discharge destination and follow up as dependent variables, and the year and annual hospital admissions as independent variables.

RESULTS

Annual hospital admissions grew at a rate (4.6%), greater than the annual increase in beds (2.0%). Psychosis, suicide attempt, past psychiatric history and behaviour became more common reasons for referral, whilst depression and somatisation became less common. Transfers to and from mental health inpatient units increased.

CONCLUSIONS

An increasing proportion of patients seen by CLP have 'acute' problems. Patients with somatisation and depression are seen less frequently. These findings indicate that CLP services need to provide timely assessment and work closely with other elements of the local mental health service in order to optimise patient flow and ensure continuity of care. Local strategies may be required to ensure an adequate breadth of experience for trainees.

Hospital costs associated with post-traumatic stress disorder in somatic patients: a retrospective study

BACKGROUND

Post-traumatic stress disorder is likely to affect clinical courses in the somatic hospital ward when appearing as comorbidity. Thus, this study aimed to assess the costs associated with comorbid post-traumatic stress disorder in a somatic hospital and to analyze if reimbursement appropriately compensated additional costs.

METHODS

The study used data from a German university hospital between 2011 and 2014, analyzing 198,819 inpatient episodes. Inpatient's episodes were included for analysis if they had a somatic primary diagnosis and a secondary diagnosis of post-traumatic stress disorder. Costs were calculated based on resource use and compared to reimbursement. Analyses were adjusted for sex, age and somatic comorbidities.

RESULTS

N = 219 Inpatient's episode were found with primary somatic disorder and a comorbid post-traumatic stress disorder. Inpatients episodes with comorbid post-traumatic stress disorder were compared to 34,229 control episodes, which were hospitalized with the same main diagnosis. Post-traumatic stress disorder was associated with additional hospital costs of €2311 [95%CI €1268 - €3355], while reimbursement rose by €1387 [€563 - €2212]. Results indicate that extra costs associated with post-traumatic stress disorder are not fully reimbursed. Male patients showed higher hospital costs associated with post-traumatic stress disorder. On average, post-traumatic stress disorder was associated with an extra length of stay of 3.4 days [2.1-4.6 days].

CONCLUSION

Costs associated with post-traumatic stress disorder were substantial and exceeded reimbursement, indicating an inadequate reimbursement for somatic patients with comorbid post-traumatic stress disorder.

Depression is independently associated with increased length of stay and readmissions in multimorbid inpatients

BACKGROUND

Little is known about the impact of depression across a broad range of multimorbid patients hospitalized for reasons other than depression. The objective of the study was to investigate in a large sample of multimorbid inpatients whether ancillary depression is associated with increased length of stay (LOS) and readmissions, two important clinical outcomes with implications for healthcare utilization and costs.

METHODS

We retrospectively analyzed a cohort of 253,009 multimorbid inpatients aged ≥18 at an academic medical center, 8/2009-8/2017.

PRIMARY OUTCOME

LOS.

SECONDARY OUTCOMES

LOS related to different main diagnoses, readmissions within 1, 3, 6, 12, and 24-months after discharge.

RESULTS

Multivariable linear regression showed 24% longer LOS in patients with ancillary depression (1.24; 95% confidence interval [CI]: 1.22, 1.25). Females stayed 22% longer (1.22; 95% CI: 1.20, 1.25), males 24% (1.24; 95% CI: 1.22, 1.27). We identified 16 main diagnosis clusters in which ancillary depression was associated with significant LOS increases, with associations being strongest for "Failure and rejection of transplanted organs and tissues", "Other noninfective gastroenteritis and colitis", and "Other soft tissue disorders, not elsewhere classified". Multivariable logistic and Poisson regression showed independent associations of ancillary depression with increased readmission odds and frequencies at 1, 3, 6, 12, and 24 months.

CONCLUSIONS

Ancillary depression was independently associated with increased LOS and more readmissions across a broad range of multimorbid inpatients.

Clinical and functional patient characteristics predict medical needs in older patients at risk of functional decline

Background

The rising number of older multimorbid in-patients has implications for medical care. There is a growing need for the identification of factors predicting the needs of older patients in hospital environments. Our aim was to evaluate the use of clinical and functional patient characteristics for the prediction of medical needs in older hospitalized patients.

Methods

Two hundred forty-two in-patients (57.4% male) aged 78.4 ± 6.4 years, who were consecutively admitted to internal medicine departments of the University Hospital Essen between July 2015 and February 2017, were prospectively enrolled. Patients were assessed upon admission using the Identification of Seniors at Risk (ISAR) screening followed by comprehensive geriatric assessment (CGA). The CGA included standardized instruments for the assessment of activities of daily living (ADL), cognition, mobility, and signs of depression upon admission. In multivariable regressions we evaluated the association of clinical patient characteristics, the ISAR score and CGA results with length of hospital stay, number of nursing hours and receiving physiotherapy as indicators for medical needs. We identified clinical characteristics and risk factors associated with higher medical needs.

Results

The 242 patients spent [median(Q1;Q3)]:9.0(4.0;16.0) days in the hospital, needed 2.0(1.5;2.7) hours of nursing each day, and 34.3% received physiotherapy.

In multivariable regression analyses including clinical patient characteristics, ISAR and CGA domains, the factors age (β = − 0.19, 95% confidence interval (CI) = − 0.66;-0.13), number of admission diagnoses (β = 0.28, 95% CI = 0.16;0.41), ADL impairment (B = 6.66, 95% CI = 3.312;10.01), and signs of depression (B = 6.69, 95% CI = 1.43;11.94) independently predicted length of hospital stay. ADL impairment (B = 1.14, 95%CI = 0.67;1.61), cognition impairment (B = 0.57, 95% CI = 0.07;1.07) and ISAR score (β =0.26, 95% CI = 0.01;0.28) independently predicted nursing hours. The number of admission diagnoses (risk ratio (RR) = 1.06, 95% CI = 1.04;1.08), ADL impairment (RR = 3.54, 95% CI = 2.29;5.47), cognition impairment (RR = 1.77, 95% CI = 1.20;2.62) and signs of depression (RR = 1.99, 95% CI = 1.39;2.85) predicted receiving physiotherapy.

Conclusion

Among older in-patients at risk for functional decline, the number of comorbidities, reduced ADL, cognition impairment and signs of depression are important predictors of length of hospital stay, nursing hours, and receiving physiotherapy during hospital stay.

My Bridge (Mi Puente), a care transitions intervention for Hispanics/Latinos with multimorbidity and behavioral health concerns: protocol for a randomized controlled trial

Background

Multimorbidity affects four of ten US adults and eight of ten adults ages 65 years and older, and frequently includes both cardiometabolic conditions and behavioral health concerns. Hispanics/Latinos (hereafter, Latinos) and other ethnic minorities are more vulnerable to these conditions, and face structural, social, and cultural barriers to obtaining quality physical and behavioral healthcare. We report the protocol for a randomized controlled trial that will compare Mi Puente (My Bridge), a cost-efficient care transitions intervention conducted by a specially trained Behavioral Health Nurse and Volunteer Community Mentor team, to usual care or best-practice discharge approaches, in reducing hospital utilization and improving patient reported outcomes in Latino adults with multiple cardiometabolic conditions and behavioral health concerns. The study will examine the degree to which Mi Puente produces superior reductions in hospital utilization at 30 and 180 days (primary aim) and better patient-reported outcomes (quality of life/physical health; barriers to healthcare; engagement with outpatient care; patient activation; resources for chronic disease management), and will examine the cost effectiveness of the Mi Puente intervention relative to usual care.

Methods

Participants are enrolled as inpatients at a South San Diego safety net hospital, using information from electronic medical records and in-person screenings. After providing written informed consent and completing self-report assessments, participants randomized to usual care receive best-practice discharge processes, which include educational materials, assistance with outpatient appointments, referrals to community-based providers, and other assistance (e.g., with billing, insurance) as required. Those randomized to Mi Puente receive usual-care materials and processes, along with inpatient visits and up to 4 weeks of follow-up phone calls from the intervention team to address their integrated physical-behavioral health needs and support the transition to outpatient care.

Discussion

The Mi Puente Behavioral Health Nurse and Volunteer Community Mentor team intervention is proposed as a cost-effective and culturally appropriate care transitions intervention for Latinos with multimorbidity and behavioral health concerns. If shown to be effective, close linkages with outpatient healthcare and community organizations will help maximize uptake, dissemination, and scaling of the Mi Puente intervention.

Trial registration

ClinicalTrials.gov: NCT02723019. Registered on 30 March 2016.

Medical comorbid diagnoses among adult psychiatric inpatients

OBJECTIVE

Shortened life expectancy of people with mental disorders has been attributed to medical comorbidities, yet these conditions remain under-recognized and under-treated. This study characterizes the medical demands placed on inpatient psychiatric units to help guide medical assessment and management practices in these settings.

METHODS

Medicaid claims records and clinician data were linked with hospital and regional data for individuals with a principal diagnosis of any mental disorder admitted to psychiatric inpatient units in New York State from 2012 to 2013. A modified Elixhauser Comorbidity Index (ECI) score was calculated for each unique individual (n = 14,458). Adjusted odds ratios (AORs) of having a medical comorbidity were calculated using logistic regression analyses.

RESULTS

74.9% of psychiatric inpatients had at least one medical comorbidity, including 57.5% of people ages 18-24. Higher rates of medical comorbidity were associated with older age, female gender, non-schizophrenia diagnoses, and engagement in care prior to hospitalization. Patients with medical comorbidities had lower odds (AOR 0.54; 99% CI 0.35-0.83) of being treated in hospitals with 100 or more total beds compared to smaller hospitals.

CONCLUSIONS

A high prevalence of common medical diagnoses among psychiatric inpatients underscores the importance of adequate detection and medical treatment of medical comorbidities in psychiatric inpatient settings.

Improving Depression Management in Patients with Medical Illness Using Collaborative Care: Linking Treatment from the Inpatient to the Outpatient Setting

Objective: This paper sought to review the impact of depression in patients with comorbid medical problems, the importance of bridging the gap between inpatient and outpatient care for medical inpatients with depression (especially for organizations that treat patients in both settings), and the elements necessary to implement a pilot for an outpatient Collaborative Care Management program for patients with depression following medical admissions. Taken into account is the presence of new billing mechanisms and potential cost offsets. Methods: The literature referenced in this paper was identified through a search of online databases, including PubMed and Google Scholar. The data used to analyze cost were drawn from national, publicly available sources, such as the Kaiser Family Foundation, Bureau of Labor Statistics, and the Organisation for Economic Cooperation and Development. Results: Collaborative care is an evidence-based intervention for depression that can aid with successful transition of care as patients move from the inpatient to the outpatient setting. It can be considered cost-effective when treating a panel of patients that falls below the recommended caseload for a single case manager (i.e., 19-46 billed encounters, depending on the payer mix), particularly when considering the savings from a reduced length of stay associated with well-controlled depressive symptoms. Conclusion: Organizations should consider implementing collaborative care management for patients with depression to improve depression outcomes, reduce costs, and prepare themselves for a health financing environment that rewards value.

Association of voice and mental health diagnoses with differences in voice-related care utilization

OBJECTIVE

To compare healthcare utilization in voice patients with versus without mental health (MH) diagnoses STUDY DESIGN: Retrospective study using electronic medical records from large regional healthcare system.

METHODS

We examined data on sociodemographic characteristics, comorbidities, voice-related diagnoses, and patterns of healthcare utilization (including medication use, tests and procedures, and outpatient visits). The study period spanned January 2005 through June 2017.

RESULTS

A total of 24,672 patients had at least one voice-related diagnosis. Of these, 11,483 (47%) also had at least one MH diagnosis compared to 14% in the overall repository (P < 0.0001). The most common voice-related diagnoses were nonspecific dysphonia (80%), acute laryngitis (30%), and vocal fold paresis/paralysis (7%). The 11,483 patients with both voice-related and MH diagnoses were more likely to have acute laryngitis and/or nonspecific dysphonia; less likely to have laryngeal cancer and/or paresis/paralysis; and more likely to have seen a primary care provider, to have received medications, and to have undergone radiology studies. In contrast, the 13,189 patients with only voice-related diagnoses had more overall voice-related visits, were more likely to have seen an otolaryngologist, and were more likely to have undergone a voice evaluation with a speech language pathologist.

CONCLUSION

Voice patients with MH diagnoses were less likely to see otolaryngology and more likely to have radiology studies than voice patients without MH diagnoses. Further study is warranted to characterize temporal sequences of care in this group of patients and determine whether these differences are attributable to referral patterns from primary care.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1496-1502, 2020.

An evaluation of proactive psychiatric consults on general medical units

OBJECTIVE

Recent studies have shown an association between proactive psychiatric consultation on medical units and shorter length of stay. The aim of this study was to assess the impact of implementing a proactive psychiatric consult service on general medical units in an urban teaching hospital on length of stay and qualitative measurement of satisfaction of adequacy of psychiatric services.

METHODS

Bivariate and multivariate analyses of demographic, clinical and outcome data were performed comparing patients seen by the proactive psychiatric consult team, patients seen contemporaneously on other general medical units by a traditional, reactive consult team and patients seen the prior year on the proactive intervention units by the reactive consult team. Length of stay was the primary outcome examined. Regression modeling was performed to assess further the relationship of length of stay with the three groups. Nursing and physician staff were queried before and after intervention regarding satisfaction with psychiatric resources on the intervention units.

RESULTS

Patients seen by the proactive team had shorter length of stay than those seen by contemporaneous reactive consult team (p = 0.005) or the prior year by the reactive team on the intervention units (p = 0.005). There was no significant difference between the latter two groups. Time to consult was also shorter for patients seen through the proactive model than the reactive model on other units at the same time (0.01) or the preceding year (<0.001). Nursing and physician satisfaction with psychiatric help increased significantly in three of four measures.

CONCLUSIONS

Proactive psychiatric consultation in our study correlated with shorter time to consult, shorter length of stay, and improved staff satisfaction compared to a reactive consult model.

Utilization of somatic healthcare in Croatian patients with schizophrenia spectrum disorder, major depression, PTSD and the general population

BACKGROUND

Utilization of somatic healthcare services is highly predictive of the development of chronic physical illnesses and increased mortality risks. The objective of this study was to assess the differences in healthcare utilization among patients with schizophrenia spectrum disorders (SSD), major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) and the general population in Croatia.

METHODS

We enrolled 566 Croatian participants from the general population, 282 with SSD, 178 with MDD, and 86 with PTSD. The primary outcome was a self-reported specialist consultation for non-psychiatric (e.g., somatic) causes within the previous 12 months.

RESULTS

Although SSD patients with chronic physical illnesses were significantly more often hospitalized for physical illness than the general population, the proportion of patients who had a specialist consultation were equal in SSD and the general population. MDD and PTSD patients had significantly higher adjusted odds for specialist consultation than the general population and SSD patients (MDD compared to SSD: OR = 2.14; 95% CI 1.27-3.59; PTSD compared to SSD: OR = 2.03; 95% CI 1.00-4.10).

CONCLUSIONS

SSD patients' utilization of somatic healthcare is equal to the general population, despite their increased healthcare needs. However, their utilization is lower than in MDD and PTSD patients and, therefore, probably not adequate.

TRIAL REGISTRATION

The study protocol was registered at ClinicalTrials.gov ( NCT02773108 ) on May 16, 2016.

Suicide attempts by jumping and length of stay in general hospital: A retrospective study of 225 patients

OBJECTIVE

Violent suicide attempts, such as jumping from a height, frequently lead to hospitalization in general hospital with high length of stay (LOS). We investigated features associated with LOS in this context.

METHODS

We retrospectively included all patients admitted after suicide attempts by jumping in non-psychiatric wards of a university hospital between 2008 and 2016. Several socio-demographic and clinical data were collected, including psychiatric diagnoses, coded with the International Classification of Diseases-10th Revision. We used general linear models to identify factors associated with LOS.

RESULTS

Among 225 patients (125 men; mean age ± sd: 37.5 ± 15.4 years), several clinical factors were independently associated with a longer LOS: number of injuries (β = 8.2 p < .001), external fixator (β = 18.1 p = .01), psychotic disorder (β = 14.6 p = .02) and delirium (β = 16.6 p = .005). Admission in psychiatric ward at discharge tended to be associated with lower LOS (β = -15.3 p = .07).

CONCLUSION

In patients admitted in non-psychiatric wards after suicide attempt by jumping, the presence of a psychotic disorder may increase LOS by several days, and indirectly costs of hospitalization, to a similar extent of non-psychiatric factors. The association of transfer in psychiatric ward with lower LOS suggests that the psychiatric disorder might interfere with medical care.

Therapeutic Approaches for NOP Receptor Antagonists in Neurobehavioral Disorders: Clinical Studies in Major Depressive Disorder and Alcohol Use Disorder with BTRX-246040 (LY2940094)

Conventional antidepressants increase the efflux of biogenic amine neurotransmitters (the monoamine hypothesis of depression) in the central nervous system (CNS) and are the principle drugs used to treat major depressive disorder (MDD). However, the lack of efficacy in some patients, the slow onset of action, and the side effect profiles of existing antidepressants necessitate the exploration of additional treatment options. The discovery of the nociceptin/orphanin FQ peptide NOP receptor (N/OFQ-NOP receptor) system and its characterization in preclinical biological and pharmacological stress-related conditions supports the potential antidepressant and anti-stress properties of a NOP receptor antagonist for the treatment of neurobehavioral disorders. BTRX-246040 (formerly LY2940094) was designed to test this hypothesis in the clinic. A small clinical proof of concept study demonstrated efficacy of BTRX-246040 in MDD patients. In this study, BTRX-246040 (40 mg, p.o.) significantly reduced negative bias as assessed by the facial recognition test within 1 week of treatment and decreased depression symptoms after 8 weeks. BTRX-246040 also reduced depression symptoms in a second trial with heavy alcohol drinkers. Given the comorbidity of MDD and alcohol use disorder, a compound with such effects in patients could be a valuable addition to the medications available. A proof of concept study showed efficacy of BTRX-246040 in reducing heavy drinking and increasing the probability of abstinence in individuals diagnosed with alcohol dependence. In addition, plasma levels of gamma-glutamyl transferase were decreased by BTRX-246040 compared to placebo control implying improvement in liver function. Collectively, the clinical data reviewed within this chapter suggest that BTRX-264040 functions to normalize dysfunction in reward circuits. The overall efficacy and safety of this compound with a novel mechanism of action are encouraging of further clinical development. BTRX-246040 is currently under development for MDD by BlackThorn Therapeutics.

Towards integrated medical and mental healthcare in the inpatient setting: what is the role of psychology?

Integrated medical and psychiatric hospital units hold great promise for improving the value and quality of care for patients with severe mental illness and concomitant acute medical needs. It is important to explore the utility of providing a range of multidisciplinary inpatient services to meet patients' complex needs. Within this context, services typically provided by psychologists have received little research attention. To address this gap in the literature, this study assessed inpatient clinicians' perceptions of the need for specific behavioural services on a medical psychiatric unit, exploring their overlap with established psychological services. Results indicate the potential utility of specific psychological services, including psychological assessments, direct psychosocial interventions, and psychoeducational training. While reimbursement and billing barriers still exist for psychologists to be routinely incorporated into hospital settings, the movement towards value-based care could provide the opportunity to think about the value added. Embedding evidence-based psychological services has the potential to promote high quality, well-rounded care that aligns with the established mission of multidisciplinary teamwork on integrated medical and psychiatric inpatient units.