Changing Patterns of Hospitalization in Eating Disorder Patients

Transcription

1 Changing Patterns of Hospitalization in Eating Disorder Patients Claire V. Wiseman, Suzanne R. Sunday, Fern Klapper, Wendy A. Harris, and Katherine A. Halmi* The Cornell Eating Disorders Program, Department of Psychiatry, Weill College of Medicine at Cornell University, White Plains, New York Accepted 8 July 2 Abstract: Objective: This study investigated the changing patterns of hospitalization of eating disorder patients over the past 15 years. Method: The records of 1,185 eating disorder patients between 1984 and 1998 were examined on several variables. Results: Over the 15 years, the number of first admissions increased from 2 to 182. There was a concomitant decrease in length of stay from days in 1984 to 23.7 days in Readmissions increased markedly from % during the first year to 27% of total admissions in The discharge weight of anorectic patients significantly decreased from a body mass index (BMI) of 19.3 in 1984 to 17.7 in These changes were particularly salient in the past 3 years, concurrent with a dramatic rise in managed care cases. Conclusions: Over the past 15 years, eating disorder hospital treatment has metamorphozed from long-term treatment of a disorder to stabilization of acute episodes. For some patients, this change has been deleterious and not cost effective. 21 by John Wiley & Sons, Inc. Int J Eat Disord 3: 69-74, 21. Key words: inpatient treatment; epidemiology; length of stay; readmissions INTRODUCTION There has been a shift in the profile of anorexia nervosa (AN) and bulimia nervosa (BN) patients. Bruch (1978) described how patients were viewed 2 years ago, "The puzzling question is why such a cruel disease should affect young and healthy girls who have been raised in privileged, even luxurious circumstances" (p. viii). Today, patients from all cultures and socioeconomic classes are treated for eating disorders. For example, Crago, Shisslak, and Estes (1996) reported comparable levels of eating disorders among Caucasians and Hispanics. Concomitant with epidemiological changes in AN and BN patients, there have been major changes in health care. A decade ago, eating disorder hospitalizations were pri- *Correspondence to: Katherine Halmi, The Cornell Eating Disorders Program, Department of Psychiatry, Weill College of Medicine at Cornell University, 21 Bloomingdale Road, White Plains, NY kah29@cornell.edu 21 by John Wiley & Sons, Inc.

2 7 Wiseman et al. marily covered by private insurance. Today, health maintenance organizations (HMOs) and managed care overseeing private insurance and public funding have increasingly replaced private insurance as the primary source of payment. They often limit payment for eating disorder hospitalizations, the most costly part of psychiatric care (Kaye, Kaplan, & Zucker, 1996). According to the American Hospital Association, the average length of stay (LOS) in psychiatric hospitals across different diagnoses decreased 25% between 1988 and 1992 (Bezold, MacDowell, & Kunkel, 1996). Longer-term patients have been transferred to supervised community residences and receive their care in medical hospitals on general medical units in order to reduce the number of public mental hospitals. Currently, inpatient stays are short. Therefore, patients who are less severely ill but are chronically impaired are not as likely to be hospitalized. Instead, severely and chronically impaired patients in acute crises are the predominant admissions (Mechanic, McAlpine, & Olfson, 1998). Eating disorders are unique among psychiatric illnesses because patients have both physical and psychological disturbances. Often, managed care companies have difficulty dealing with the overlap and opt to treat the physical problems in general hospitals, which does not address the psychological problems. When treating AN patients in a hospital, refeeding is the primary task. However, this process is often time consuming and medically complicated. Few managed care companies have staff who are accustomed to dealing with the intricacies of treating eating disorders, thereby failing to approve ample length of stays to provide proper care (Kaye et al, 1996). Recent studies found that AN patients who left the hospital while still underweight had a poor outcome and a high rate of relapse (Baran, Weltzin, & Kaye, 1995; Commerford, Licinio, & Halmi, 1997; Halmi & Licinio, 1989; Howard, Evans, Quintero-Howard, Bowers, & Andersen, 1999). The current investigation examines the changing pattern of eating disorder hospitalizations over the past 15 years in an established eating disorder treatment program representing a metropolitan area with a population of 1 million people. METHOD Records of 1,185 consecutive eating disorder patients over the period January 1,1984 to December 31,1998 at the Eating Disorders Program at New York Presbyterian Hospital- Westchester Division, Weill Medical College of Cornell University (NYPH), were examined. There were 67 males and 1,118 females. Information was obtained on eating disorder diagnosis, LOS, gender, age, race, marital status, geographic location, number of readmissions, form of payment, and body mass indices (BMI) at admission and at discharge for AN patients. Diagnoses were based on criteria described in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association [APA], 1994). Geographic location was coded across 5-year blocks in Westchester County (where the hospital is located). New York City, Long Island, the remainder of New York State, neighboring states (NJ, CT), other states, and other countries. Data were analyzed using Pearson correlations, chi-square and t tests, analyses of variance (ANOVAs), and multivariate analyses of variance (MANOVAs). For all results reported as significant, p <.5.

3 Changing Patterns of Hospitalization 71 RESULTS Table 1 presents a summary of age, LOS, gender, number of first admissions and readmissions, and diagnoses. There was a significant increase in the number of first admissions, x 2 = 483.9, df= 14. LOS decreased significantly, F(14,1163) = In 1984, the mean LOS was days, which decreased to days in 1989 and 57.4 in This number decreased by more than one half in the next 5 years to a low of 23.7 days in There was a significant increase in readmissions (comparing 3-year blocks; x 2 = 21.22, d/= 4) and there was a significant difference by diagnosis (x 2 = 14.2, df= 3). A correlation of mean yearly LOS and percentage of yearly readmissions was highly significant (r = -.931). BN patients were significantly less likely to be readmitted than AN patients and patients with eating disorders not otherwise specified (EDNOS; x 2 = 6.44, df= 1). Restricting anorexics (AN-Rs) were significantly more likely to be readmitted (x 2 = 3.9, df = 1). There was also a decrease in the number of days between the initial admission and the first readmission, F(ll,126) = The mean number of admissions within the calendar year also changed. Among the readmitted patients from 1989 to 1991, there was a mean number of one readmission per year. That is, each of the readmitted patients had only a single admission for that specific calendar year. This increased in the subsequent years: 1.17, 1.38, 1.33, 1.26, 1.42, 1.69, and 1.83, respectively, from 1992 to For readmitted patients within the 1998 calendar year, 14 had one, 18 had two, 2 had three, 1 had four, and 1 had six admissions. There was a significant difference between diagnostic groups (using 5-year blocks; x 2 = 78.6, df= 12). The percentage of AN-R and BN patients has remained relatively stable at 22-35%, except in when the number of BN patients increased to 47.4% (x 2 = 8.9, df = 1). AN-BP (anorexia nervosa and binge purge) admissions have decreased significantly over the past 15 years, from 45.2% in (x 2 = 17.8, df = 1) to 15.99% in (x 2 = 8.2, df = 1). There has also been a rise in the number of EDNOS admissions, from 1.37% in (x 2 = 11.15, df= 1) to 22.5% in (x 2 = 5.7, df= 1). EDNOS comprised those meeting partial criteria for AN (n = 96, 45.1%), those meeting partial criteria for BN (n = 11,51.6%), and those meeting criteria for binge eating disorder (BED; APA, 1994; n = 7, 3.3%). AN partial criteria were (1) patients' weight was <85% of ideal and patients were either not amenorrheic or had no fear of being fat, (2) patients' weight was >85% of ideal in the last month but patients met full criteria for AN immediately before that month, and (3) patients' weight was >85% of body weight but patients recently restricted and lost a significant amount of weight. Patients met criteria for partial BN if their weight was >85% of ideal weight and if they binged/purged less than twice weekly over the last 3 months or if they purged only. Overall, there was a significant increase in age at first admission, F(14, 1,174) = Patients aged 4-49 accounted for 4.2% of admissions in 1988; previously there were no admissions from that cohort. This percentage doubled in 1998 to 8.8% of admissions. The percentage of males admitted fluctuated but generally increased during this period. The proportion of non-caucasians increased significantly during the period (x 2 = 22.9, df= 1). The greatest increase occurred from 1996 to 1998 when 11.4% (64 patients) were non- Caucasians. The marital status of patients has changed little during this time period, with 75-95% of patients being single. Geographic location of the first admission has not changed significantly (x 2 = 13.85, df = 1) and readmissions had a similar pattern. First admissions during the 15-year period included 158 (13.4%) patients from Westchester County, 323 (27.5%) patients from New York City, 177 (15.1%) patients from Long Island, 335 (28.5%) patients from New York

4 Table demographics means (percent) Year Admissions LOS Readmissions AN-R (%) AN-BP (%) BN (%) NOS (%) Age Female (%) Male (%( ± ± ± ± ± ± ± ± ± ± ± ± ± ± (25.) 9 (37.5) 9 (31.) 8 (23.5) 12 (25.) 1 (19.6) 15 (25.9) 17 (23.9) 25 (34.7) 23 (28.8) 18 (18.2) 3 (27.5) 43 (32.6) 55 (3.6) 47 (25.8) 11 (55.) 1 (42.) 12 (41.4) 1 (29.4) 11 (22.9) 15 (29.4) 14 (24.1) 14 (19.7) 16 (?? 2) 21 (26.3) 25 (25.3) 24 (22.) 25 (18.9) 23 (12.8) 31 (17.) 4 (2.) 4 (17.) 8 (27.6) 16 (47.1) 22 (45.8) 25 (49.) 23 (39.7) 25 (35.2) 16 (22.2) 26 (32.5) 38 (38.4) 22 (2.2) 37 (28.) 56 (31.1) 66 (36.3) (.) 1 (4.) (.) (.) 3 (6.3) 1 (2.) 6 (1.3) 15 (21.1) 15 (2.8) 1 (12.5) 18 (18.2) 33 (3.3) 27 (2.5) 46 (25.6) 38 (2.9) ± ± ± ± ± ± ± ± ± ± (95) 24 (1) 28(97) 34 (1) 45 (94) 48 (94) 54 (95) 7 (99) 66 (93) 72(9) 87 (9) 99 (91) 126 (95.5) 169 (94) 177(97) 1(5) 1(3) 3(6) 3(6) 3(5) KD 5(7) 8(1) 1 (1) 1(9) 6 (4.5) 11(6) 5(3) Note: LOS = length of stay; AN-R = restricting anorexics; AN-BP = binge/purge anorexics; BN = bulimia nervosa; NOS = not otherwise specified.

5 Changing Patterns of Hospitalization 73 State, 119 (1.1%) patients from New Jersey/Connecticut, and 63 (5.4%) patients from other states. Only 5 admissions were from another country. Admission BMIs for anorectics ranged from 14.8 to but did not show a difference across years, F(14,567) = 1.. AN discharge BMI did have a significant year effect, F(14,567) = 4.48, ranging from 19 to 2 before 1995, from to in , and decreasing to in Thus, although AN patients were admitted at approximately the same BMIs over this period, discharges occurred at a significantly lower BMI, particularly over the past 4 years. The form of payment has changed dramatically over the past several years. There has been a consistent rate of government-funded payment (Medicaid and Medicare). The percentage of people with private nonmanaged insurance dropped considerably from 64.3% between 1984 and 1987 to 17.3% between 1995 and 1998, with managed private insurance replacing private nonmanaged insurance. Managed care first appeared at this hospital in However, by 1998 it accounted for the majority of all payments for admission to our unit (Table 2). DISCUSSION Over the past 15 years, we have seen a significant change in inpatient treatment of eating disorder patients. Inpatient eating disorder treatment had been reserved for chronic disorders. It has metamorphosed into management and stabilization of acute episodes. This is in response to a combination of factors. The most important factor has been the changing economics of health care. In 1984, the total cost for an inpatient day at New York Presbyterian Hospital was $415 (equivalent to $651 in 1998 dollars). This rose to $1,4 per day in Due to the higher costs for inpatient hospitalization, intense pressure has been applied to reduce the length of inpatient stays. LOS has been exponentially decreasing over the past 15 years in our eating disorder program to its current length of 23 days. At the same time, there has been an increase in the number of readmissions. Although causality cannot be presumed from the current data, increasing the LOS might decrease the number of readmissions or multiple Table 2. Form of payment, Year Medicare or Medicaid (%) Nonmanaged Insurance (%) Managed Insurance (%) Self-Pay (%) (44.4) 5 (23.8) 7 (41.2) 7 (41.2) 18 (4) 14 (28.6) 27 (49.1) 27 (38.6) 29 (41.4) 37 (51.4) 41 (44.1) 55 (52.9) 58 (44.6) 76 (44.7) 65 (36.1) 1 (55.6) 16 (76.2) 1 (58.8) 1 (58.8) 26 (57.8) 34 (69.4) 25 (45.5) 4 (57.1) 38 (54.3) 33 (45.8) 49 (52.7) 44 (42.3) 61 (46.9) 7(4.1) 15 (8.3) 1 (1.4) 2 (2.2) 2(1.9) 1 (7.7) 85 (5.) 98 (54.4) 1 (2.) 3(5.5) 2 (2.9) 3 (4.3) 2 (2.8) 1 (1.1) 3 (2.9) 1 (.8) 2(1.2) 2(1.1)

6 74 Wiseman et al. readmissions. Further, these data are only a small indicator of relapse rate because many patients could be readmitted elsewhere. Although the shift toward managed care was originally conceived as a cost-cutting measure, there are significant hidden costs. It is often difficult to obtain approval for coverage for inpatient stays and many hours are spent maintaining the admission. It is imperative to examine the term "... 'cost containment'- to ask what cost to whom we are avoiding, and who and what is being contained" (Wooley, 1993, p. 4). In response to the decrease in LOS, patients are being transferred rapidly to outpatient settings. Unlike other psychiatric disorders such as depression, people with disordered eating are usually so resistant to treatment that they become noncompliant in outpatient settings where they cannot be as closely monitored by staff. In outpatient settings, patients may restrict, binge, purge, and overexercise. These activities may lead to rehospitalizations, which ultimately do not increase cost effectiveness. Generally, seriously ill patients require strict behavioral interventions that are found only in a specialized inpatient setting. There may be diagnostic differences in response to short-term inpatient hospitalization. The lower readmission rates that we found with BN patients suggest that a brief, structured, and highly controlled inpatient milieu may effectively break the binge-purge cycle, which can then be maintained in an outpatient setting. A short-term hospitalization does not appear to work as effectively for AN patients, apparent from their higher rates of readmission as LOS decreased. Discharge at lower weights has been associated with increased relapse rates and poor prognosis (Commerford et al., 1997). Many insurance companies have advocated treating eating disorders medically and using a medical facility for refeeding and rehydration. Again, the lack of close supervision can lead to continued restriction and purging. A medical hospitalization can be successful in feeding and hydrating patients. However, it can create a false sense of success because underlying cognitive distortions are never addressed, which may lead to relapse. Although we are certainly not suggesting a return to the 198s when the norm was 6 months of inpatient treatment, the current "frequent flier" model of eating disorder treatment is helping neither our economy nor our patients. REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Baran, S., Weltzin, T., & Kaye, W. (1995). Low discharge weight and outcome in anorexia nervosa. American Journal of Psychiatry, 152, Bezold, H., MacDowell, M., & Kunkel, R. (1996). Predicting psychiatric length of stay. Administration and Policy in Mental Health, 23, Bruch, H. (1978). The golden cage. New York: Basic Books. Commerford, M., Licinio, J., & Halmi, K. (1997). Guidelines for discharging eating disorder inpatients. Eating Disorders, 5, Commerford, M.C., Licinio, J., & Halmi, K.A. (1997). Guidelines for discharging eating disorder patients. Eating Disorders, 5, Crago, M., Shisslak, G, & Estes, L. (1996). Eating disturbances among American minority groups: A review. International Journal of Eating Disorders, 19, Halmi, K., & Licinio, E. (1989), Outcome: Hospital program for eating disorders. CME syllabus and proceedings summary, 142nd annual meeting of the American Psychiatric Association, Washington, DC. Howard, W., Evans, K., Quintero-Howard, C, Bowers, W., & Andersen, A. (1999). Predictors of success or failure of transition to day hospital treatment for inpatients with anorexia nervosa. American Journal of Psychiatry, 156, Kaye, W., Kaplan, A., & Zucker, M. (1996). Treating eating-disorder patients in a managed care environment. Psychiatric Clinics of North America, 19, Mechanic, D., McAlpine, D., & Olfson, M. (1998). Changing patterns of psychiatric inpatient care in the United States, Archives of General Psychiatry, 55, Wooley, S. (1993). Managed care and mental health: The silencing of a profession. International Journal of Eating Disorders, 14,