Psychiatric comorbidity and length of stay in hospitalized AIDS patients

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

BACKGROUND

Hospital inpatients often experience medical and psychiatric problems simultaneously. Although this implies a certain relationship between healthcare utilization and costs, this relationship has never been systematically reviewed.

OBJECTIVE

The objective is to examine the extent to which medical-psychiatric comorbidities relate to health-economic outcomes in general and in different subgroups. If the relationship is significant, this would give additional reasons to facilitate the search for targeted and effective treatments for this complex population.

METHOD

A systematic review in Embase, Medline, Psycinfo, Cochrane, Web of Science and Google Scholar was performed up to August 2016 and included cross-references from included studies. Only peer-reviewed empirical studies examining the impact of inpatient medical-psychiatric comorbidities on three health-economic outcomes (length of stay (LOS), medical costs and rehospitalizations) were included. Study design was not an exclusion criterion, there were no restrictions on publication dates and patients included had to be over 18 years. The examined populations consisted of inpatients with medical-psychiatric comorbidities and controls. The controls were inpatients without a comorbid medical or psychiatric disorder. Non-English studies were excluded.

RESULTS

From electronic literature databases, 3165 extracted articles were scrutinized on the basis of title and abstract. This resulted in a full-text review of 86 articles: 52 unique studies were included. The review showed that the presence of medical-psychiatric comorbidity was related to increased LOS, higher medical costs and more rehospitalizations. The meta-analysis revealed that patients with comorbid depression had an increased mean LOS of 4.38 days compared to patients without comorbidity (95% CI: 3.07 to 5.68, I2 = 31%).

CONCLUSIONS

Medical-psychiatric comorbidity is related to increased LOS, medical costs and rehospitalization; this is also shown for specific subgroups. This study had some limitations; namely, that the studies were very heterogenetic and, in some cases, of poor quality in terms of risk of bias. Nevertheless, the findings remain valid and justify the search for targeted and effective interventions for this complex population.

Association between Total Daily Doses with duration of hospitalization among readmitted patients in a multi-ethnic Asian population

Increased length of stay (LOS) in the hospital incurs substantial financial costs on the healthcare system. Multiple factors are associated with LOS. However, few studies have been done to associate the impact of Total Daily Doses (TDD) and LOS. Hence, the aim of this study is to examine the association between patients’ LOS upon readmission and their TDD before readmission. A retrospective cross-sectional study of readmission cases occurring from 1st January to 31st March 2013 was conducted at a regional hospital. Demographics and clinical variables were collected using electronic medical databases. Univariable and multiple linear regressions were used. Confounders such as comorbidities and drug related problems (DRP) were controlled for in this study. There were 432 patients and 649 readmissions examined. The average TDD and LOS were 18.04 ± 8.16 and 7.63 days ± 7.08 respectively. In the univariable analysis, variables that were significantly associated with the LOS included age above 75 year-old, race, comorbidity, number of comorbidities, number of medications, TDD and thrombocytopenia as DRPs. In the multiple linear regression, there was a statistically significant association between TDD (β = 0.0733, p = 0.030) and LOS. Variables that were found significant were age above 75 year-old (β = 1.5477, p = 0.008), Malay (β = −1.5123, p = 0.033), other races (β = −2.6174, p = 0.007), depression (β = 2.1551, p = 0.031) and thrombocytopenia as a type of DRP (β = 7.5548, p = 0.027). When TDD was replaced with number of medications, number of medications (β = 0.1487, p = 0.021), age of 75 year-old (β = 1.5303, p = 0.009), Malay (β = −1.4687, p = 0.038), race of others (β = −2.6499, p = 0.007), depression (β = 2.1951, p = 0.028) and thrombocytopenia as a type of DRP (β = 7.5260, p = 0.028) were significant. In conclusion, a significant relationship between TDD and number of medications before readmission and the LOS upon readmission was established. This finding highlights the importance of optimizing patients’ TDD in the attempt of reducing their LOS.

Depression and reasons for living among AIDS patients: protecting quality of life when the end is in sight

BACKGROUND

Patients with AIDS are at risk for becoming depressed, pessimistic, and may begin to desire to die. The desire to live may remain strong in AIDS patients through the maintenance of physical health and a lack of pain. However, improvement in physical health is not always followed by resurgence in the will to live. Psychological variables may be important for protecting reasons for living in AIDS patients.

AIMS

The current study was designed to examine protective factors associated with the will to live among AIDS patients, including physical functioning, depression, and quality of life.

METHOD

Sixty-eight AIDS patients participated in the current study during their outpatient visits to an infectious disease unit. Self-report questionnaires were administered to assess depression, quality of life, a variety of physical health variables, and reasons for living.

RESULTS

Analyses revealed that reasons for living reported by AIDS patients were best understood by overall quality of life. Depression was associated with pessimistic beliefs about the medical illness. Depression was not significantly related to physical functioning or role limitations.

CONCLUSIONS

AIDS patients with poor physical functioning may maintain important reasons for living if a high sense of quality of life is achieved. The assessment and treatment of quality of life in AIDS patients should include strategies that foster a sense of achievement, strengthen interpersonal relationships, and increase positive self-expression.

Race, outpatient mental health service use, and survival after an AIDS diagnosis in the highly active antiretroviral therapy era

We examined the relationships between survival after AIDS diagnosis and outpatient mental health service use among men with history of highly active antiretroviral therapy (HAART). Analysis involved 1913 black and 1684 white men with AIDS who received HIV care in 2003 in the Veterans Affairs health care system. Negative binomial regression was used to assess the association between service use and length of AIDS diagnosis. Patients with longer survival after AIDS had higher rates of outpatient visits for stress and adjustment disorders as well as for mood, anxiety, and sexual disorders. Blacks had more visits for stress and adjustment disorders (7.4 versus 5.1; p < 0.05). Multiple regression analysis showed that prolonged survival after AIDS (incident rate ratios [IRR] = 1.87; 95% confidence interval [CI] = 1.25-2.77), having CD4 cell count less than 200 cells/mm(3) (IRR = 1.91; 95% CI = 1.19-3.04), and mortality (IRR = 3.84; 95% CI = 1.29-11.43) were associated with greater number of visits for mood, anxiety, and sexual disorders. Injection drug users (IRR = 3.52; 95% CI = 1.94-6.38), men who have sex with men (IRR = 2.87; 95% CI = 1.62-5.06), and patients with AIDS-defining illness (IRR = 2.48; 95% CI = 1.47-4.17) had greater rates of visits for stress and adjustment disorders. Survival after AIDS is associated with mental health service use. As more HIV-infected persons survive longer, adequate risk assessment of mental health concerns that considers race and HIV risk factors should be undertaken to effectively address the impact of mental health on treatment outcomes and mortality.

Psychologic issues in palliative care

As medical science progresses and the life spans of patients with serious illnesses increase, the process that leads to death is becoming more feared than death itself. This fear is particularly intense in technologically advanced cultures with access to advanced medical care. The lives of patients who previously would have died rapidly are now often extended. As a result, images of suffering, such as dying in isolation and experiencing great pain, often are at the forefront of concerns about those struggling with terminal illnesses. This article provides medical practitioners with an overview of the issues and symptoms common in terminal illness, to help them work most effectively with their mental health colleagues.

Mental illness and length of inpatient stay for medicaid recipients with AIDS

OBJECTIVE

To examine the associations between comorbid mental illness and length of hospital stays (LOS) among Medicaid beneficiaries with AIDS. DATA SOURCE AND COLLECTION/STUDY SETTING: Merged 1992-1998 Medicaid claims and AIDS surveillance data obtained from the State of New Jersey for adults with >or=1 inpatient stay after an AIDS diagnosis from 1992 to 1996.

STUDY DESIGN

Observational study of 6,247 AIDS patients with 24,975 inpatient visits. Severe mental illness (SMI) and other less severe mental illness (OMI) diagnoses at visits were ascertained from ICD-9 Codes. About 4 percent of visits had an SMI diagnosis; 5 percent had an OMI diagnosis; 43 percent did not have a mental illness diagnosis, but were patients who had been identified as having an SMI or OMI history; and 48 percent were from patients with no identified history of mental illness.

PRINCIPAL FINDINGS

The overall mean hospital LOS was 12.7 days. After adjusting for measures of HIV disease severity and health care access in multivariate models, patients presenting with primary and secondary severe mental illness (SMI) diagnoses had approximately 32 percent and approximately 11 percent longer LOS, respectively, than did similar patients without a mental illness history (p<0.001 for each). But in these adjusted models of length of stay: (1) diagnosis of OMI was not related to LOS, and (2) in the absence of a mental illness diagnosed at the visit, an identified history of either SMI or OMI was also not related to LOS. In adjusted models of time to readmission for a new visit, current diagnosis of SMI or OMI and in the absences of a current diagnosis, history of SMI or OMI all tended to be associated with quicker readmission.

CONCLUSIONS

This study finds greater (adjusted) LOS for AIDS patients diagnosed with severe mental illness (but not for those diagnosed with less severe mental comorbidity) at a visit. The effect of acute severe mental illness on hospitalization time may be comparable to that of an acute AIDS opportunistic illness. While previous research raises concerns that mental illness increases LOS by interfering with treatment of HIV conditions, the associations here may simply indicate that extra time is needed to treat severe mental illnesses or arrange for discharge of afflicted patients.

Psychiatric morbidity and impact on hospital length of stay among hematologic cancer patients receiving stem-cell transplantation

PURPOSE

To determine the prevalence of psychiatric disorders during hospitalization for hematopoietic stem-cell transplantation (SCT) and to estimate their impact on hospital length of stay (LOS).

PATIENTS AND METHODS

In a prospective inpatient study conducted from July 1994 to August 1997, 220 patients aged 16 to 65 years received SCT for hematologic cancer at a single institution. Patients received a psychiatric assessment at hospital admission and weekly during hospitalization until discharge or death, yielding a total of 1,062 psychiatric interviews performed. Psychiatric disorders were determined on the basis of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Univariate and multivariate linear regression analyses were used to identify variables associated with LOS.

RESULTS

Overall psychiatric disorder prevalence was 44.1%; an adjustment disorder was diagnosed in 22.7% of patients, a mood disorder in 14.1%, an anxiety disorder in 8.2%, and delirium in 7.3%. After adjusting for admission and in-hospital risk factors, diagnosis of any mood, anxiety, or adjustment disorder (P =.022), chronic myelogenous leukemia (P =.003), Karnofsky performance score less than 90 at hospital admission (P =.025), and higher regimen-related toxicity (P <.001) were associated with a longer LOS. Acute lymphoblastic leukemia (P =.009), non-Hodgkin's lymphoma (P =.04), use of peripheral-blood stem cells (P <.001), second year of study (P <.001), and third year of study (P <.001) were associated with a shorter LOS.

CONCLUSION

Our data indicate high psychiatric morbidity and an association with longer LOS, underscoring the need for early recognition and effective treatment.

Depressive disorders and personality variables in HIV positive and negative intravenous drug-users

BACKGROUND

Only a few reports investigated the prevalence of depression in intravenous drug-users with HIV infection, including both asymptomatic and symptomatic subjects. In the same group, the association of depression and personality diagnoses was also poorly researched.

METHODS

A consecutive sample of intravenous drug-users was collected from patients admitted to an infectious disease clinic, another random sample was taken from out-patients attending a methadone maintenance treatment program. Subjects were first screened with the Hospital Anxiety and Depression Scale, and then all positive subjects were evaluated with the Composite International Diagnostic Interview. Depression was diagnosed according to DSM-IIIR. In-patients were also given a structured personality inventory (Karolinska Psychodynamic Profile).

RESULTS

HIV-positive patients had a high rate of depression (major depression 36.2%, dysthymic disorder 7.1%) when compared to HIV-negatives (15.7 and 3.9%, respectively). In-patients had the highest rate of depression, irrespective of HIV clinical staging. A personality disorder was diagnosed in 36% of the sample, but these subjects were no more significantly depressed.

LIMITATIONS

Poor detection of depression by the admitting physician may have led to selective hospitalization of patients with both HIV and mood disorder. The composition of the sample may also be biased by the help-seeking behavior of HIV patients who are also depressed.

CONCLUSION

Physicians treating AIDS patients should be alerted to the high rate of depression in clinical HIV illness, in order to identify and properly treat depression.

Psychiatric comorbidity and the long-term care of people with AIDS

OBJECTIVES

To examine the association of comorbid psychiatric disorders with admission and discharge characteristics for patients residing at a long-term care facility designated for acquired immunodeficiency syndrome (AIDS).

METHODS

Demographic and clinical characteristics were obtained by systematic chart review for all patients (N = 180) admitted to the facility from its opening in October 1995 through December 1999. Lifetime history of severe and persistent psychiatric disorders (major depression, bipolar and psychotic disorders) was determined by current diagnosis on baseline clinical evaluation or a documented past history.

RESULTS

Forty-five patients (25%) had comorbid psychiatric disorders. At admission, patients with comorbidity were more likely to be ambulatory (80% vs. 62%, P = .03) and had fewer deficits in activities of daily living (27% vs. 43%, P = .05). After controlling for human immunodeficiency virus (HIV) disease severity, patients with comorbidity had significantly lower discharge rates (relative risk = 0.43, 95% confidence interval 0.23-0.78, P = .0001) and death rates (relative risk = 0.53, 95% confidence interval 0.42-0.68, P = .009).

CONCLUSIONS

Patients with AIDS and comorbid psychiatric disorders at this facility had more favorable admission characteristics and were less likely to be discharged or to die. They may have been admitted earlier in their disease course for reasons not exclusively due to HIV infection. Once admitted, community-based residential alternatives may be unavailable as a discharge option. These findings are unlikely to be an anomaly and may become more pronounced with prolonged survival due to further therapeutic improvements in HIV care. Health services planners must anticipate rising demands on the costs of care for an increasing number of patients who may require long-term care and expanded discharge options for the comanagement of HIV disease and chronic psychiatric disorders.

HIV as a chronic disease: implications for long-term care at an AIDS-dedicated skilled nursing facility

OBJECTIVE

To describe the characteristics and outcomes of the first 3 years of admissions to a dedicated skilled nursing facility for people with acquired immunodeficiency syndrome (AIDS).

METHODS

Systematic chart review of consecutive admissions to a 30-bed, AIDS-designated long-term care facility in New Haven, Connecticut, from October 1995 through December 1998.

RESULTS

The facility has remained filled to 90% or more of its bed capacity since opening. Of 180 patients (representing 222 admissions), 69% were male; mean age was 41 years; 57% were injection drug users; 71% were admitted directly from a hospital. Leading reasons for admission were (1) the need for 24-hour nursing/medical supervision, (2) completion of acute medical treatment, and (3) terminal care. On admission, the median Karnofsky score was 40, and median CD4+ cell count was 24/mm3; 48% were diagnosed with serious neurologic disease, 44% with psychiatric illness; patients were receiving a median of 11 medications on admission. Of 202 completed admissions, 44% of patients died, 48% were discharged to the community, 8% were discharged to a hospital. Median length of stay was 59 days (range 1 to 1,353). Early (< or = 6 months) mortality was predicted by lower admission CD4+ count, impairments in activities of daily living, and the absence of a psychiatric history; long-term stay (> 6 months) was predicted by total number of admission medications, neurologic disease, and dementia. Comparison of admissions from 1995 to 1996 to those in 1997 to 1998 indicated significantly decreased mortality rates and increased prevalence of psychiatric illness between the two periods (P < .01).

CONCLUSIONS

A dedicated skilled nursing facility for people with AIDS can fill an important service need for patients with advanced disease, acute convalescence, long-term care, and terminal care. The need for long-term care may continue to grow for patients who do not respond fully to current antiretroviral therapies and/or have significant neuropsychiatric comorbidities. This level of care may be increasingly important not only in reducing lengths of stay in the hospital, but also as a bridge to community-based residential options in the emerging chronic disease phase of the AIDS epidemic.

Use of hospital services by AIDS patients with psychiatric illness

The purpose of this study was to assess the effect of psychiatric illness on length of stay and patterns of admission among AIDS patients hospitalized for medical illnesses. Medical records were abstracted for AIDS patients admitted to hospitals in Washington State from 1990 through 1992. Psychiatric comorbidity was defined by the presence of an International Classification of Disease-9 code reflecting psychiatric illness. Medical morbidity was addressed using CD4 count and AIDS-defining illnesses as markers of disease severity. Of 2834 admissions, 15% included one or more psychiatric diagnoses. Psychiatric illness (F 39.1; df 1,2830; p < 0.001) and discharge disposition (F 81.2; df 2,2830; p < 0.001) contributed significantly to the model, explaining increased length of stay (F 67.2; df 3,2830; p < 0.001). Future research needs to address the possible etiology of psychiatric comorbidity's contribution to length of stay and the effect on quality and cost of care.

Avoidance coping behaviors and low social support are related to depressive symptoms in HIV-positive patients in Japan

The authors examined the influences of several psychosocial factors (i.e., coping behavior responses, social support, etc.) on mood states in 47 human immunodeficiency virus (HIV)-positive patients without the acquired immunodeficiency syndrome (AIDS). No patients fulfilled the DSM-III-R diagnostic criteria for mood disorders, including major depression. However, the HIV group indicate significantly stronger depressive symptoms and lower social support than the healthy control group. The strength of depressive symptoms and poor social support were significantly correlated with one another. Although the HIV group indicated significantly stronger active coping behaviors than the healthy control group, depressive symptoms were significantly and positively correlated with avoidance coping behaviors. When existence of social support was controlled for, this significant correlation was not noted, indicating that avoidance coping behaviors are independently and significantly related to depressive symptoms. The results suggest that, although depressive symptoms are not strong enough to warrant a psychiatric diagnosis of mood disorders, including major depression, avoidance coping behaviors and poor existence of social support may be a high-risk combination for the manifestation of depressive symptoms in HIV-positive patients without AIDS in Japan.

Comorbidity as a correlate of length of stay for hospitalized patients with acute chest pain

OBJECTIVE

To determine whether comorbid medical conditions as measured with the Charlson Comorbidity Index are independent correlates of length of stay after adjusting for other clinical and socioeconomic data.

DESIGN

Prospective cohort study.

SETTING

Urban teaching hospital.

PATIENTS

All 1,261 patient aged 30 years or more who were admitted to this hospital after coming to the emergency department with acute chest pain between October 1990 and May 1992.

MEASUREMENTS AND OUTCOMES

Clinical data including comorbid medical conditions used in the Charlson index were prospectively recorded by the evaluating physician at the time of admission or by a research nurse who was blinded to the subsequent events. History of myocardial infarction was excluded from the calculation of the Charlson index score. Charlson index scores were 0 to 1 for 921 patients (73%), 2 to 3 for 263 (21%), and greater than 3 for 77 (6%). Unadjusted means (+/- SD) lengths of stay in these groups were 4.4 +/- 5.2, 5.2 +/- 5.9, and 7.5 +/- 9.3 days, respectively. In multiple linear regression analysis, compared with Charlson index scores of 0 to 1, scores of 2 to 3 and greater than 3 were significant (p < .01) independent correlates of the log transformation of length of stay after adjusting for clinical data from the initial presentation and subsequent course (model R2 = .510). In an analysis restricted to the 795 patients without clinical complications, a Charlson index score greater than 3 was an independent correlate of length of stay compared with scores of 0 to 1 (p < .01). Individual comorbid conditions were not significant correlates of length of stay after controlling for Charlson index score.

CONCLUSIONS

In this population of patients with acute chest pain, comorbidity as measured with the Charlson index was independently associated with length of stay after adjustment for other clinical data. After adjusting for the Charlson index, no separate comorbid condition was significantly correlated with length of stay. These findings suggest that the Charlson index can be used to adjust for comorbidities in analyses of length of stay for patients with this condition.

General hospital psychiatry and the new behavioral health care delivery system

Mental health care delivery has undergone substantial changes in recent years. This article reviews the evolution of managed care in the mental health care field and outlines managed behavioral health care techniques used in providing access to high-quality, cost-effective care. The expansion of general hospital psychiatry over the last 25 years is also reviewed. Current strengths of general hospital psychiatry which make it well positioned for an expanded role in behavioral health care delivery are examined. Recommendations are made for further improvements in the clinical, administrative, and financial aspects of general hospital psychiatry care delivery to prepare it for the integrated behavioral health care systems of tomorrow.