Cost analysis of inpatient treatment of anorexia nervosa in adolescents: hospital and caregiver perspectives

Improvements in Adolescents' Disordered Eating Behaviors in a Collaborative Care Digital Mental Health Intervention: Retrospective Observational Study

BACKGROUND

Young people today are exhibiting increasing rates of disordered eating behaviors, as well as eating disorders (EDs), alongside other mental and behavioral problems such as anxiety and depression. However, limited access to mental health care means that EDs, disordered eating behaviors, and comorbid mental health problems are often underdiagnosed and undertreated. Digital mental health interventions (DMHIs) offer accessible and scalable alternatives to traditional treatment modalities, but their effectiveness has not been well established among adolescents with EDs and disordered eating behaviors.

OBJECTIVE

This study uses data from a collaborative care pediatric DMHI to determine whether participation in a DMHI is associated with a reduction in adolescents' disordered eating behaviors.

METHODS

Adolescent members in care with Bend Health Inc completed the SCOFF questionnaire at baseline (before the start of care) and approximately every month during care to assess disordered eating behaviors. They also completed assessments of mental health symptoms at baseline. Member characteristics, mental health symptoms, and disordered eating behaviors of adolescents with elevated SCOFF scores at baseline (before the start of care) were compared to those of adolescents with nonelevated SCOFF scores at baseline. Members participated in web-based coaching or therapy sessions throughout the duration of mental health care.

RESULTS

Compared to adolescents with nonelevated SCOFF scores (n=520), adolescents with elevated SCOFF scores (n=169) were predominantly female and exhibited higher rates of elevated anxiety and depressive symptoms. SCOFF scores decreased over time in care with the DMHI for 61.4% (n=70) of adolescents with elevated SCOFF scores, and each additional month of participation was associated with greater improvements in disordered eating behaviors (F1,233=72.82; P<.001).

CONCLUSIONS

Our findings offer promising preliminary evidence that participation in mental health care with a collaborative care DMHI may be beneficial in the reduction of disordered eating symptoms in adolescents, including those who are experiencing comorbid anxiety and depressive symptoms.

Methods used to account for caregivers' sex and gender within studies examining the financial burden of caregivers of children and adolescents : Results from a scoping review

Background

Interest in the financial burden of informal caregivers has been growing. Unfortunately, it remains unclear which method(s) should be used when quantifying this burden.

Purpose

We conducted a scoping review aimed at identifying which methods have been used to conduct such work and quantified their performance. We were also interested in examining how sex and gender considerations were considered within selected studies.

Data Sources

Using a standardized approach, we identified studies published between 2012 and 2022 that aimed to document the financial burden of caregivers to child and adolescent patients. Our search strategy was applied to the MEDLINE, Embase, CINHAL, and Academic Search Premier databases.

Study Selection

Manuscript selection was performed by pairs of reviewers.

Data Extraction

Data extraction was performed by one reviewer with a second reviewer performing quality control. Results were reported using a narrative approach.

Data Synthesis

We identified 9801 unique citations, of which 200 were included in our review. Selected studies covered various disease area (eg, infection/parasitic diseases [n = 31, 16%]) and included quantitative (n = 180, 90%), qualitative (n = 4, 2%) and mixed study designs (n = 16, 8%). Most studies (n = 182, 91%) used questionnaires/surveys, either alone or in combination with other methods, to assess caregivers' financial burden. Less than half (n = 93, 47%) of studies reported on caregivers' sex and none reported on their gender.

Conclusion

We conducted an unrestricted review of published studies examining caregiver's financial burden which allowed us to identify general methodological trends observed in this literature. We believe this work may help improve future studies focusing on this important issue.

Distance to home does not influence treatment success during and after inpatient treatment in adolescents with anorexia nervosa

Current treatment guidelines recommend that inpatients with eating disorders-particularly adolescents with anorexia nervosa-should receive treatment at facilities within close distance to their home. However, whether distance to home actually influences short- and long-term treatment outcome in adolescents with anorexia nervosa has not been investigated yet. We re-analyzed data at admission, discharge, and 1-year follow up from a recent study with N = 142 female, adolescent inpatients with anorexia nervosa. Distance to home did not moderate changes in body weight, eating disorder symptoms, depressive symptoms, compulsive exercise, and life satisfaction. This is the first analysis that indicates that specialized inpatient treatment for adolescents with anorexia nervosa is effective both close to and away from home.

Pediatric Patients Hospitalized With Eating Disorders in Ontario, Canada, Over Time

Importance

Understanding the evolving characteristics of pediatric patients hospitalized for eating disorders is important to ensure that services and treatments align with patient needs.

Objective

To examine temporal trends in the rates of hospitalizations for pediatric eating disorders by clinical and demographic characteristics in Ontario, Canada, over a 17-year period.

Design, Setting, and Participants

This population-based, repeated, cross-sectional study used linked health administrative and demographic databases in Ontario, Canada, to identify individuals aged 5 to 17 years hospitalized with eating disorder diagnoses from April 1, 2002, to March 31, 2020. Data analyses were performed from May 2021 to June 2023.

Exposure

Fiscal year (April 1-March 31) of eating disorder hospitalization.

Main Outcomes and Measures

Outcomes of interest were absolute and relative changes in pediatric eating disorder hospitalization rates overall and stratified by patient sex, age groups, and eating disorder diagnostic groups.

Results

Over the study period, there were 11 654 pediatric eating disorder hospitalizations, of which 5268 (45.2%) were for anorexia nervosa and 1374 (11.8%) were for bulimia nervosa. There were a total of 10 648 hospitalizations (91.4%) among female patients, and the median (IQR) age was 15.0 (14-0-16.0) years. Hospitalization rates increased 139% from 2002 to 2019, from 2.0 per 10 000 population to 4.8 per 10 000 population. The largest relative changes were observed among male patients (416%; from 0.2 per 10 000 population to 1.1 per 10 000 population), individuals aged 12 to 14 years (196%; from 2.2 per 10 000 population to 6.6 per 10 000 population), and individuals with eating disorders other than anorexia or bulimia nervosa (255%; from 0.6 per 10 000 population to 2.1 per 10 000 population). Male patients, younger adolescents, and individuals with other eating disorders also represented larger proportions of hospitalizations by fiscal 2019.

Conclusions and Relevance

In this cross-sectional study of eating disorder hospitalizations, pediatric hospitalizations increased over time, particularly among populations traditionally considered atypical. Existing eating disorder programs must adapt to accommodate changing patient presentations and increased volumes to ensure effective care delivery.

Inpatient Treatment Outcome in a Large Sample of Adolescents with Anorexia Nervosa

Anorexia nervosa is an illness affecting primarily adolescent girls and young women. Clinical guidelines recommend early intervention, with inpatient treatment for more severe cases. We present an evaluation of a multi-modal cognitive-behavioral inpatient treatment (CBT-E) involving carers in specialized units for adolescents. Routine data of 962 adolescent inpatients (26 boys) (mean age 15.48 [1.26]; range 12-17 years) were analyzed. Predictors of good body weight outcome (achieving a discharge BMI of at least 18.5 kg/m2) were identified by logistic regression analysis. Mean inpatient treatment lasted 96.69 (45.96) days. The BMI increased significantly from 14.93 (1.38) kg/m2 at admission to 17.53 (1.58) kg/m2 at discharge (z = 26.41; p < 0.001; d = 1.708). Drive for thinness decreased from 29.08 (9.87) to 22.63 (9.77; z = 18.41; p < 0.001; d = 0.787). All other subscores of the Eating Disorder Inventory also decreased significantly, with small to medium effect sizes. General psychopathology also showed significant decreases. The Beck Depression Inventory-II score decreased from 26.06 (11.74) to 16.35 (12.51; z = 18.41; p < 0.001; d = 0.883). A good body weight outcome was predicted by a higher BMI at admission (OR = 1.828), age at onset at 15 years or higher (OR = 1.722), and higher Somatization (OR = 1.436), Anxiety (OR = 1.320), and Bulimia (OR = 1.029) scores. CBT-E involving carers is an efficient intervention for adolescents with anorexia nervosa.

Intensive community and home-based treatments for eating disorders: a scoping review study protocol

INTRODUCTION

Institutionally based intensive treatment modalities (inpatient, day patient and residential treatments) for eating disorders (EDs) are associated with high treatment costs and significant challenges for patients and carers, including access difficulties and disruption to daily routines. Intensive community and home-based treatments have been suggested as alternatives to institutionally based intensive treatments for other severe mental illnesses, with promising clinical, social and health economic outcomes. The possible advantages of these treatments have been proposed for EDs, but this emerging area of research has not yet been systematically investigated. This scoping review aims to map the available literature on intensive community and home treatments for EDs, focusing on their conceptualisation, implementation and clinical outcomes.

METHODS

This proposed scoping review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol extension for Scoping Reviews checklist and the Joanna Briggs Institute Reviewer's Manual. This review will include any peer-reviewed study concerning intensive community and home-based treatments for any EDs, with no restrictions on geographical context or study design. Grey literature will also be considered. The literature search will be conducted in four databases: PubMed, PsycInfo, MEDLINE and Web of Science. Two researchers will independently screen the titles, abstracts and text of the returned articles for eligibility. Data charting and analysis will consist of a narrative description of the included studies, quantitative and qualitative findings relative to the aims of this scoping review. Gaps in the literature will be highlighted to inform future research, clinical practice, and policy.

ETHICS AND DISSEMINATION

Ethical approval is not required as all data are available from public sources. The results of this scoping review will be disseminated through peer-reviewed publication, conference presentation, and social media.

Research in eating disorders: the misunderstanding of supposing serious mental illnesses as a niche specialty

PURPOSE

Eating disorders (EDs) are mental illnesses with severe consequences and high mortality rates. Notwithstanding, EDs are considered a niche specialty making it often difficult for researchers to publish in high-impact journals. Subsequently, research on EDs receives less funding than other fields of psychiatry potentially slowing treatment progress. This study aimed to compare research vitality between EDs and schizophrenia focusing on: number and type of publications; top-cited articles; geographical distribution of top-ten publishing countries; journal distribution of scientific production as measured by bibliometric analysis; funded research and collaborations.

METHODS

We used the Scopus database, then we adopted the Bibliometrix R-package software with the web interface app Biblioshiny. We included in the analyses 1,916 papers on EDs and 6491 on schizophrenia.

RESULTS

The ED field published three times less than schizophrenia in top-ranking journals - with letters and notes particularly lacking-notwithstanding a comparable number of papers published per author. Only 50% of top-cited articles focused on EDs and a smaller pool of journals available for ED research (i.e., Zones 1 and 2 according to Bradford's law) emerged; journals publishing on EDs showed an overall lower rank compared to the schizophrenia field. Schizophrenia research was more geographically distributed and more funded; in contrast, a comparable collaboration index was found between the fields.

CONCLUSION

These data show that research on EDs is currently marginalized and top-rank journals are seldom achievable by researchers in EDs. Such difficulties in research dissemination entail potentially serious repercussions on clinical advancements.

LEVEL OF EVIDENCE

Level V: opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

An experimental protocol for a double-blind placebo-controlled evaluation of the effectiveness of oral naltrexone in management of adolescent eating disorders

BACKGROUND

This double-blind, placebo-controlled study evaluates the effectiveness of oral naltrexone in adolescents and young adults with eating disorders (EDs) characterized by purging with or without binge-eating behaviors. We hypothesize that participants receiving oral naltrexone will demonstrate greater improvements in body mass index in underweight participants and self-reported ED symptomatology compared to placebo.

METHODS

Thirty individuals receiving treatment in a partial hospitalization program for EDs with diagnoses of anorexia nervosa binge-eating/purging type, bulimia nervosa, or purging disorder will receive six weeks of either placebo or oral naltrexone. Participants will complete a battery of self-report measures and laboratory safety monitoring every three weeks in addition to standard of medical care for treatment environment.

RESULTS

Analysis will compare outcomes at weeks three and six, and follow-up at nine weeks and six-months across the oral naltrexone and placebo groups. Main effects for time will examine improvements over the course of treatment for all participants, while group × time interactions will examine differences in the rate of change over time between study arms.

CONCLUSIONS

We hypothesize that participants receiving oral naltrexone will experience more rapid improvements in symptom severity and weight restoration compared to placebo across study time points. There are very few medications with high-quality data demonstrating both safety and efficacy in the treatment of eating disorders. The authors theorize this study will demonstrate a clinically significant effect of oral naltrexone on impulsive-type EDs and support its use as an effective option for treatment augmentation.

A retrospective cohort study examining health care utilization patterns in individuals diagnosed with an eating disorder in childhood and/or adolescence

OBJECTIVE

This study examined a 2-year period following an eating disorder (ED) diagnosis in order to determine patterns of health care utilization.

METHOD

We conducted a retrospective cohort study of children (n = 1560) diagnosed with an ED between 2000 and 2017. The ED diagnosis was made at a tertiary level hospital for children and adolescents presenting for outpatient assessment by specialist adolescent medicine physicians and recorded in a program database over this period of time. We then created three sex- and age-matched comparison cohorts using provincial health administrative databases including: a general population cohort, a diabetes cohort (to compare nonmental health care utilization) and a mood disorder cohort (to compare mental health care utilization). Outcomes included hospitalizations, emergency department visits, as well as general practitioner, psychiatrist, and pediatrician visits. Odds ratios (dichotomous outcomes) and rate ratios (continuous outcomes) were calculated.

RESULTS

Compared to the general population cohort, the ED cohort had higher odds and rates of all types of health care utilization. Compared to the diabetes cohort, the ED cohort had higher odds of nonmental health-related admissions (OR 1.45, 95% CI 1.09-1.95) and higher rates of nonmental health-related emergency department visits (RR 1.59, 95% CI 1.18-2.13). Compared to the mood disorder cohort, the ED cohort had higher rates of pediatrician visits, which were mental health-related (RR 14.88, 95% CI 10.64-20.82), however most other types of mental health service utilization were lower.

DISCUSSION

These patterns indicate that the service needs of young people diagnosed with EDs are higher than those with diabetes with respect to nonmental health admissions and emergency department visits, while in terms of mental health service utilization, there appears to be a lack of use of mental health services compared to youth with mood disorders with the exception of pediatrician mental health visits. These findings must be interpreted in the context of under-detection and under-treatment of EDs.

PUBLIC SIGNIFICANCE STATEMENT

Our study found that the health service needs of young people with EDs are higher than those with diabetes with respect to admissions and emergency department visits, while there appears to be a lack of use of mental health services compared to youth with mood disorders with the exception of pediatrician mental health visits.

The Impact of Inpatient Multimodal Treatment or Family-Based Treatment on Six-Month Weight Outcomes in Youth with Anorexia Nervosa: A Naturalistic, Cross-Continental Comparison

In the USA, family-based treatment (FBT) with inpatient medical stabilization as needed is the leading evidence-based treatment for youth with anorexia nervosa (AN). In continental Europe, typically inpatient multimodal treatment targeting weight recovery followed by outpatient care (IMT) is standard care, if prior outpatient treatment was not sufficient. Our aim was to compare weekly weight gain and hospital days over six months for adolescents receiving FBT (USA) versus IMT (Germany) using naturalistic treatment data. To yield similar subgroups of youth aged 12−18 years, inclusion criteria were a percent median BMI (%mBMI) between 70−85 and the restrictive AN subtype. Weight gain and hospital days were compared, adjusted further in a multiple linear regression analysis (MLRA) for baseline group differences. Samples differed on baseline %mBMI (FBT [n = 71], 90.5 ± 12.8; IMT [n = 29], 78.3 ± 9.1, p < 0.05). In subgroups with comparable baseline %mBMI, the weekly weight gain over 6 months was similar (FBT [n = 21]: 0.35 ± 0.18 kg/week; IMT [n = 20]: 0.30 ± 0.18, p = 0.390, p = 0.166 after MLRA), but achieved fewer hospital days in FBT (FBT [n = 7]: 4 ± 6 days, IMT [n = 20]: 121 ± 42 days, p < 0.0001 before and after MLRA). FBT may be effective for a subgroup of adolescents with AN currently receiving IMT, but head-to-head studies in the same healthcare system are needed.

Gender-related differences in health-care and economic costs for eating disorders: A comparative cost-development analysis for anorexia and bulimia nervosa based on anonymized claims data

OBJECTIVE

Anorexia nervosa (AN) and bulimia nervosa (BN) impose a significant financial burden and immense sufferings on affected individuals. Yet little is known about the differences between how each disorder affects males and females, respectively.

METHOD

We performed a retrospective cost-development analysis of anonymized claims data from the German statutory health-insurance system. Insured persons who suffered from an onset of AN (F50.0; N = 1,242 females and 71 males) or BN (F50.2; N = 1,104 females and 64 males) were analyzed for cost-of-illness over a 5-year period, beginning 2 years before the index diagnosis.

RESULTS

In total, all groups incurred similar distributions of total costs over the 5-year observation period, with roughly 14,000-20,000 EUR median costs. About two-thirds of the total costs for females and males with AN are associated with mental illness, whereas for females and males with BN, this applies to approximately half the total costs. Analyses revealed differences between disorders and genders for single outcomes. AN is associated with a stronger increase in costs within a short period following onset and higher inpatient treatment costs, whereas BN entails more instances of incapacity to work before and after onset. Compared to females, males incurred lower costs in outpatient treatments.

DISCUSSION

Our study adds evidence as to the disparities in health-care utilizations and costs over the course of illness, in outcome ratios, and between genders, for both AN and BN.

Impact of caloric prescriptions and degree of malnutrition on incidence of refeeding syndrome and clinical outcomes in patients with eating disorders: A retrospective review

BACKGROUND

For individuals with eating disorders (EDs), medical stabilization is paramount for restoration of body weight. Careful nutritional rehabilitation minimizes risk of refeeding syndrome. Study's purpose: describe clinical outcomes of pediatric/adolescent patients with EDs treated with lower calorie (<1300 kcals/day, n = 137), higher calorie (≥1400 kcals/day, n = 154) diets.

METHODS

Retrospective chart reviews conducted for patients with known/suspected EDs. Inclusion: patients ages 12-21 years with anorexia nervosa (AN), bulimia nervosa (BN), eating disorder not otherwise specified (EDNOS), atypical anorexia nervosa (AtAN). Exclusion: patients with other EDs, co-morbid medical conditions. Demographic information, length of stay, anthropometrics, prior weight loss were recorded. Malnutrition classifications based on: %mBMI, BMI z-score, prior weight loss percentage. Laboratory data, electrolyte supplementations were collected. Initial calorie intake/calorie intake day 7 were recorded.

RESULTS

No significant differences in age, admit weight, BMI, BMI z-score, %mBMI at admission, weight gain between the two groups. Six (4.4%) patients in lower calorie group, 4 (2.6%) in higher calorie group met criteria for severe refeeding syndrome based on ASPEN consensus recommendations (P = .52). Higher calorie group length of stay was significantly shorter than lower calorie group (P = .006). Shorter length of stay associated with increased calorie intake (P < .001), greater %mBMI (P < .001). Higher calorie prescriptions were not associated with different rates of hypomagnesia (P = 1) and hypokalemia (P = .34). There was significant increase in rate of hypophosphatemia in the lower calorie group versus the higher calorie group.

CONCLUSION

Higher calorie diets were associated with decreased length of stay without impacting risk of refeeding syndrome.

Family-based inpatient treatment for adolescent anorexia nervosa: a thematic analysis of former patients' post-treatment reflections

This study investigated former patients' experiences with family-based inpatient treatment. Interviews of thirty-seven patients diagnosed with anorexia nervosa during the admissions were conducted to examine their post-treatment perspectives. The accounts were analyzed by utilizing an inductive thematic analytic approach. The analysis yielded 4 main themes, constituted by in all 8 subthemes. The main themes were; 1) Enabling new ways of understanding and relating, 2) Enhancing or maintaining negative power dynamics, 3) Vulnerable transitions, and 4) Sibling relationships and different ways of involvement. With its "insider focus," this study contributes to knowledge on how family-based inpatient treatment is perceived from a user perspective. The current study has value for both advancing the development of family-based inpatient treatment, and by adding patient perspectives to the ongoing effort of providing family-based approaches at higher levels of care.

Restrictive Eating Disorders: Accelerating Treatment Outcomes in the Medical Hospital

Pediatric patients with anorexia nervosa and atypical anorexia nervosa may present to hospitals with significant vital sign instability or serum laboratory abnormalities necessitating inpatient medical hospitalization. These patients require specialized care, numerous resources, and interdisciplinary collaboration during what can be a protracted admission. Recent evidence informs areas in which care can be accelerated, and published protocols from major children's hospitals are helpful roadmaps to creating a streamlined hospitalization. In our narrative review, we focused on 3 key areas: (1) implementation of a rapid nutritional rehabilitation program; (2) assessment and management of the refeeding syndrome; and (3) early integration of psychoeducation and therapeutic interventions during inpatient hospitalization. A practical review of the literature in these 3 areas will give concrete, actionable information to pediatric hospitalists as they care for young people with restrictive eating disorders.

The economic cost of bulimia nervosa and binge eating disorder: a population-based study

BACKGROUND

The most common eating disorders (EDs) are bulimia nervosa (BN) and binge eating disorder (BED), serious psychiatric illnesses that have devastating effects on the physical and psychological wellbeing of sufferers. EDs range in complexity and severity but can be life-threatening without appropriate treatment. Although it is well-known that quality of life impacts is high for ED sufferers, research regarding fiscal and related costs is severely limited. The aim of this study was to understand economic and other costs of EDs at the community level.

METHOD

Data were derived from 2017 household community representative structured interview of 2977 people aged ⩾ 15 years in South Australia. ED diagnoses, health systems, productivity, transaction, out-of-pocket expenses and other related costs of BN and BED were used to estimate the economic burden of EDs in South Australia.

RESULTS

The annual total economic cost of EDs in 2018 was estimated at $84 billion for South Australia. This included $81 billion from the burden of disease as the result of years lived with disability (YLD) ($62 billion) and years of life lost ($19 billion). The health system costs, productivity and tax revenue loss to the Australian economy were estimated at $1 billion, $1.6 billion and $0.6 billion, respectively.

CONCLUSIONS

The YLD average cost in 2018 in South Australia was $296 649 per person. This is two-thirds of the costs borne by individuals and the wider economy. Prevention and management initiatives for EDs need to take into account these costs when assessing their potential benefits.

Integrating Family-Based Treatment Principles in the Acute Inpatient Treatment of Adolescents with Restrictive Eating Disorders

Eating disorders (ED) are serious psychiatric illnesses with one of the highest mortality rate of any psychiatric disorder. The health sequelae of eating disorders are one of the most common causes of medical hospitalizations at freestanding pediatric hospitals in the United States. The economic impact of EDs on health systems and families is substantial. The Society for Adolescent Medicine (SAHM) recommends family-based treatment (FBT) as the first-line approach for adolescents with restrictive eating disorders due to a large body of evidence demonstrating the treatment's efficacy and cost effectiveness. Although FBT was originally developed as an outpatient treatment, the tenets and principles of the treatment have also been used in higher levels of care. This brief report discusses how components of FBT were adapted for a medical inpatient unit at a pediatric hospital in order to integrate empirically based treatment.

A peer interview qualitative study exploring support for carers of people with comorbid autism and eating disorders

BACKGROUND

Carers of people with eating disorders (EDs) are known to experience a lack of support, high levels of unmet needs and resulting distress. Specific support and interventions for carers may benefit both the carer, and their loved one with an ED. Individuals with co-occurring autism and EDs may present with additional needs and difficulties relating to their Autism Spectrum Condition (ASC) that impact their carers. However, there is a lack of research exploring whether carers of people with ASC and EDs have specific support needs, and what kinds of support may be most beneficial for this population.

METHODS

This study used a qualitative interview design, utilising peer interviews. Eleven carers participated in interviews about their experiences as a carer, and their views on existing support systems and potential improvements. As the study took place during the initial UK coronavirus lockdown, the impact of the lockdown also emerged as a topic during the interviews. Interviews were transcribed and analysed using thematic analysis.

RESULTS

Five themes were identified: challenges associated with co-occurring Autism and EDs, a lack of existing support for carers from healthcare services, the personal impact of caring for someone with both ASC and EDs, ideas for how carers can be best supported, and the impact of the coronavirus on carers.

CONCLUSIONS

Carers of loved ones with both ASC and EDs described the experience as having a significant personal impact on their lives, but also experienced a lack of support from healthcare services. There was a perception that caring for someone with both an ASC and EDs presents additional challenges compared to caring for someone with an ED only, and that this population therefore requires specialised support. Recommendations for possible support options, and for further research, are outlined.

Length of stay for anorexia nervosa: Systematic review and meta-analysis

OBJECTIVE

Evidence regarding global trends in length of stay for patients with anorexia nervosa is limited. The aim of this study is to conduct a meta-analysis examining the length of stay for anorexia nervosa patients globally, and to investigate moderators of the variance.

METHOD

Medline, EMBASE and PsycINFO were searched for studies published up to January 2019. Two independent reviewers assessed the eligibility of each report based on predefined inclusion criteria. A meta-analysis was performed to calculate a pooled mean length of stay using the random-effects model. Subgroup analyses and meta-regression were conducted to explore potential sources of heterogeneity between studies.

RESULTS

Of 305 abstracts reviewed, 71 studies met the inclusion criteria, generating 111 datasets. The pooled mean length of stay (95% confidence interval) was 76.3 days (73.3, 79.4) using the random-effects model, with marked variation across countries and time. Heterogeneity between studies was explained by age and admission body mass index.

CONCLUSIONS

This meta-analysis found that although clinical features do contribute to length of admissions for anorexia nervosa, there are also global and temporal variations. Future research should provide an in-depth analysis of why and how this variation exists and what the impact is on the well-being of people with anorexia nervosa.

Family members' reflections upon a family-based inpatient treatment program for adolescent anorexia nervosa: a thematic analysis

BACKGROUND

Family-based outpatient treatment is usually recommended as the treatment of choice when a child develops anorexia nervosa. However, some young persons will inevitably require higher levels of care. Qualitative research on family perspectives may help inform strategies to adapt family-based practices into intensified treatment settings. Our overarching aim was to investigate family members' perspectives following a family-based inpatient treatment program for adolescent anorexia nervosa and to discuss clinical implications for treatment providers.

METHODS

A subsample of eight families taking part in a naturalistic outcome study at a specialized eating disorder unit participated in the study (8 patients, 14 parents, and 10 siblings). The thematic analyses were inductive, predominantly descriptive, and guided by a multi-perspective framework.

RESULTS

Five main themes were identified: 1: Expectations and evaluation of needs. Entering treatment from different vantage points, 2: Interactions with peers during the admission as highly beneficial or problematic, 3: Perspectives on staff expertise and the eating disorder unit's structure, 4: Influencing within family relationships in different ways, and 5: Being admitted is at best only half the job: reflections on leaving the eating disorder unit.

CONCLUSIONS

Our study offers insight into how former inpatients and their family members experienced an inpatient treatment program designed to align treatment with the central elements of an outpatient family-based treatment approach for adolescent anorexia nervosa. Overall, the findings support emerging research underlining the necessity of strengthening the family-based treatment approach within intensified treatment settings. Moreover, the results emphasized the need for more knowledge on how to optimize inpatient treatment as well as the importance of providing smooth transitions between care settings.

Identification and Management of Eating Disorders in Children and Adolescents

Eating disorders are serious, potentially life-threatening illnesses afflicting individuals through the life span, with a particular impact on both the physical and psychological development of children and adolescents. Because care for children and adolescents with eating disorders can be complex and resources for the treatment of eating disorders are often limited, pediatricians may be called on to not only provide medical supervision for their patients with diagnosed eating disorders but also coordinate care and advocate for appropriate services. This clinical report includes a review of common eating disorders diagnosed in children and adolescents, outlines the medical evaluation of patients suspected of having an eating disorder, presents an overview of treatment strategies, and highlights opportunities for advocacy.

Anorexia nervosa in adolescents

Anorexia nervosa is an eating disorder with peak onset in adolescence, which carries the highest mortality rate of all psychiatric illnesses. It is commonly comorbid with other physical and mental health problems, yet training on management of people with eating disorders and working knowledge of clinicians working with underweight adolescents is inconsistent. This review of anorexia nervosa in adolescents provides an overview of the presentation, aetiology and treatment of this disorder, with a particular focus on the assessment and management of physical health risks, including refeeding syndrome.

Outcomes of inpatient psychological treatments for children and adolescents with eating disorders at time of discharge: a systematic review

BACKGROUND

Recommended first line treatment for children and adolescent eating disorders is outpatient therapy. However, a significant number of children and adolescents with eating disorders continue to require inpatient treatment during the course of their illness. The effect of psychological treatments in an inpatient setting on outcomes at the time of discharge remains unclear. This paper presents the results of a review of the literature on outcomes at the time of discharge following inpatient psychological treatment for children and adolescents with eating disorders.

MAIN BODY

The majority of studies found were observational and of low quality. The most consistently reported positive outcome of inpatient treatment is weight gain. Results related to symptom change and motivation vary between studies. Within the inpatient setting, there is considerable heterogeneity in the types of treatments offered, goals of treatment, length of stay and outcomes measured.

CONCLUSION

There remains a paucity of high-quality studies examining the effect of psychological treatments provided to children and adolescents in an inpatient setting. The significant heterogeneity between studies makes it not possible to compare across studies. Future research should aim to resolve these deficiencies in order to better determine the specific factors that contribute to positive outcomes of inpatient treatment for children and adolescents with eating disorders.

Nutrition Approach for Inpatients With Anorexia Nervosa: Impact of a Clinical Refeeding Guideline

OBJECTIVE

This study assesses the impact of a clinical refeeding guideline on weight restoration, length of stay, rate of refeeding complications, and rehospitalizations.

METHOD

This retrospective study included patient records of 107 participants aged 13-55 years with a diagnosis of AN, admitted for at least 7 days for renutrition before and after introduction of the refeeding guideline. Weight evolution graphs were rated by 2 clinical experts independently. Binary logistic regression models were erected to identify clinical outcomes associated independently with the guideline as well as to control for potential confounding by sociodemographic and clinical characteristics at admission.

RESULTS

The proportion of patients achieving optimal weight gain after the first 2 weeks increased significantly from 6.3% pre-guideline to 41.8% post guideline (adjusted odds ratio [AOR] = 37.6; 95% confidence interval [CI], 2.77-510.3; P = 0.006). Average length of hospitalization was reduced from 96.7 (SD 48.3) days pre-guideline to 62.2 (SD 45.5) days post guideline (AOR = 0.99; 95% CI, 0.97-1.01; P = 0.18). None of the patients developed a full refeeding syndrome. There was no significant change in the rate of rehospitalization: 48.5% pre-guideline to 43.2% post guideline (OR = 0.81; 95% CI, 0.36-1.84; P = 0.62).

DISCUSSION

The clinical guideline proved highly effective in bolstering weight gain via intensive refeeding procedures while also being safe. Harmonizing clinical practices improves quality of care for patients with anorexia and, interestingly, may decrease costs by cutting average length of stay by a third without increasing the rehospitalization rate.

Vocal cord dysfunction following esophageal atresia and tracheoesophageal fistula (EA/TEF) repair

BACKGROUND

The purpose of this study was to determine risk factors and long-term outcomes in patients with esophageal atresia +/-tracheoesophageal fistula (EA/TEF) with vocal cord dysfunction (VCD) owing to recurrent laryngeal nerve (RLN) injury.

METHOD

A retrospective chart review was performed for EA/TEF patients repaired at our institution from 1999 to 2014 (REB #1000032265).

RESULTS

Of 197 patients, 22 (11.2%) were diagnosed with VCD by indirect laryngoscopy following EA/TEF repair. Aspiration was documented on video swallow study for 21 patients, and as a result, 13 required thickened feeds and 8 required gastrostomy tube feeds. Of the 16 H-type TEF patients, 8 (50%) had VCD. Following discharge, 20 (90.9%) patients with VCD eventually tolerated full feeds orally without aspiration but only 8 (36.4%) had documented recovery of vocal cord movement at long-term follow up (mean 452 days). Overall, patients with VCD were more likely to have feeding modifications, increased exposure to radiological studies, and increased frequency of Otolaryngology follow-up compared to EA/TEF patients without VCD.

CONCLUSION

EA/TEF patients are at risk for VCD. Clinical improvement did not always correlate with recovery of VC motion. Strategies to minimize RLN damage will improve outcomes and quality of life for EA/TEF patients.

LEVEL OF EVIDENCE

Level III.

The calorie counter-intuitive effect of restaurant menu calorie labelling

As of January 1, 2017, the Healthy Menu Choices Act mandates that food service premises with 20 or more locations in Ontario must display the number of calories in every food item sold on menus. The impetus for this legislation was to enable Ontarians to become aware of the calorie content of foods and beverages consumed outside the home, and make healthier dietary choices while dining out. Though arising as an initiative to attenuate the development of obesity and current obesity rates, evidence suggests menu labelling does not significantly alter individuals' food choices. Moreover, focusing primarily on caloric content may be an ineffective, and perhaps detrimental, strategy to effect change in the obesity epidemic. Beyond the initiative's questionable utility, there has been a lack of consideration as of yet to the unintended negative implications this initiative may have on eating disorder (ED) symptomatology in the general population and those attempting to recover from an ED. The objective of the current commentary is thus to argue that in light of evidence of minimal benefit and the potential for harm, nutrition labelling on menus may be a misguided public health initiative.

Eating disorders-Related hospitalizations in Portugal: A nationwide study from 2000 to 2014

INTRODUCTION

Recent evidence suggests that incidence of Anorexia nervosa (AN) has remained stable over the last decades in Western Europe, while decreasing for Bulimia nervosa (BN). It is well-known that most individuals with an ED (Eating disorder) do not seek medical treatment.

OBJECTIVE

The present study analyses hospitalizations related with EDs held in mainland Portuguese public hospitals between 2000 and 2014.

METHOD

A retrospective observational study was performed gathering all inpatient episodes with primary or secondary diagnosis of ED. Number of patients, gender, mean age at discharge, suicide-attempts related hospitalizations, in-hospital mortality, length of stay, and mean charges were analyzed.

RESULTS

There were a total of 4,485 hospitalizations with an associated ED. AN was the most frequent ED (n = 2,806). Suicide attempt-related hospitalizations were most common among patients with BN (10.1% of BN hospitalizations) or AN (5.2% of AN hospitalizations).

DISCUSSION

AN has higher in-hospital mortality than BN. We observed a higher proportion of suicide related hospitalizations in BN when compared to AN. Although pica, rumination disorder, and psychogenic vomiting represent a smaller portion of all EDs, this study was the first to describe hospitalization trends for this set of EDs for a 15-year period, to the best of our knowledge.

Does continuing family-based treatment for adolescent anorexia nervosa improve outcomes in those not remitted after 20 sessions?

OBJECTIVE

Our aim was to investigate the benefit of ongoing family-based treatment (FBT) sessions for adolescent anorexia nervosa if remission criteria were not met at session 20.

METHOD

Participants were 69 medically unstable adolescents with Diagnostic and Statistical Manual of Mental Disorders (4th ed; DSM-IV) anorexia nervosa from a randomized controlled trial investigating length of hospital admission prior to outpatient FBT. Participants were divided post hoc into those meeting remission criteria at session 20 ( n = 16), those that had not remitted but continued with FBT ( n = 39) and those who ceased FBT undertaking alternative treatments ( n = 14). Outcome was assessed as remission and hospital readmission days at 12 months after FBT session 20.

RESULTS

There were no differences between groups at baseline. There was a significant difference in the use of hospital admission days with those in the Alternate Treatment Group who did not continue with FBT using 71.93 days compared to those in Additional FBT Group with only 12.51 days ( F(2, 66) = 13.239, p < .01). At 12 months after FBT session 20, the Additional FBT Group had a 28.2% increase in remission rate, significantly higher than those in the Alternate Treatment Group (χ²(2) = 17.68, p  < .001).

DISCUSSION

Continuing FBT after session 20 if remission is not achieved can significantly reduce hospital readmission days and improve remission rates.

A Novel In-Home Relapse Prevention Treatment for Anorexia Nervosa

Anorexia nervosa (AN) is a difficult-to-treat mental illness associated with dangerous behavioral symptomatology. Interventions that augment the outcomes of existing inpatient and outpatient protocols for AN are critically needed. In-home treatments that address environmental change as a means to further promote behavior change have been applied for the care of multiple behaviorally based psychiatric illnesses, but not for eating disorders. The present study outlines the pilot application of a posthospitalization, four-session in-home relapse prevention treatment for a woman with a long history of AN. Over a 1-, 3-, and 6-month follow-up period, the patient exhibited substantial improvements in eating disorder symptomatology, sustained a healthy body mass index, and maintained positive environmental changes made by the end of treatment. The treatment was feasible and readily accepted by the patient. These positive findings suggest that more formalized research to further evaluate this novel adjunctive treatment for AN is warranted.

The direct health care costs of eating disorders among hospitalized patients: A population-based study

OBJECTIVE

To estimate the direct health care costs of eating disorders in Ontario, Canada, in 2012, using a prevalence-based cost-of-illness approach.

METHOD

We selected a population-based sample of all patients eligible for public health care insurance over the age of 4 with a hospitalization for an eating disorder at any point since 1988. We estimated total and mean direct net costs per patient in 2012, from the third public payer perspective, by sex, age group, and health service type.

RESULTS

In 2012, there were 6,326 patients ever hospitalized for an eating disorder. They had a mean age of 31 at hospitalization, were mostly female (93%), and generally from high-income, urban neighborhoods. Direct total costs were just under $63 million CAD; direct net costs were roughly $48 million CAD. Mean net costs per patient were higher for females than males ($7,743.40 and $6,340.50, respectively), and higher for patients under 20 and patients 65+ ($17,961.50 and $14,953.90, respectively). The main cost drivers were psychiatric hospitalizations and physician visits, although this varied by age group. For younger patients, net costs were mainly because of psychiatric hospitalizations, while for older patients net costs were mainly because of psychiatric and nonpsychiatric hospitalizations, and other care.

DISCUSSION

The cost of eating disorders is substantial and varies by sex and age group. Our findings suggest that, from a health care utilization/cost perspective, the effect of eating disorders is likely to persist over the lifespan.

Reducing the burden of suffering from eating disorders: Unmet treatment needs, cost of illness, and the quest for cost-effectiveness

Eating disorders are serious mental disorders as reflected in significant impairments in health and psychosocial functioning and excess mortality. Despite the clear evidence of clinical significance and despite availability of evidence-based, effective treatments, research has shown a paradox of elevated health services use and, yet, infrequent treatment specifically targeting the eating disorder (i.e., high unmet treatment need). This review paper summarizes key studies conducted in collaboration with G. Terence Wilson and offers an update of the research literature published since 2011 in three research areas that undergirded our collaborative research project: unmet treatment needs, cost of illness, and cost-effectiveness of treatments. In regards to unmet treatment needs, epidemiological studies find that the number of individuals with an eating disorder who do not receive disorder-specific treatment continues to remain high. Cost-of-illness show that eating disorders are associated with substantial financial burdens for individuals, their family, and society, yet comprehensive examination of costs across public sectors is lacking. Cost measures vary widely, making it difficult to draw firm conclusions. Hospitalization is a major driver of medical costs incurred by individuals with an eating disorder. Only a handful of cost-effectiveness studies have been conducted, leaving policy makers with little information on which to base decisions about allocation of resources to help reduce the burden of suffering attributable to eating disorders.

First Sociodemographic, Pretreatment and Clinical Data from a German Web-Based Registry for Child and Adolescent Anorexia Nervosa

Abstract. Objective: The first web-based registry for childhood and adolescent anorexia nervosa (AN) in Germany was established to systematically collect demographic and clinical data. These data as well as information on how young individuals with AN can find access to healthcare services are presented. Method: Patients´ data from child and adolescent psychiatry departments of 12 university hospitals and two major nonuniversity hospitals in Germany were collected between January 2015 and December 2016. All patients met the ICD-10 diagnostic criteria for (atypical) AN. Sociodemographic data, type and amount of healthcare utilization before admission, and clinical data at admission and discharge were compiled. Results: 258 patients with a mean age of 14.7 years and a mean BMI at admission of 15.3 kg/m2 were included. The parents and patients had a higher educational level than the general German population. More than 80 % of the patients reported having utilized healthcare before hospitalization. The mean duration of outpatient treatment before hospitalization was 7 months. Conclusions: There seem to be major barriers to specialist treatment for young patients with AN in Germany, which should be analyzed in future studies.

A Comparison of Personality, Life Events, Comorbidity, and Health in Monozygotic Twins Discordant for Anorexia Nervosa

Genetic and environmental factors contribute to the etiology of anorexia nervosa (AN). The co-twin control design is one of the most powerful methods available to evaluate environmental factors that could contribute to differences between monozygotic (MZ) twins who are discordant for AN. Using available data from a unique and rare sample of 22 Swedish female MZ pairs discordant for AN, we compared personality, life events, comorbidity, and health factors. Twins with AN had significantly higher perfectionism scores than unaffected co-twins and reported younger ages at first diet than unaffected co-twins who had dieted. Consistent with previous literature, more twins with AN reported gastrointestinal problems than unaffected co-twins. Although not significant due to low statistical power, more unaffected co-twins reported experiencing emotional neglect than twins with AN. Early dieting may be a harbinger of the development of AN or an early symptom. Higher perfectionism may represent a risk factor, sequela, or both. Sibling perception of neglect is noteworthy given the impact of an ill child with AN on family function and wellbeing. The health and wellbeing of siblings should be addressed clinically when one child in the family suffers from AN.

Cost-effectiveness of achieving clinical improvement with a dissonance-based eating disorder prevention program

Using data from an effectiveness trial delivered by college clinicians, we examined the cost-effectiveness of the dissonance-based Body Project program for reducing eating disorder symptoms in women with body dissatisfaction. The outcome of interest was individual-level change; 14.9% of Body Project participants attained clinically meaningful improvement vs. 6.7% of controls. Delivering the intervention costs approximately $70 (2012 U.S. dollars) per person. Incremental cost-effectiveness was $838 for each additional at-risk person reducing eating disorder symptomology to a clinically meaningful degree. These analyses demonstrate the economic value of the Body Project for college-age women with symptoms below the eating disorder diagnosis threshold.

Key factors that influence government policies and decision making about healthcare priorities: Lessons for the field of eating disorders

Worldwide, the demand for healthcare exceeds what individuals and governments are able to afford. Priority setting is therefore inevitable, and mental health services have often been given low priority in the decision-making process. Drawing on established economic criteria, and specifically the work of Philip Musgrove, key factors which influence government decision-making about health priorities are reviewed. These factors include the size of the health burden, the availability of cost-effective interventions to reduce the burden, whether private markets can provide the necessary treatment efficiently, whether there are "catastrophic costs" incurred in accessing treatment, whether negative externalities arise from not providing care, and if the "rule of rescue" applies. Beyond setting priorities for resource allocation, governments also become involved where there is a need for regulation to maintain quality in the delivery of healthcare. By providing field-specific examples for each factor, we illustrate how advocates in the eating disorder field may use evidence to inform government policy about resource allocation and regulation in support of individuals with an eating disorder.

Population-based cost-offset analyses for disorder-specific treatment of anorexia nervosa and bulimia nervosa in Germany

Previous research has shown that anorexia nervosa (AN) and bulimia nervosa (BN) are expensive illnesses to treat. To reduce their economic burden, adequate interventions need to be established. Our objective was to conduct cost-offset analyses for evidence-based treatment of eating disorders using outcome data from a psychotherapy trial involving cognitive behavioral therapy (CBT) and focal psychodynamic therapy (FPT) for AN and a trial involving CBT for BN. Assuming a currently running, ideal healthcare system using a 12-month, prevalence-based approach and varying the willingness to participate in treatment, we investigated whether the potential financial benefits of AN- and BN-related treatment outweigh the therapy costs at the population level. We elaborated on a formula that allows calculating cost-benefit relationships whereby the calculation of the parameters is based on estimates from data of health institutions within the German healthcare system. Additional intangible benefits were calculated with the aid of Quality-Adjusted Life Years. The annual costs of an untreated eating disorder were 2.38 billion EUR for AN and 617.69 million EUR for BN. Independent of the willingness to participate in treatment, the cost-benefit relationships for the treatment remained constant at 2.51 (CBT) and 2.33 (FPT) for AN and 4.05 (CBT) for BN. This consistency implies that for each EUR invested in the treatment, between 2.33 and 4.05 EUR could be saved each year. Our findings suggest that the implementation of evidence-based psychotherapy treatments for AN and BN may achieve substantial cost savings at the population level.

Outcomes of an inpatient refeeding protocol in youth with Anorexia Nervosa and atypical Anorexia Nervosa at Children's Hospitals and Clinics of Minnesota

BACKGROUND

Historically, inpatient protocols have adopted relatively conservative approaches to refeeding in Anorexia Nervosa (AN) in order to reduce the risk of refeeding syndrome, a potentially fatal constellation of symptoms. However, increasing evidence suggests that patients with AN can tolerate higher caloric prescriptions during treatment, which may result in prevention of initial weight loss, shorter hospital stays, and less exposure to the effects of severe malnutrition. Therefore the present study sought to examine the effectiveness of a more accelerated refeeding protocol in an inpatient AN and atypical AN sample.

METHODS

Participants were youth (ages 10-22) with AN (n = 113) and atypical AN (n = 16) who were hospitalized for medical stabilization. A retrospective chart review was conducted to assess changes in calories, weight status (percentage of median BMI, %mBMI), and indicators of refeeding syndrome, specifically hypophosphatemia, during hospitalization. Weight was assessed again approximately 4 weeks after discharge.

RESULTS

No cases of refeeding syndrome were observed, though 47.3 % of participants evidenced hypophosphatemia during treatment. Phosphorous levels were monitored in all participants, and 77.5 % were prescribed supplemental phosphorous at the time of discharge. Higher rates of caloric changes were predictive of greater changes in %mBMI during hospitalization. Rates of caloric and weight change were not related to an increased likelihood of re-admission.

CONCLUSIONS

Results suggest that a more accelerated approach to inpatient refeeding in youth with AN and atypical AN can be safely implemented and is not associated with refeeding syndrome, provided there is close monitoring and correction of electrolytes. These findings suggest that this approach has the potential to decrease length of stay and burden associated with inpatient hospitalization, while supporting continued progress after hospitalization.

Cost evaluation of out-of-country care for patients with eating disorders in Ontario: a population-based study

BACKGROUND

Eating disorders, specifically anorexia nervosa, bulimia nervosa and eating disorder not otherwise specified, represent a substantial burden to the health care system. Our goal was to estimate the economic burden of patients who received specialized inpatient care for an eating disorder out of country.

METHOD

We conducted a cost-of-illness study evaluating health care costs among patients in Ontario who received specialized inpatient care for an eating disorder out of country from 2003 to 2011, from the public third-party payer perspective. Using linked administrative databases, we estimated net costs of eating disorders for 2 patient groups: those who received specialized inpatient care both out of country and in province (n = 160), and those who received specialized inpatient care out of country only (n = 126).

RESULTS

Patients approved for specialized out-of-country inpatient care were mostly girls and young women from high-income, urban neighbourhoods. Total net costs varied annually and were higher for patients treated both out of country and in province (about $11 million before 2007, $6.5 million after) than for those treated out of country alone (about $5 million and $2 million, respectively). The main cost drivers were out-of-country care and physician services.

INTERPRETATION

Costs associated with eating disorder care represent a substantial economic burden to the Ontario health care system. Given the high costs of out-of-country care, there may be opportunity to redirect these funds to increase capacity and expertise for eating disorder treatment within Ontario.

Medical stabilization of adolescents with nutritional insufficiency: a clinical care path

PURPOSE

Nutritional insufficiency (NI) is a potential consequence of restrictive eating disorders. NI patients often require hospitalization for refeeding to restore medical stability and prevent complications such as refeeding syndrome. Limited information is available on the optimal approach to refeeding. In this study, we describe an inpatient NI care path and compare treatment outcomes at an academic medical center and a community hospital.

METHODS

A retrospective chart review was conducted on inpatients treated using a standardized NI care path at either the academic site, from August 2012 to July 2013 (n = 51), or the community site, from August 2013 to July 2014 (n = 39). Demographic information, eating disorder history, and treatment variables were recorded for each patient. Data were compared using the Kruskal-Wallis test and Fisher's exact test.

RESULTS

Patients admitted to the community site had shorter hospital stays than patients admitted to the academic site (IQR 2-4 vs. 2-7 days, p = 0.03). All patients were discharged in <14 days with a median stay of 3 days. The median initial calorie prescription was 2200 calories for both groups. No clinical cases of refeeding syndrome occurred, with only one patient developing hypophosphatemia during refeeding.

CONCLUSIONS

A standardized care path with a higher-calorie intervention allows for short-term hospitalization of NI patients without increasing the risk of refeeding syndrome, regardless of treatment site. This study demonstrates the efficiency and safety of treating NI patients on a regular medical floor at a community hospital.