Evaluation of medical-psychiatric consultation

The effectiveness of consultation-liaison psychiatry in the general hospital setting: a systematic review

OBJECTIVE

The aim of this study was to review how the effectiveness of consultation liaison psychiatry (CLP) services has been measured and to evaluate the strength of the evidence for effectiveness.

METHODS

Systematic review of medical databases using broad search terms as well as expert opinion was sought. The literature search was restricted to studies of general, whole-of-hospital inpatient CLP services.

RESULTS

Forty articles were found and grouped into five measurements of effectiveness: cost effectiveness including length of stay, concordance, staff and patient feedback, and follow-up outcome studies. All measurements contributed to the evaluation of CLP services, but no one measure in isolation could adequately cover the multifaceted roles of CLP. Concordance was the only measurement with an established, consistent approach for evaluation. Cost effectiveness and follow-up outcome studies were the only measures with levels of evidence above four, however the three follow-up outcome studies reported conflicting results. Subjective evidence derived from patient and staff feedback is important but presently lacking due to methodological problems. The effectiveness of CLP services was demonstrated by cost-effectiveness, earlier referrals to CLP predicting shorter length of stay, and concordance with some management recommendations.

CONCLUSION

There is evidence that some CLP services are cost-effective and reduce length of stay when involved early and that referrers follow certain recommendations. However, many studies had disparate results and were methodologically flawed. Future research should focus on standardising patient and staff feedback, and short-term patient outcomes.

The timing of psychiatric consultation requests. Utilization, liaison, and diagnostic considerations

Psychiatric consultation timing results from the interaction of multiple systems. This study examines the key clinical and systems variables and the effect of consultation timing on subsequent length of hospital stay. One hundred and forty-five consecutive psychiatric consultations at a New York City teaching hospital were assessed by demographic criteria, medical and psychiatric diagnoses, reasons for consultation, and the timing of the consultation with respect to the academic year. Twenty-five percent of the consultations occurred within the first 48 hours after admission and 32% occurred between Days 2 and 5. Consultations for schizophrenia patients were called earlier (P < 0.02) than those for patients with other diagnoses, and those for patients with the acquired immunodeficiency syndrome were called later (P < 0.04). Earlier consultations were associated with a shorter time to discharge (P < 0.002).

The attitudes of medical inpatients toward psychiatric consultation: a re-examination

OBJECTIVE

Several surveys from twenty to thirty years ago demonstrated that approximately 80 percent of patients were readily accepting of psychiatric consultation. The aim of this study was to re-examine whether medical inpatient attitudes toward psychiatric consultation have changed in the past twenty-five years and whether the type of psychiatric disorder affects the attitude toward consultation.

METHOD

Forty-eight medical inpatients seen in psychiatric consultation consented to answering a questionnaire pre- and post-consultation to assess their attitudes to this intervention. Chi-square and t-tests were used to determine statistically significant differences between the "before" and "after" consultation groups.

RESULTS

Eight-one percent stated they would be moderately, to very, agreeable to psychiatric consultation if their primary care doctor felt it was indicted. Sixty-seven percent claimed not to have been informed beforehand that a psychiatric consultation was requested. Only 8 percent of patients were disinterested in having the consultation. Psychiatric diagnosis (primary vs. organic) and the attitude toward psychiatric consultation were not significantly related.

CONCLUSIONS

Our results show little change in attitude over the past twenty-five years and support earlier studies that show medical inpatients are generally accepting of psychiatric consultation, that consultation does not pose a threat to the doctor-patient relationship, and that careful preparation of the patient by the primary care provider can improve patients' attitudes toward the consultation.

Consultee satisfaction with a psychiatric consultation-liaison nursing service

A consumer satisfaction survey was conducted with nurses who made consecutive consultation requests to a general hospital psychiatric consultation-liaison nursing service. In each of 69 responses, global satisfaction ratings indicated that the consultee either was satisfied or very satisfied with the assistance provided. Particular strengths were noted in relation to the ease with which the consultants could be notified, the speed of response, and the clarity with which their formulations were expressed. The respondents were least satisfied with the extent of written documentation and the amount of follow-up. In a multiple regression analysis, only the total number of visits emerged as a significant predictor of satisfaction scores. However, comparisons of replies of most satisfied and least satisfied also indicated that high satisfaction ratings were more likely to be given to consultations requesting assistance with patients' families rather than to consultations requesting help in the management of patients with major psychiatric disorders.

Interventions in consultation/liaison psychiatry. Part II: Concordance

The psychiatric consultant is dependent upon the consultee for the implementation of many of his or her recommendations. Therefore, research as to the fate of recommendations suggested to the consultee is of eminent importance. The concordance (performing a suggested recommendation) paradigm, as developed by Popkin et al. is further elaborated for biologic and psychologic, as well as social, recommendations that were described in an earlier study. The results of the assessment of consultee concordance for 317 psychiatric consultation patients are described. Specific attention is directed to the development of criteria, the method of assessment, the mechanisms underlying nonconcordance, and the description of methods to enhance concordance. This study indicates that assessment of and control for concordance needs to be an integrated part of all consultation/liaison psychiatry (C/L) intervention studies in order to document the actual implementation of recommendations, accurately assess the findings of C/L outcome research, and avoid error measurement.

Effect of liaison psychiatry on attitudes toward psychiatry, rate of consultation, and psychosocial documentation

Prior literature suggested that psychiatric liaison on medical wards would produce a more positive attitude towards psychiatry, more psychosocial chart documentation, and a higher consultation request rate. Over 3 years, liaison was conducted on two medical wards, and its effect was contrasted with two control (consultation only) medical wards. Liaison activities were more favorably received by consultees than consultation alone and increased the consultation request rate, but produced no change in psychosocial documentation. Additional effectiveness of liaison activities might be achieved through direct, focused interventions, and through active involvement of senior medical faculty.

Pitfalls and pratfalls in consultation-liaison psychiatry in a general hospital

As Consultation-Liaison Services continue to develop and expand in general hospitals, psychiatrists must be aware of pitfalls and pratfalls inherent in dealing with medical colleagues and other allied health professionals, as well as with the patients. Practical considerations in answering consultation requests are discussed with respect to "hidden agendas" of the consultee, role and expectations of the psychiatrist, and problem referrals. It is only through mutual respect and collaboration that Consultation-Liaison Services can truly be effective.

Interventions in consultation-liaison psychiatry: the development of a schema and a checklist for operationalized interventions

A literature review and pilot investigations reveal that (ward-) management consultation-liaison (C/L) psychiatry recommendations are infrequent and unsystematically used. Furthermore, the communication with the operational group as defined by Meyer and Mendelson is not sufficiently activated. The major focus of the consultation is the first contact, but follow-up is infrequent. With the exception of biologic recommendations and disposition, chart notes by psychiatric consultants do not sufficiently specify the actions to be taken by the ward staff in a general hospital. A schema for the systematic organization of the intervention was developed. A checklist of operationalized C/L interventions is reported. This combination provides a tool for the systematic use of strategic ward management and discharge recommendations. Its basic structure is currently integrated in MICRO CARES [Hammer et al, SCAMC]. The impact on clinical care, education, and research is described.

Psychiatric consultations in a military general hospital. A report on 1065 cases

The authors describe the demographic and diagnostic characteristics of 1065 medical and surgical inpatients referred for psychiatric consultation over a 1-year period at a military medical center. The referral rate was 5.8% of all hospital admissions with the percentage of referrals from surgical and neurology services being higher than recent civilian studies. Although the variety and frequency of psychiatric and physical disorders are quite similar to civilian consultation-liaison (C/L) psychiatric services, the authors reported lower rates of personality disorder diagnoses and higher percentages of V code and no-psychiatric-disorder diagnoses.

The general hospital psychiatrist: too many tasks and too few roles?

What should the general hospital psychiatrist do, and how should he do it? In psychiatric settings, psychiatrists may legitimately confine their attention to those patients whose disorders can be classified according to ICD-9, but in general hospital settings, the same approach defines a very restricted range of activities. Evidence is reviewed which highlights the differences between psychiatric disorders encountered in psychiatric hospitals and those found in primary care or general hospital settings. Different activities proposed for the general hospital psychiatrist, and the results of research comparing these, are reviewed. A recent study is discussed in which alteration of the psychiatrist's method of practice in a general medical unit produced considerable changes in the pattern of psychiatric referrals. Evaluation of the efficacy of their interventions should remain the ultimate goal of general hospital psychiatrists. This can be adequately undertaken only by means of better understanding of the process by which general hospital patients attract psychiatric referral.

The relationship between attitudinal and behavioral change in pediatric residents in a psychiatric liaison teaching program: a pilot study

Two behavioral measures--chart audits and requests for psychiatric consultations--and two attitudinal measures--case conference comments and a case management questionnaire--were used to assess changes in pediatric residents' approaches to psychosocial issues over the course of liaison training. Both attitudinal measures showed changes in the residents' approaches, including an increased attention to patients' and families' feelings and an expanded awareness of the options available in dealing with psychosocial problems. These changes in attitude, however, did not result in increases in the amount of psychosocial data recorded in the charts or increases in resident-initiated consultation requests. The authors use their observations on the wards and in case conferences and interviews with pediatric residents to explain why chart contents and psychiatric consultation practices are resistant to change. Their findings indicate a gap between attitudinal and behavioral change that requires further research on how pediatric residents identify psychosocial problems, and how liaison training is integrated with the needs and expectations of nonpsychiatric physicians.

Psychiatric consultations in a Dutch university hospital: a report on 1814 referrals, compared with a literature review

A report is presented of four years of psychiatric consultations with inpatients in the University Hospital Leyden, The Netherlands. The characteristics of these 1814 consultations are compared with a comprehensive review of 42 publications (mostly from the United States) on psychiatric referral patterns in general hospitals. Compared to the literature, the present study covers a long period of investigation and a high number of consultations in quite a large hospital. Yet, the figures in this report are surprisingly similar to the median numbers that can be compiled from the literature. There is, however, a striking lack of conformity in the classifications used by authors in reporting reasons for referral, psychiatric diagnoses, and the actions of psychiatric consultants. A plea is made, therefore, for better definition and classification of patients seen by consultation-liaison services.

Current trends in consultation-liaison psychiatry

Consultation-psychiatry has grown rapidly and become a subspecialty of psychiatry in the past decade. The author reviews the history of this field at the interface of psychiatry and medicine, offers its definition, and discusses current trends pertaining to the organization of liaison services and to the teaching and research activities of liaison psychiatrists. He concludes that a liaison service has become a recognized division of a general hospital psychiatric unit for the provision of psychiatric consultation and teaching to the nonpsychiatric departments of the hospital. Consultation-liaison psychiatry (or liaison psychiatry for short) has emerged in the past decade as a subspecialty of psychiatry, one concerned with mental health problems among medical and surgical patients. Diagnosis, treatment, study and prevention of psychiatric disorders in those patients constitute the proper domain of liaison psychiatry. I will review in this article the major current trends in this field as they pertain to matters of organization, education, and research. A brief historical note and a definition of liaison psychiatry will introduce my review.

Impact of inter-physician communication on the effectiveness of medical consultations

To evaluate the impact of the inter-physician communication on the effectiveness of consultations, consultations performed by general and subspecialty medical consultation services for one week both early and late in the academic year were prospectively evaluated. Physicians commonly requested consultations to get advice on diagnosis (56 percent), advice on management (37 percent), or assistance in arranging or performing a procedure or test (20 percent). Despite our very liberal definitions, the requesting physician and the consultant completely disagreed on both the reason for the consultation and the principal clinical issue in 22 (14 percent) of 156 consultations. Consultants were twice as likely as the requesting physicians to rate consultations as crucial for management (35 percent versus 18 percent, p = 0.001) because they gave significantly higher ratings when they and the requesting physicians did not agree on the reasons for consultation. Consultations ordered for very specific purposes, such as assistance in arranging or performing a test, were rated significantly higher by the requesting physicians. It was found that breakdowns in communication are not uncommon in the consultation process and may adversely affect patient care, cost effectiveness, and education.

Evaluative research in consultation-liaison psychiatry. Review of the literature: 1970-1981

In the last decade, the biopsychosocial concept of medicine had flourished clinically in the form of consultation-liaison (C-L) psychiatry. However, full acceptance by the medical profession will depend, in part, upon scientific demonstration that psychological and social factors influence biological medical illness, and that C-L psychiatric teaching and patient intervention can improve the medical treatment of patients. This review surveys the literature over the last 10 years that describes and evaluates C-L activities as they impact upon clinical medicine and medical education. A conceptual grid for organizing research in the field is presented that distinguishes decision-oriented, or descriptive studies, from conclusion-oriented, or outcome studies. Further, this grid specifies the focus of the C-L activity, either the patient or health care professional. It seems clear that the very recent shift from descriptive studies to more outcome-oriented research, particularly regarding patient outcomes, should be the direction of the future. A greater emphasis on defining the exact components of C-L work that are most useful is also indicated. Several other specific recommendations for evaluative research in C-L psychiatry conclude this review.