Alternatives to inpatient treatment in adolescents with anorexia nervosa: Effectiveness and characteristics of a new intensive model of day patient treatment

INTRODUCTION

Inpatient Treatment (IT) is the treatment of choice for moderate or severely ill adolescents with Anorexia Nervosa (AN). Nevertheless, it is expensive, and the risk for relapse or readmissions is high. A less costly alternative to IT is Day Patient Treatment (DP), which may also help to avoid relapses and readmissions because facilitates transition from hospital to community treatment.

AIM

To assess the effectiveness of the 11-hour DP program for Eating Disorders (DP-ED-11h), a new intensive DP treatment for adolescents with AN, with respect to weight recovery, avoidance of hospital admission and decrease of Length of Stay (LoS).

METHOD

A longitudinal, naturalistic study was carried out analysing clinical and sociodemographic variables from 77 patients with AN who were consecutively discharged from DP-ED-11h, during years 2015-2016.

RESULTS

There were 77 discharges. The average age was 14.4 years old (SD: 1.62). The LoS at DP-ED-11h was 28.9 days (SD: 18.5). The mean body mass index increased significantly at discharge (17.2 vs. 17.9, p<0.001) and at 12 months follow- up (17.9 vs. 19.3, p<0.001). Twenty nine (70.8%) of the patients treated at DP-ED-11h, who came from a less intensive setting, avoided an admission. Fourteen (18.2%) required readmission at DP-ED-11h within two years. The LoS at IT was significantly reduced (from 33 to 24 days, p<0.043).

CONCLUSION

DP-ED-11h has shown to be an effective resource as an alternative to IT for adolescents with moderate to severe AN. This new model has cost-effectiveness implications as it is a safe resource and is less costly than IT.

Development of a new statewide eating disorder service: The role of evidence in a real world setting

OBJECTIVE

There are three aims of this report. First, to describe how research evidence informed a service development rationale for a new statewide eating disorder service (SEDS) for people aged 15 years and older. Second, to examine the profile of people accessing SEDS in the first 2 years of its operation with respect to the three broad dimensions: illness stage, illness severity, and previous history of treatment. Finally, to examine which patient characteristics resulted in the recommendation of ongoing treatment contact with SEDS.

METHOD

Over a 2-year period (July 2014 to July 2016) 292 people were referred to the service, 171 (59%) who consented to have their data used in research.

RESULTS

Half of the referrals related to anorexia nervosa (AN; 51.2%), with the remainder split between bulimia nervosa (25.3%) and other specified feeding and eating disorders (23.5%); 65.9% had previously received treatment for an eating disorder. The initial information about the service was typically provided by the general practitioner/primary care physician. Compared with any other eating disorder diagnosis, people with AN were three times more likely to be recommended to retain treatment contact with SEDS.

DISCUSSION

Service development informed by research evidence, clinical expertise, and consideration of patients' characteristics, values, and circumstances, allows for a flexible but accountable development strategy.

Cost-effectiveness of focal psychodynamic therapy and enhanced cognitive-behavioural therapy in out-patients with anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a serious illness leading to substantial morbidity and mortality. The treatment of AN very often is protracted; repeated hospitalizations and lost productivity generate substantial economic costs in the health care system. Therefore, this study aimed to determine the differential cost-effectiveness of out-patient focal psychodynamic psychotherapy (FPT), enhanced cognitive-behavioural therapy (CBT-E), and optimized treatment as usual (TAU-O) in the treatment of adult women with AN.

METHOD

The analysis was conducted alongside the randomized controlled Anorexia Nervosa Treatment of OutPatients (ANTOP) study. Cost-effectiveness was determined using direct costs per recovery at 22 months post-randomization (n = 156). Unadjusted incremental cost-effectiveness ratios (ICERs) were calculated. To derive cost-effectiveness acceptability curves (CEACs) adjusted net-benefit regressions were applied assuming different values for the maximum willingness to pay (WTP) per additional recovery. Cost-utility and assumptions underlying the base case were investigated in exploratory analyses.

RESULTS

Costs of in-patient treatment and the percentage of patients who required in-patient treatment were considerably lower in both intervention groups. The unadjusted ICERs indicated FPT and CBT-E to be dominant compared with TAU-O. Moreover, FPT was dominant compared with CBT-E. CEACs showed that the probability for cost-effectiveness of FTP compared with TAU-O and CBT-E was ⩾95% if the WTP per recovery was ⩾€9825 and ⩾€24 550, respectively. Comparing CBT-E with TAU-O, the probability of being cost-effective remained <90% for all WTPs. The exploratory analyses showed similar but less pronounced trends.

CONCLUSIONS

Depending on the WTP, FPT proved cost-effective in the treatment of adult AN.

Family history of education predicts eating disorders across multiple generations among 2 million Swedish males and females

Purpose

To investigate which facets of parent and grandparent socio-economic position (SEP) are associated with eating disorders (ED), and how this varies by ED subtype and over time.

Methods

Total-population cohort study of 1,040,165 females and 1,098,188 males born 1973–1998 in Sweden, and followed for inpatient or outpatient ED diagnoses until 2010. Proportional hazards models estimated associations with parental education, income and social class, and with grandparental education and income.

Results

15,747 females and 1051 males in our sample received an ED diagnosis, with rates increasing in both sexes over time. ED incidence in females was independently predicted by greater educational level among the father, mother and maternal grandparents, but parent social class and parental income showed little or no independent effect. The associations with education were equally strong for anorexia nervosa, bulimia nervosa and ED not-otherwise-specified, and had increased over time. Among males, an apparently similar pattern was seen with respect to anorexia nervosa, but non-anorexia ED showed no association with parental education and an inverse association with parental income.

Conclusions

Family history of education predicts ED in gender- and disorder-specific ways, and in females the effect is observed across multiple generations. Particularly given that these effects may have grown stronger in more recent cohorts, these findings highlight the need for further research to clarify the underlying mechanisms and identify promising targets for prevention. Speculatively, one such mechanism may involve greater internal and external demands for academic success in highly educated families.

The MOSAIC study - comparison of the Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA) with Specialist Supportive Clinical Management (SSCM) in outpatients with anorexia nervosa or eating disorder not otherwise specified, anorexia nervosa type: study protocol for a randomized controlled trial

BACKGROUND

Anorexia nervosa (AN) is a biologically based serious mental disorder with high levels of mortality and disability, physical and psychological morbidity and impaired quality of life. AN is one of the leading causes of disease burden in terms of years of life lost through death or disability in young women. Psychotherapeutic interventions are the treatment of choice for AN, but the results of psychotherapy depend critically on the stage of the illness. The treatment response in adults with a chronic form of the illness is poor and drop-out from treatment is high. Despite the seriousness of the disorder the evidence-base for psychological treatment of adults with AN is extremely limited and there is no leading treatment. There is therefore an urgent need to develop more effective treatments for adults with AN. The aim of the Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions (MOSAIC) is to evaluate the efficacy and cost effectiveness of two outpatient treatments for adults with AN, Specialist Supportive Clinical Management (SSCM) and the Maudsley Model of Treatment for Adults with Anorexia Nervosa (MANTRA).

METHODS/DESIGN

138 patients meeting the inclusion criteria are randomly assigned to one of the two treatment groups (MANTRA or SSCM). All participants receive 20 once-weekly individual therapy sessions (with 10 extra weekly sessions for those who are severely ill) and four follow-up sessions with monthly spacing thereafter. There is also optional access to a dietician and extra sessions involving a family member or a close other. Body weight, eating disorder- related symptoms, neurocognitive and psychosocial measures, and service use data are measured during the course of treatment and across a one year follow up period. The primary outcome measure is body mass index (BMI) taken at twelve months after randomization.

DISCUSSION

This multi-center study provides a large sample size, broad inclusion criteria and a follow-up period. However, the study has to contend with difficulties directly related to running a large multi-center randomized controlled trial and the psychopathology of AN. These issues are discussed.

Cost-effectiveness of guided self-help treatment for recurrent binge eating

OBJECTIVE

Adoption of effective treatments for recurrent binge-eating disorders depends on the balance of costs and benefits. Using data from a recent randomized controlled trial, we conducted an incremental cost-effectiveness analysis (CEA) of a cognitive-behavioral therapy guided self-help intervention (CBT-GSH) to treat recurrent binge eating compared to treatment as usual (TAU).

METHOD

Participants were 123 adult members of an HMO (mean age = 37.2 years, 91.9% female, 96.7% non-Hispanic White) who met criteria for eating disorders involving binge eating as measured by the Eating Disorder Examination (C. G. Fairburn & Z. Cooper, 1993). Participants were randomized either to treatment as usual (TAU) or to TAU plus CBT-GSH. The clinical outcomes were binge-free days and quality-adjusted life years (QALYs); total societal cost was estimated using costs to patients and the health plan and related costs.

RESULTS

Compared to those receiving TAU only, those who received TAU plus CBT-GSH experienced 25.2 more binge-free days and had lower total societal costs of $427 over 12 months following the intervention (incremental CEA ratio of -$20.23 per binge-free day or -$26,847 per QALY). Lower costs in the TAU plus CBT-GSH group were due to reduced use of TAU services in that group, resulting in lower net costs for the TAU plus CBT group despite the additional cost of CBT-GSH.

CONCLUSIONS

Findings support CBT-GSH dissemination for recurrent binge-eating treatment.

Health care utilization in patients with eating disorders

OBJECTIVE

To examine health care costs among patients with eating disorders (EDs) using the Blue Cross Blue Shield of North Dakota claims database system.

METHOD

Four groups of individuals enrolled between 1999 and 2005 were identified: (1) a group diagnosed with EDs at the beginning of the study period, in 2000 or 2001; (2) a group diagnosed with EDs later in the study period, in 2004 or 2005; (3) a comparison group with depression; and (4) a non-eating disordered comparison group.

RESULTS

Health care costs were high for patients diagnosed with an ED during the period when the diagnosis was made but remained elevated in the years following. Such costs were consistently higher than those for the non-eating disordered comparison group, but similar to the depression comparison group.

DISCUSSION

Health care costs remained elevated after a diagnosis of an ED for an extended period of time.

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.

Residential treatment for eating disorders

OBJECTIVE

The current study describes residential treatment for eating disorders in the United States.

METHOD

A national study involving 22 residential eating disorder treatment programs was conducted using a survey to determine treatment program descriptions and trends. Data from 19 respondents, representing 86% of all residential treatment programs in the United States, were examined.

RESULTS

Residential treatment options for individuals with anorexia nervosa and bulimia nervosa are becoming increasingly more common. A wide variety of techniques and methods are employed in the treatment of individuals with eating disorders in residential treatment programs. The average length of stay in treatment was 83 days, with an average cost per day of 956 US dollars.

CONCLUSION

The residential treatment of individuals with eating disorders is a growing, variable, and largely unregulated enterprise. Future research is needed to focus on quantifying treatment program effectiveness in the residential treatment of individuals with eating disorders.

Health services research in anorexia nervosa

The present paper reviews studies of the delivery of health services for individuals with anorexia nervosa, utilizing four interrelated concepts that guide much of health services research: equity, effectiveness, efficiency, and economy. It identifies major gaps in knowledge regarding health services utilization and costs.

Unmasking a current medical pretender: anorexia nervosa in gastrointestinal practice

Anorexia nervosa (AN) resembles the 'great pretenders' of medicine in the nineteenth century, syphilis and tuberculosis, by presenting occultly as a disorder of specific organs. Many physicians fail to identify the true primary cause, AN, which can mimic in its medical consequences gastrointestinal disorders, endocrine failure, pituitary tumors, or cancer. This is especially likely when the patients are older, have an established complex medical history, and challenge a specialist to find a medical cause and treatment, resulting in ordering more laboratory tests and medical instrumentation. Everyone suffers as a result, including the patient, the family, the frustrated physician, and the National Health Service, for whom the costs of medical care of these patients are enormous and out of proportion. Remembering that AN is as much a medical as a psychological disorder, assessing the patient with more time and expertise in history taking, and referring to a psychiatric consultant when National Institute for Clinical Excellence guidelines for identifying AN in non-mental health settings trigger suspicions, results in good outcome of the AN, cessation of ineffective gastrointestinal treatments, and substantial savings to the National Health Service.

The cost-effectiveness of anorexia nervosa treatment

OBJECTIVE

Anorexia nervosa (AN) is an expensive-to-treat illness with a high mortality rate. Some health care systems have limited the amount of treatment provided for AN despite the lack of clearly documented efficacy for these limited-intensity approaches. One method that can inform decisions about AN treatment is cost-effectiveness analysis.

METHOD

Cost-modeling analysis was used to estimate the incremental cost-effectiveness of AN treatment. Modeling was chosen given the lack of primary data on costs and outcomes in AN treatment. Data for age of onset, life expectancy, and disease-associated mortality were taken from the literature. The costs of treatment used in the analysis were those in use at the University of Minnesota.

RESULTS

Assuming an approach consisting of inpatient weight restoration, followed by treatment of gradually diminishing intensity (partial hospitalization, then outpatient psychotherapy plus medication management), incremental cost-effectiveness ratios were calculated and compared with a limited intensity, "usual care" model. These assumptions yielded a cost per year of life saved of 30,180 dollars.

DISCUSSION

Relative to many other medical interventions, the comprehensive treatment of AN appears to be quite cost-effective in terms of cost per year of life saved. Such data may have an impact on payer decisions and underscore the serious nature of AN.

Anorexia nervosa: a 63-year population-based survival study

As eating disorders attract increasing publicity, more affected individuals will seek medical attention. Many will have needs for life insurance. Due to selection bias, most of the literature on anorexia nervosa (AN) presents an unfavorable prognosis. Therefore, the impairment is considered an adverse life insurance risk. This review is from an unselected, community population. The demographics of the study population and its expected mortality are similar to a population purchasing life insurance products. Comparative experience over 63 years of follow-up reveals mortality ratios and excess death rates similar to those expected for the population. High-risk comorbid diagnoses of depression and alcoholism are discussed.

Private health insurance for adolescents: is it adequate?

PURPOSE

To examine the nature and extent of private insurance coverage available for health services needed by six hypothetical adolescents with physical and mental health conditions.

METHODS

Health insurance information was obtained from the most commonly sold product of the largest health maintenance organization (HMO) and preferred provider organization (PPO) in each state and the District of Columbia. Contract documents were collected in 1999 and were in effect at the end of 1998. Our response rate was 97% and included 49 HMOs and 49 PPOs. The extent of coverage was analyzed according to benefit availability, structure, limits, and protections, as well as condition and treatment restrictions.

RESULTS

The two hypothetical adolescents with asthma and depression had coverage for their recommended health services in most of the 98 plans. However, the four hypothetical adolescents whose conditions included pregnancy and sexually transmitted disease, anorexia nervosa, injury, and substance abuse and bipolar disorder would rarely have access to coverage for all of their recommended services. Ancillary and behavioral health therapies were least likely to be available in the amounts considered necessary by medical experts. All of the hypothetical adolescents would be more likely to obtain coverage for certain services in HMO than in PPO plans.

CONCLUSIONS

Despite the obvious value of the private health insurance system, insurance benefits are not always matched to the needs of the adolescent. Employers and policymakers may want to consider financial or other incentives to create more uniformity in employer-based coverage, particularly for preventive care, prescription drugs, and reproductive services; greater availability of mental health and substance abuse benefits; and new mechanisms to support access to confidential care.

Anorexia nervosa: the cost of long-term disability

This study was performed to estimate the cost of long-term disability in people who have anorexia nervosa (AN) that live in the province of British Columbia (BC), Canada. Canada provides universal socialized health and welfare services, and each of the 10 provinces is responsible for its own funding. As the provincial government of BC does not categorize its disability payments by the cause of the disability, a survey was used to determine the rate of disability from AN. A sensitivity analysis was performed to assess the influence of variations on the yearly cost of disability in BC: the number of patients with AN was varied between 1.0 and 2.0% of the female and 0.05 and 0.1% of the male population; the percentage of patients with AN receiving disability payments was determined by the survey to be 35%; the cost of these payments was varied between the lowest and highest benefits a single person can receive from the BC provincial government; and finally, to allow for possible sampling bias and a possible lower prevalence of AN, the lower limit of the sensitivity analysis was derived by dividing the lowest estimate above by seven. The sensitivity analysis revealed that the total estimated cost of long-term disability in BC could be as low as $2.5 million (Canadian) or as high as $101.7 million per year, which is a cost of up to 30 times the total yearly cost of all tertiary care services for the treatment of eating disorders in BC. In view of this finding, an increase in funding is warranted for primary, secondary and tertiary prevention programs for AN in BC.

Questioning starvation

By comparing early modern cases of self-starvation with current theories of anorexia nervosa, this article explores the framing of the starving body as a cultural product, and questions the implications of culture in the perception and representations of the refusal of food. This allows a consideration of self-starvation as both a product and reflection of cultural values attributed to consumption, gender, and the body.

Future directions in obesity and eating disorders

The purpose of this article is to explore future directions in the treatment of obesity and eating disorders. After briefly reviewing the costs of eating disorders, in terms of morbidity, mortality, and economics, we provide suggestions for future research and treatment. We first focus on changes that should be considered to improve etiological and outcome research, with the idea that a better understanding of etiological factors will lead to better interventions. We then examine promising treatment approaches, public health initiatives, and the importance of focusing on health and self-acceptance as valid treatment outcomes.