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

Does embedding pediatric eating disorder treatment in primary care bridge the access gap?

Given the numerous barriers to accessing child and adolescent eating disorder treatment, there is a need for innovation in how this care is delivered. Primary care-based eating disorder treatment has established proof-of-concept, yet it is unclear whether this model can bridge the treatment-access gap. This retrospective chart review study compared demographic and illness characteristics of 106 adolescents (M age = 15.1 years)  SD = 1.8 consecutively evaluated in a primary care-based eating disorder clinic with 103 adolescent patients (M age = 15.2 years)  SD = 2.2 seen consecutively in a specialty eating disorder clinic at the same medical center. Relative to adolescents in specialty care, those in the primary care group presented at a significantly higher BMI percentile, had less weight suppression, a shorter illness duration, lower rates of amenorrhea and lower scores on the EDE-Q Dietary Restraint subscale. In addition, more patients in the primary care group identified as non-white and had government/public assistance insurance compared to those in the specialty group. The results suggest that, compared to traditional specialty care clinics, embedded eating disorder treatment in primary care may reach a more racially and socioeconomically diverse group of adolescents when they are earlier in the course of their illness. Future research determining the relative effectiveness of this model as compared to interventions delivered in specialty care is needed.

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.

Canadian practice guidelines for the treatment of children and adolescents with eating disorders

OBJECTIVES

Eating disorders are common and serious conditions affecting up to 4% of the population. The mortality rate is high. Despite the seriousness and prevalence of eating disorders in children and adolescents, no Canadian practice guidelines exist to facilitate treatment decisions. This leaves clinicians without any guidance as to which treatment they should use. Our objective was to produce such a guideline.

METHODS

Using systematic review, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, and the assembly of a panel of diverse stakeholders from across the country, we developed high quality treatment guidelines that are focused on interventions for children and adolescents with eating disorders.

RESULTS

Strong recommendations were supported specifically in favour of Family-Based Treatment, and more generally in terms of least intensive treatment environment. Weak recommendations in favour of Multi-Family Therapy, Cognitive Behavioural Therapy, Adolescent Focused Psychotherapy, adjunctive Yoga and atypical antipsychotics were confirmed.

CONCLUSIONS

Several gaps for future work were identified including enhanced research efforts on new primary and adjunctive treatments in order to address severe eating disorders and complex co-morbidities.

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.

Rate of weight gain as a predictor of readmission in adolescents with eating disorders

BACKGROUND

Readmission after hospital discharge is common in adolescents with eating disorders. Studies on the association between rapidity of weight gain and readmission are inconsistent. With an emphasis on more rapid weight gain during hospitalization, the effect of this strategy on readmission rates warrants further investigation.

OBJECTIVE

This project explored the relationship between rate of weight gain during hospitalization and medically necessitated readmissions.

SUBJECTS

Eighty-two patients who: were admitted due to an eating disorder during a 5-year period; achieved weight restoration to ≥84% of ideal body weight (IBW); had a follow-up visit with the adolescent medicine service after discharge; and, had information available on rate of weight gain.

METHODS

Data were extracted from medical records. Multiple logistic regression was used to analyze the effect of rate of weight gain on readmission. The effect of a comorbid psychiatric diagnosis was tested for an interaction.

RESULTS

Of patients 20.7% required readmission. The median rate of weight gain was 118.6 g/day [interquartile range (IQR) = 91.8-150.8]. There was a 1.8 times [95% confidence interval (CI) = 0.9-3.6, p = 0.087] greater odds of readmission with each increase in weight gain quartile after adjusting for potential confounders. Patients in the lowest rate of weight gain quartile and no psychiatric co-morbidity had a significantly lower predicted probability of readmission (25.1%) compared to those with a psychiatric comorbidity and in the highest quartile of rate of weight gain (48.4%).

CONCLUSION

Patients with eating disorders who have rapid inpatient weight gain and psychiatric co-morbidities may be at increased risk for readmission.

A systematic review of the health-related quality of life and economic burdens of anorexia nervosa, bulimia nervosa, and binge eating disorder

PURPOSE

To perform a systematic review of the health-related quality of life (HRQoL) and economic burdens of anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED).

METHODS

A systematic literature search of English-language studies was performed in Medline, Embase, PsycINFO, PsycARTICLES, Academic Search Complete, CINAHL Plus, Business Source Premier, and Cochrane Library. Cost data were converted to 2014 Euro.

RESULTS

Sixty-nine studies were included. Data on HRQoL were reported in 41 studies (18 for AN, 17 for BN, and 18 for BED), on healthcare utilization in 20 studies (14 for AN, 12 for BN, and 8 for BED), and on healthcare costs in 17 studies (9 for AN, 11 for BN, and only 2 for BED). Patients' HRQoL was significantly worse with AN, BN, and BED compared with healthy populations. AN, BN, and BED were associated with a high rate of hospitalization, outpatient care, and emergency department visits. However, patients rarely received specific treatment for their eating disorder. The annual healthcare costs for AN, BN, and BED were €2993 to €55,270, €888 to €18,823, and €1762 to €2902, respectively.

CONCLUSIONS

AN, BN, and BED have a serious impact on patient's HRQoL and are also associated with increased healthcare utilization and healthcare costs. The burden of BED should be examined separately from that of BN. The limited evidence suggests that further research is warranted to better understand the differences in long-term HRQoL and economic burdens of AN, BN, and BED.

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

BACKGROUND

Admission to hospital is the treatment of choice for anorexia nervosa in adolescent patients who are medically unstable; however, stays are often prolonged and frequently disrupt normal adolescent development, family functioning, school and work productivity. We sought to determine the costs of inpatient treatment in this population from a hospital and caregiver perspective, and to identify determinants of such costs.

METHODS

We used micro-costing methods for this cohort study involving all adolescent patients (age 12-18 yr) admitted for treatment of anorexia nervosa at a tertiary care child and adolescent eating disorder program in Toronto, between Sept. 1, 2011, and Mar. 31, 2013. We used hospital administrative data and Canadian census data to calculate hospital and caregiver costs.

RESULTS

We included 73 adolescents in our cohort for cost-analysis. We determined a mean total hospital cost in 2013 Canadian dollars of $51 349 (standard deviation [SD] $26 598) and a mean total societal cost of $54 932 (SD $27 864) per admission, based on a mean length of stay of 37.9 days (SD 19.7 d). We found patient body mass index (BMI) to be the only significant negative predictor of hospital cost (p < 0.001). For every unit increase in BMI, we saw a 15.7% decrease in hospital cost. In addition, we found higher BMI (p < 0.001) and younger age (p < 0.05) to be significant negative predictors of caregiver costs.

INTERPRETATION

The economic burden of inpatient treatment for adolescents with anorexia nervosa on hospitals and caregivers is substantial, especially among younger patients and those with lower BMI. Recognizing the symptoms of eating disorders early may preclude the need for admission to hospital altogether or result in admissions at higher BMIs, thereby potentially reducing these costs.

Comparing online and face-to-face dissonance-based eating disorder prevention

Disordered eating behavior is common in college women. Thus, it is important to develop programs to reduce eating disorder (ED) risk. Studies suggest that dissonance-based (DB) prevention programs successfully reduce ED risk factors; however, face-to-face DB groups lack anonymity and convenience. One way to address these barriers is to adapt DB programs for online use. Few studies have examined the feasibility of this delivery mode. This study compared the efficacy of an online DB program with a face-to-face DB program and an assessment-only condition. Undergraduate women (N = 333) recruited from a participant pool at a public university in the mid-Atlantic United States participated (n = 107 face-to-face DB, n = 112 online DB, n = 114 assessment-only). It was hypothesized that: (a) participants in the face-to-face and online DB conditions would report greater decreases in thin-ideal internalization, body dissatisfaction, and ED symptoms at post-testing relative to participants in the assessment-only control group, and (b) online and face-to-face programs would yield comparable results. Modified intent-to-treat analyses indicated that participants in both conditions manifested less body dissatisfaction at post-test compared with assessment-only participants; there were no significant differences in outcomes between the two modes of program delivery. These findings indicate that DB ED prevention programs can be successfully adapted for online use. Future studies should continue to refine online adaptations of such programs and examine their effects with samples that include older and younger women, and men.

Cost-of-illness studies and cost-effectiveness analyses in eating disorders: a systematic review

OBJECTIVE

To review cost-of-illness studies (COIs) and cost-effectiveness analyses (CEAs) of eating disorders (EDs) and to describe their methodological quality.

METHOD

A systematic literature search was done. Search results passed through a selection process, included studies were classified as COIs, CEAs, or "other cost studies" (OCS). Costs were inflated and converted to 2008 US$ purchasing power parities (PPP). Quality criteria were developed and applied to each study.

RESULTS

Five COI, two CEA, and eleven "OCS" were reviewed. Most studies focused on anorexia nervosa and bulimia nervosa. Annual costs per patient ranged from 1,288 to 8,042 US$-PPP. All interventions, investigated in CEA, were more effective and less costly than the alternative treatments.

DISCUSSION

The number of publications investigating costs in EDs has increased recently. However, no COI provided a comprehensive estimate of costs, and the comparability of CEA was limited. Nonetheless, the results indicate that the costs arising from EDs are substantial.