Anorexia nervosa. Hospitalization on adolescent medicine units and third-party payments

A randomized controlled trial of in-patient treatment for anorexia nervosa in medically unstable adolescents

BACKGROUND

Anorexia nervosa (AN) is a serious disorder incurring high costs due to hospitalization. International treatments vary, with prolonged hospitalizations in Europe and shorter hospitalizations in the USA. Uncontrolled studies suggest that longer initial hospitalizations that normalize weight produce better outcomes and fewer admissions than shorter hospitalizations with lower discharge weights. This study aimed to compare the effectiveness of hospitalization for weight restoration (WR) to medical stabilization (MS) in adolescent AN.

METHOD

We performed a randomized controlled trial (RCT) with 82 adolescents, aged 12-18 years, with a DSM-IV diagnosis of AN and medical instability, admitted to two pediatric units in Australia. Participants were randomized to shorter hospitalization for MS or longer hospitalization for WR to 90% expected body weight (EBW) for gender, age and height, both followed by 20 sessions of out-patient, manualized family-based treatment (FBT).

RESULTS

The primary outcome was the number of hospital days, following initial admission, at the 12-month follow-up. Secondary outcomes were the total number of hospital days used up to 12 months and full remission, defined as healthy weight (>95% EBW) and a global Eating Disorder Examination (EDE) score within 1 standard deviation (s.d.) of published means. There was no significant difference between groups in hospital days following initial admission. There were significantly more total hospital days used and post-protocol FBT sessions in the WR group. There were no moderators of primary outcome but participants with higher eating psychopathology and compulsive features reported better clinical outcomes in the MS group.

CONCLUSIONS

Outcomes are similar with hospitalizations for MS or WR when combined with FBT. Cost savings would result from combining shorter hospitalization with FBT.

Variations in admission practices for adolescents with anorexia nervosa: a North American sample

PURPOSE

The purpose of this study was to assess the variability in admission practices and medical inpatient care for adolescent patients with anorexia nervosa (AN).

METHODS

Participants consisted of members of the 2001-2003 Eating Disorder Special Interest Group from the Society for Adolescent Medicine who completed a structured telephone interview about their admission practices and patterns of inpatient care for teens with AN. Questions focused on admission threshold for heart rate (HR), percentage of ideal body weight (% IBW), and refeeding protocols. Case vignettes were used.

RESULTS

Of 95 eligible practitioners, 51 (53%) agreed to participate. Participants represented 25 American states, one Canadian province, and 45 different adolescent programs. The majority of physicians reported they would hospitalize an AN patient with HR <40 beats/min. The most common response for when to hospitalize based on % IBW was 75% IBW. There were no differences in admission practices based on number of years in practice, gender of physician, or practice setting. Regional differences in admission practices were noted, with physicians in the western United States less likely to admit patients with HR >or=40 beats per minute (p = .018). Physicians described 28 different methods of advancing a diet during an admission. Only 37% of physicians were aware of a standardized refeeding protocol in their institution.

CONCLUSION

This study indicates variability in admission criteria and refeeding practices and shows evidence of geographic variations of admission standards. These data provide a baseline for outcome trials investigating medical admissions for adolescents with AN.

Hospitalization of patients with eating disorders on adolescent medical units is threatened by current reimbursement systems

Eating disorders are chronic, life-threatening medical conditions that are the third most common chronic illness in adolescent females in the US. Although successful treatment of eating disorders on medical units has occurred for at least thirty years, some insurance companies refuse payment for such care.

OBJECTIVE

To describe outcomes of and reimbursement for treatment of patients with eating disorders (ED) on an adolescent medical unit.

STUDY GROUP

39 participants, mean age 16.1 +/- 1.9 years, with anorexia nervosa (AN) or eating disorder not-otherwise-specified, subtype AN (EDNOS) admitted to an inpatient adolescent medical unit at a large, urban teaching hospital.

METHODS

Using a retrospective, cohort study design, medical records were reviewed for outcomes at hospital discharge for patients admitted between 2001-2003. Data on hospital and professional charges and payments from medical insurers were collected. Results showed that admission percent estimated ideal body weight was lower in AN vs. EDNOS participants. Controlling for admission weight, length of stay and daily weight gain were independent of the diagnosis of AN vs. EDNOS. Mean length of stay was 51 days. 37/39 patients completed their stay. Insurance companies reimbursed 62% of charges.

CONCLUSION

Other than admission weight, there were no significant clinical differences between AN and EDNOS participants. 95% responded favorably to interdisciplinary treatment. Length of stay could be reduced with earlier admission of malnourished patients. In spite of effective services, reimbursement by insurance companies remains inadequate for patients with ED hospitalized on medical units.

Hospitalization of children and adolescents for eating disorders in the State of New York

PURPOSE

To examine hospitalization patterns, length of stay, cost and insurance status for children and adolescents with Eating Disorders.

METHODS

A cross-sectional study was conducted of patients with eating disorders aged 9 to 17 years, discharged from hospitals in the State of New York in 1995. All patients discharged in the state were registered by the State Planning and Research Collaborative System (SPARCS). A subset was identified based on coding by the International Classification of Diseases (ICD) for Anorexia Nervosa, Bulimia and Eating Disturbance Not Otherwise Specified. The Statistical Analysis System (SAS) was used for data analysis. The variables selected were gender, ethnicity, insurance status and length of stay.

RESULTS

In one year there were 352 hospitalizations, 312 females (88.6%) and 40 males (11.4%); 279 Caucasians (79.3%), 35 African Americans (9.9%), and 38 Other (10.8%); commercial insurance 246 (69.9%), Medicaid 68 (19.3%), other 38 (10.8%). The diagnostic categories were Anorexia Nervosa 242, Bulimia 59, and Eating Disturbance Not Otherwise Specified 63 (reflecting dual diagnosis in 13). Mean length of stay was 18.43 days, the median was 7 days. The cost per stay ranged between 341.78 dollars and 148,471 dollars; with a median of 3817 dollars and a mean of 10,019 dollars. Length of stay was not influenced by gender, age, or ethnicity; only payor status, availability of insurance, was dominant.

CONCLUSIONS

This is the first statewide report on hospitalization of children and adolescents for eating disorders. The mean cost in 1995 exceeded 10,000 dollars. A correlation was found between length of stay and insurance status. Hospitalizations for eating disorder have a significant public health impact, calling for the formulation of fair and rational strategies to optimize care.

What predicts maintenance of weight for adolescents medically hospitalized for anorexia nervosa?

We assessed the relationship between outcomes at one year and a variety of possible predictors among a group of adolescents who were hospitalized for medical complications associated with adolescent onset AN. We reviewed the 12 month outcomes of 41 adolescent patients admitted for medical complications associated with AN to our center. Data on initial percent ideal body weight, length of initial hospitalization, and percent ideal body weight at discharge from first admission were collected. Our primary outcome measure was percent ideal body weight obtained 12 months after initial discharge. Using multiple linear regression to predict percent ideal body weight achieved at 12 months postdischarge, we found that only percent of ideal body weight at discharge predicted better outcomes. Response to initial hospitalization in terms of weight gain, rather than admission weight or length of initial hospital stay, predict better outcomes at 12 months. These results suggest the need for further study of predictors of response to intensive hospital treatment in order to improve initial response rates and ultimately to better outcomes postdischarge.

A health service perspective on anorexia nervosa

This article reviews anorexia nervosa from a health services perspective. From such a perspective, costs of care, changes in insurance types, lack of empirically supported treatments, and involvement of legislative and judicial processes are discussed. Based on this review, processes for designing optimal insurance strategies are outlined, needs for treatment, service, and prevention development suggested, and the need for systematic evaluation of effective treatments identified.

Identifying and treating eating disorders

Pediatricians are called on to become involved in the identification and management of eating disorders in several settings and at several critical points in the illness. In the primary care pediatrician's practice, early detection, initial evaluation, and ongoing management can play a significant role in preventing the illness from progressing to a more severe or chronic state. In the subspecialty setting, management of medical complications, provision of nutritional rehabilitation, and coordination with the psychosocial and psychiatric aspects of care are often handled by pediatricians, especially those who have experience or expertise in the care of adolescents with eating disorders. In hospital and day program settings, pediatricians are involved in program development, determining appropriate admission and discharge criteria, and provision and coordination of care. Lastly, primary care pediatricians need to be involved at local, state, and national levels in preventive efforts and in providing advocacy for patients and families. The roles of pediatricians in the management of eating disorders in the pediatric practice, subspecialty, hospital, day program, and community settings are reviewed in this statement.

Children and adolescents with eating disorders: the state of the art

BACKGROUND

Eating disorders in children and adolescents remain a serious cause of morbidity and mortality in children, adolescents, and young adults. The working knowledge of pathophysiology, recognition, and management of eating disorders continues to evolve as research in this field continues.

OBJECTIVES

This article builds on previous background and position papers outlining issues relevant to the care of the adolescent patient with an eating disorder.

METHODS

The eating disorder special interest group from the Society for Adolescent Medicine recognized the need to update the state of the art published guidelines for the care of the adolescent patient with an eating disorder. This article was a multidisciplinary, group effort to summarize the current knowledge of best practice in the field.

RESULTS

This article summarizes newer findings on pathogenesis and etiology, prevention and screening, risk factors, nutritional issues, care from the primary care clinician's perspective, appropriate use of a multidisciplinary team, and issues of managed care and reimbursement.

CONCLUSIONS

Primary prevention combined with early recognition and treatment helps decrease morbidity and mortality in adolescents with eating disorders.

Eating disorders and health insurance understanding and overcoming obstacles to treatment

Eating disorders are complex in cause and course, with biomedical, psychiatric, and psychosocial components. To maximize the likelihood of recovery, patients require skillful and coordinated care from various health care professionals, including medical professionals, mental health professionals, and nutritionists. All too often, at some point in treatment, clinicians discover that their patients' health insurance status has been compromised or that further treatment is denied because of maximization of mental health benefits. It is important for patients, families, and health care professionals to understand the health insurance issues that are involved in the treatment of eating disorders and learn strategies that may help to overcome the obstacles that these issues present.

Long-term fracture risk among women with anorexia nervosa: a population-based cohort study

OBJECTIVE

To determine if fractures represent an important problem for women with anorexia nervosa who may fail to achieve peak bone mass and may experience premature bone loss from decreased estrogen levels.

PATIENTS AND METHODS

In this population-based retrospective cohort study, we identified 208 Rochester, Minn, residents that were first diagnosed as having anorexia nervosa between 1935 and 1989, whose subsequent fractures were documented in contemporary medical records and compared with expected numbers of fractures (standardized incidence ratios [SIRs]).

RESULTS

Subjects were followed up for 2689 person-years during which time 45 patients suffered 88 fractures. Fracture risk was increased among the 193 women (SIR, 2.9; 95% confidence interval, 2.0-3.9) as well as the 15 men (SIR, 3.4; 95% confidence interval, 1.1-7.9). The cumulative incidence of any fracture at 40 years after the diagnosis of anorexia nervosa was 57%. Fractures of the hip, spine, and forearm were late complications, occurring on average 38, 25, and 24 years, respectively, after diagnosis.

CONCLUSION

Young women with anorexia nervosa are at increased risk of fractures later in life. Greater attention should be paid to the skeletal health of these individuals.

Eating disorder patients at a NSW teaching hospital: a comparison with state-wide data

The aim of the study was to present data which may be useful in deciding the type of services needed for eating disorder (ED) patients in New South Wales (NSW). The demographic and clinical characteristics of 155 patients consecutively admitted to a special ED unit at a major Sydney teaching hospital during the triennium 1989-1991 were documented and compared with relevant data from the State as a whole (709 admissions for ED to public facilities and 938 admissions for ED to private facilities during the same period). The findings are discussed in the light of information from overseas studies. Although a relatively large number of ED patients are admitted to hospitals in NSW, their short duration of stay suggests that many may receive inadequate treatment. The unit in the Department of Psychiatry at the Royal Prince Alfred Hospital (RPA), the largest public ED service in NSW, provides a special service for these patients. It is effective in bringing about nutritional restoration, with a duration of stay similar to those reported from centres overseas. Most referrals are tertiary, and there is a high prevalence of physical morbidity indicating a need for access to general medical facilities. Most serious physical complications occur in patients who can be identified by their chronicity and by the pattern of their behavioural disturbance. These various factors are considered in the formulation of recommendations for rationalizing the service.

The validity of the eating disorder examination and its subscales

The EDE is a semistructured interview which has been developed as a measure of the specific psychopathology of anorexia nervosa and bulimia nervosa. To establish its discriminant validity it was administered to 100 patients with anorexia nervosa or bulimia nervosa and to 42 controls. The two groups differed significantly on all items. Five subscales were derived on rational grounds and evaluated on the two populations. The alpha coefficients for each subscale indicated a satisfactory degree of internal consistency. The EDE provides clinicians and research workers with a detailed and comprehensive profile of the psychopathological features of patients with eating disorders.