Psychosomatics 41:366-367, August 2000
© 2000 The Academy of Psychosomatic Medicine
Integrating Medical and Psychiatric Treatment in an Inpatient Medical Setting
Alan Stoudemire, M.D. , Atlanta, Georgia Dr. Stoudemire died on February 2, 2000.
EDITOR'S NOTE: I hope that the two letters below on integrating medical and psychiatric treatment will stimulate further debate about the nature and viability of medical psychiatric units. Both Drs. Kathol and Stoudemire have directed such programs, and their views may lead to a synthesis that will offer new options for psychiatry in the general hospital, the arena where such units exist.
TO THE EDITOR: In the July-August, 1999 issue of Psychosomatics, Drs. Kishi and Kathol present an overview1 of the University of Iowa Hospital's Medical–Psychiatric Unit (MPU). They compare 105 directly and internally transferred admissions to their MPU with another group of 105 patients with concurrent medical-psychiatric problems directly admitted or transferred to traditional general internal medicine and subspecialty medicine wards (IMW) at the same institution. In this study, the protocol consisted of deriving medical and psychiatric diagnoses for both groups of patients from chart reviews. Psychiatric diagnosis was also assisted by using ancilliary sources of information such as family and nursing staff. In neither group were patients (MPU or IMW) directly interviewed using structured psychiatric diagnostic instruments to arrive at a diagnosis.
The authors then proceed to compare the two populations (MPU vs. IMW) on a number of variables, including medical diagnoses, psychiatric diagnoses, illness acuity, and length of stay (LOS). In respect to LOS, the authors note the following: 1) patients on the IMW with comorbid psychiatric illness had longer LOS compared with IMW patients without recordable active psychiatric illness; 2) the overall LOSs were longer on the MPU compared with the IMW units; but 3) if patients on the MPU who were transferred to the MPU from IMW are excluded from the LOS calculations, then the LOS of patients directly admitted to the MPU (who did not have a previous LOS on an IMW) was not significantly different from the LOS of the IMW patients who had comorbid medical-psychiatric illness.
The authors conclude that because most of the medical problems of the IMW patients with comorbid medical-psychiatric illness who were eventually transferred to the MPU could have been cared for on the MPU from the beginning as the IMW, significant cost savings could be derived for the hospital system by admitting most if not all patients with comorbid medical-psychiatric disorders directly to the MPU, which in reality is another subspecialty internal medicine unit. The Iowa MPU is administered under the Department of Medicine, and internists, administratively and for reimbursement purposes, serve as the primary attending physician for the MPU patients even though from the practical clinical standpoint the unit operates under a coattending model.
Drs. Kishi and Kathol then speculate about the cost savings that might theoretically be achieved by directly admitting patients with comorbid medical-psychiatric illness directly to an MPU. The authors argue that concurrent medical-psychiatric care on an MPU requiring one admission per hospital stay is more cost-effective than consecutive medical-psychiatric care involving two intrahospital admissions. Kishi and Kathol argue that two admissions (one to the IMW and the other to the MPU) for patients with medical-psychiatric illness is more expensive than a single MPU admission during a patient's hospital stay.
The authors also criticize "Type III" medical-psychiatric units using a hierarchical topology proposed by Dr. Kathol. Type III units in this I, II, III, and IV level hierarchy (medium-to-high psychiatric acuity and low-to-medium medical acuity) are operated under the auspices of psychiatric departments but are considered to be limited in the medical quality of care they can provide because, to quote the authors, Type III units are "located in the stand-alone psychiatric facilities." Among other criticisms of Type III MPUs, the authors contend that Type III units are "hampered by their ability to handle high-acuity medical illness" and "often lack an adequate level of medical nursing expertise...and the availability of medical physician coverage."
The authors are to be commended in their indirect attempt to prove the cost-effectiveness of MPUs. Such cost-effective care would facilitate the further growth and the development of MPUs in the current reimbursement environment. Dr. Kathol, in particular has been an outstanding leader in integrating medical-psychiatric care, training, and research. I would temper the author's conclusion because of the following:
First, the assignment of patients to the IMW vs. MPU groups was not random or blinded in regard to patient selection. Patients of the IMW were usually identified by nurses as having psychiatric problems and then brought to the attention of the authors for chart review.
Second, psychiatric diagnoses were assigned on the basis of chart review and information collected from collateral sources. The study's data in respect to the types and frequency of psychiatric illness in the two patient populations may not be sufficiently reliable for the research purposes, which are critically dependent on the accuracy of the psychiatric diagnoses rendered. For example, the study cannot account for patients whose active psychiatric problems could not be detected or confirmed by chart review or were missed by the nursing staff.
Third, the authors promote a model of medical-psychiatric care where such units are located under the auspices of the department of medicine, yet, the preponderance of psychiatric care is provided by attending psychiatrists or psychiatric residents. Although the psychiatric attendings may have submitted charges for consultations and follow-up care to the patients' insurance carriers (assuming the patients had coverage) given the LOS on the MPU=17.5 days, it is almost certain that only a small fraction of these consultation charges would have been reimbursed. Hence the "psychiatric" component of their model Type IV MPU is underwritten and supported by funds from the state of Iowa and other governmental funds that support this university hospital and its academic department of psychiatry. The real costs of providing the psychiatric care of these patients is not examined, nor are the financial losses to the department of psychiatry resulting from payment denials.
Fourth, the authors do not believe that Type III units, in which attending psychiatrists serve as the primary attending physicians or their nursing staffs, are as a rule, medically competent to care for high-medical-acuity patients and that Type III units are universally isolated outside of general hospital settings. Neither of these assumptions are valid and the authors present no data to support them.
Fifth, although the authors note that their study data were collected in 1994, it would be expected that a current MPU would be more outpatient focused in the range of services provided and have a "step-down" or transitional hospital day program in addition to an outpatient network of clinics or providers to provide follow-up care for this complex patient population. Any MPU in today's environment would be considered below standard, and clinically and fiscally inefficient to third-party payers without these transitional hospital and outpatient services readily available.
In all fairness, several of the above criticisms are noted to some degree by the authors. What needs to be emphasized is that Type III MPUs operated under departments of psychiatry within general hospital complexes remain viable models for patient care. The extent of medical acuity allowable on Type III units is, of course, determined by the medical skills and backgrounds of the psychiatric attending staff, the availability and support of the general medical and surgery staffs and their respective subspecialities, and the degree of dual medical-psychiatric skills possessed by the MPU nursing staff. Like any highly specialized treatment service, an MPU program will only be as successful as the dedication and skills of its leaders and the fiscal management of the unit
Drs. Kishi and Kathol are to be commended on their effort to demonstrate the cost-effectiveness of combined medical-psychiatric treatment programs. Analyzing the limitations of this study may serve a very useful purpose in efforts to plan more refined future research designed to demonstrate not only the cost-effectiveness of such programs but the cost-benefits of well-integrated systems of medical-psychiatric care.2–4
REFERENCES
-
Kishi Y, Kathol RG: Integrating medical and psychiatric treatment in an inpatient medical setting: the type IV program. Psychosomatics 1999; 40:345–355[Abstract/Free Full Text]
-
Kathol RG, Stoudemire A: Medical psychiatric units, in Textbook of Consultation-Liaison Psychiatry, Second Edition, edited by Rundell J, Wise M. Washington, DC, American Psychiatric Press, in press
-
Stoudemire A: Medical psychiatric units, in Textbook of Consultation-Liaison Psychiatry, First Edition, edited by Wise M, Rundell J. Washington, DC, American Psychiatric Press, 1996 pp 900–913
-
Psychiatric Care of the Medical Patient, Second Edition, edited by Stoudemire A, Fogel B, Greenberg D. Oxford, UK, Oxford University Press, 1999
Get information about faster international access.
Privacy Policy
Copyright © 2000
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
