Psychosomatics 43:24-30, February 2002
© 2002 The Academy of Psychosomatic Medicine
Medical Comorbidity in Psychiatric Inpatients
Relation to Clinical Outcomes and Hospital Length of Stay
Constantine G. Lyketsos, M.D., M.H.S.,
Gary Dunn, R.N., M.S.N.,
Michael J. Kaminsky, M.D., and
William R. Breakey, M.D., FRCPsych.
Received April 18, 2001; revised September 1, 2001; accepted September 6, 2001. From the Neuropsychiatry Service, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, Baltimore, MD. Address correspondence and reprint requests to Dr. Lyketsos, The Johns Hopkins School of Medicine, 600 North Wolfe St, Osler 320, Baltimore, MD 21287. E-mail: kostas{at}jhmi.edu
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ABSTRACT
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Medical comorbidity is common in psychiatric inpatients and may be associated with substantial impairment and mortality. Few studies have examined the relation between this comorbidity and psychiatric outcomes. A series of 950 admissions to the Johns Hopkins Hospital Phipps Psychiatric Service were rated by attending psychiatrists at admission and discharge on symptom and functional measures. A subset was also evaluated on the General Medical Health Rating, a valid and reliable measure of seriousness of medical comorbidity. Attending psychiatrists were also asked at discharge whether medical comorbidity had been a focus of care during the hospitalization; medical comorbidity had been a focus of care in about 20% of the patients. Serious active medical comorbidity was present in 15% of patients on admission and 12% at discharge. Medical comorbidity was associated with a 10%–15% increase in psychiatric symptoms and functional impairment at discharge, even after adjustment for admission clinical status. In addition, when comorbidity had been a focus of care during the hospitalization, length of stay was prolonged by 3.25 days on average. Medical comorbidity has measurable effects on the psychiatric outcomes of psychiatric inpatients and in some cases prolongs hospital stay. Psychiatrists should redouble their efforts to detect and treat this comorbidity and should consider whether special inpatient units might be needed to care for psychiatric patients with complex medical comorbidity.
Key Words: Diagnostic Tools • Comorbidity
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INTRODUCTION
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The medical comorbidity of psychiatric patients is a topic of increasing clinical and research interest. Several studies have documented high rates of comorbid medical illness in psychiatric patients.1,2 A wide range of comorbidity has been described, with chronic medical illnesses such as hypertension, heart disease, pulmonary disease, and diabetes being the most common.
The high rate of comorbid medical illness among psychiatric patients has multiple etiologies.2,3 There may be specific associations between medical illnesses and psychiatric illnesses. For example, an association between manic-depressive illness and diabetes mellitus has been attributed to genetic relations between the diseases or to pathogenic mechanisms that are common to both.3 Another link is that psychiatric patients are less motivated to seek care for medical illness. They are often neglectful of their health and self-care. Psychiatric medications also have health effects, such as impaired glucose tolerance, effects on renal function, effects on liver function, and many others. Medications used to treat medical illness often have psychiatric effects. Finally, psychiatric patients often have limited access to medical care.
Regardless of its cause, the association between psychiatric illness and medical comorbidity has important implications for patient care. The fact that comorbid medical illness is associated with worse medical outcomes is well established. Sternberg4 proposed that this occurs for three types of reasons: disease-related, patient-related, and physician-related, with the latter being the most important. For example, psychiatric patients are less likely to receive necessary medical care2 and have higher rates of morbidity and mortality from medical illnesses when compared with control populations.1 Mortality rates from comorbid medical illness are especially high when the psychiatric illness involves substance abuse, when patients are elderly, or when they suffer from "organic brain syndromes." Therefore, the standard of care for the psychiatrically ill requires that the detection and treatment of comorbid medical illnesses be a high priority. The principal goal of this effort is to reduce medical morbidity and its associated mortality.
The relation between medical comorbidity and psychiatric outcomes has received considerably less attention. It is possible that medical illness among psychiatric patients leads to worse psychiatric outcomes. For example, medically ill psychiatric patients might have more severe psychiatric symptoms, might have greater functional impairment, and might have longer lengths of stay when hospitalized on psychiatric units. Although this hypothesis makes sense intuitively, it has limited empirical support. After a MEDLINE search and upon inspection of recent reviews on the topic,1,2 we could find only two studies that addressed the question of how the medical comorbidity of psychiatric patients influences psychiatric outcomes. Sloan et al.5 reported that the presence of a physical diagnosis in depressed inpatients was associated with a stay on the psychiatric unit of a general hospital that was on average 4 days longer. Their study did not assess the impact of medical comorbidity on other psychiatric outcomes, such as psychiatric symptoms or psychosocial functioning.
Kishi and Kathol6 reported on the benefits of an innovative treatment program, a "Type IV" medicine and psychiatry inpatient unit. A Type IV unit is designed to care for chronic psychiatric patients with active and complex medical comorbidity. When outcomes from a Type IV unit were compared with those from a traditional psychiatric unit, psychiatric outcomes, including length of stay (LOS), were better on the Type IV unit. In contrast, medical outcomes were similar in the two types of units. This finding suggests that in general inpatient units, the detection and treatment of medical comorbidity in psychiatric inpatients are successful with regard to medical outcomes. In contrast, for inpatients with significant medical comorbidity, further improvements in care, perhaps through the establishment of Type IV units, might lead to better psychiatric outcomes as well, although not necessarily improvements in medical outcomes.
In recognizing the possibility that medical comorbidity might adversely affect psychiatric outcomes, we sought to investigate the impact of medical comorbidity on several clinical outcomes among psychiatric inpatients. We specifically hypothesized that inpatients with more severe medical comorbidity or in whom medical comorbidity required active management during the hospitalization would have worse psychiatric outcomes. We also hypothesized that medical comorbidity would be associated with a longer stay in the hospital.
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METHODS
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Design
This was a naturalistic observational study. Beginning in the fall of 1999, clinical outcome ratings have been made on psychiatric inpatients at the Johns Hopkins Hospital in Baltimore. These ratings are made at admission and at discharge for the purpose of monitoring clinical outcomes. The information collected includes the following: 1) sociodemographic characteristics (age, race, gender); 2) psychiatric discharge diagnoses; 3) admission and discharge ratings of psychosocial functioning and psychiatric symptomatology; 4) admission and discharge ratings on the Global Assessment of Functioning (GAF) scale7; and 5) hospital LOS, as determined by the hospital administration using standard definitions in the process of reporting to the State of Maryland.
As of the spring of 2000, the General Medical Health Rating (GMHR)8 has also been obtained at admission and discharge. Because these data were collected on all patients for clinical purposes and recorded without identifiers, the data collection and analyses were exempt from Institutional Review Board review.
Participants
Since its inception, this database has information on a total of 950 inpatients; given that there was a 6-month delay in including GMHRs on all admissions, data involving the GMHR have been collected on a subsample of 571 patients. The analyses reported here included data from all patients (n = 950), except for analyses involving the GMHR, for which we included data only on patients who were rated on the scale (n = 571).
Procedure
After admission of each patient to the hospital, typically within 48–72 hours, the attending physician was asked to provide clinical information, including rating the patient on several standardized scales (see below). Similarly, within a few days of discharge, the attending psychiatrist was asked to repeat the ratings on the same scales and to provide one or more discharge diagnoses, using DSM-IV criteria.7 These data were collected on specific forms that were entered into a database by one of the authors (G.D.).
Study Measures
The principal independent variable under study was medical comorbidity. This was assessed in two ways.
1) At the time of discharge, the attending psychiatrist was asked to state whether medical comorbidity had played a role in the clinical care of the patient during his or her hospital stay. The response was recorded as a "yes/no" variable.
2) At the time of admission, and also at the time of discharge, the attending psychiatrist rated each patient on the GMHR.8 The GMHR is a rapid, global rating of the severity of medical comorbidity that can be performed at the bedside. Severity of psychiatric illness does not contribute to the rating. The GMHR was originally designed for use in patients with dementia, but has application in the rating of medical comorbidity in psychiatric patients in general. It has high inter-observer reliability (kappa = 0.93).8 Also, it has high concurrent validity, given that GMHR is correlated with the number of active medical conditions and medications. Lower GMHR is also associated with greater impairment in the performance of activities of daily living. Furthermore, it is predictive of the frequency of falls and time to death for patients with dementia.8 The GMHR is scored on a four-point scale: 4 = excellent health; 3 = good health; 2 = fair health; and 1 = poor health. Appendix 1 contains the GMHR scale and its anchors. Ratings are made after obtaining a medical history, reviewing systems, and briefly interacting with the patient. Clinicians are encouraged to use their clinical judgment in making GMHRs, focusing on the severity of medical comorbidity and current general health.
The dependent variables in this study included psychiatric symptomatology, psychosocial functioning, and GAF scale ratings at admission and discharge. These were assessed as follows.
1) Ratings of psychiatric symptomatology were made by attending psychiatrists at admission and at discharge. Specifically, the psychiatrists were asked to rate each patient in terms of the severity of the patient's symptoms in each of the following ten domains: cognitive, perceptual, affective, anxious, somatic, substance abuse, behavioral, risk of harm to self, risk of harm to others, and other risks. Ratings were made on a four-point Likert scale: 0 = "none"; 1 = "mild"; 2 = "moderate"; and 3 = "severe." The scores for each domain were then added to form a total score of Psychiatric Symptom Severity (PSS). Scores could range between 0 and 30, with higher scores indicating greater severity of psychiatric symptoms.
2) Ratings of psychosocial functioning on admission and discharge were made by psychiatrists on a four-point Likert scale: 0 = "no impairment"; 1 = "mild impairment"; 2 = "moderate impairment"; and 3 = "severe impairment." Separate ratings were made in the following seven domains: job/school, financial, physical health, legal, friends/social, residential, and substance abuse. The scores were added to produce a total Functional Impairment Rating (FIR). Scores could range between 0 and 21, with higher scores indicating more severe functional impairment.
3) On admission and discharge, psychiatrists were asked to rate the patients on the GAF scale.
Analyses
To assess the influence of GMHR or whether medical comorbidity was a focus of care during the hospitalization, we estimated a series of analysis of variance (ANOVA) models. The independent variable was the GMHR or the rating of whether medical comorbidity was a focus of care. The dependent variable was the discharge FIR, the discharge PSS, or the discharge GAF. In addition, in other ANOVAs, LOS was the dependent variable. These analyses allowed us to compare the means at discharge on all these measures across GMHRs, or across the two levels of whether or not comorbidity was a focus of care.
Given that discharge ratings on the above outcome measures were associated with ratings on the same measures at admission, we also estimated linear regression models in which we adjusted for admission ratings on the same scale to evaluate the independent effect of GMHR on discharge ratings. Specifically, in these regressions we used the same dependent and independent variables as for the ANOVAs described above. In addition, we included as a covariate the attending psychiatrist's admission rating on the same scales. For example, in the linear regressions in which discharge FIR was the dependent variable, we included as independent variables both GMHR and the admission FIR. The latter analysis is similar to an analysis of the effect of GMHR on changes in FIR, PSS, or GAF from admission to discharge.
The study groups were compared only four times, on each of the four study outcomes (PSS, FIR, GAF, and LOS). Further, adjustments were made in regressions for other covariates, such as the Health Care Financing Administration (HCFA) "Case Complexity Rating." Also, P values were <0.0001 in almost every case, which would have met even the most stringent Bonferroni correction. Therefore, we do not think that the study has a multiple-comparisons problem or that a correction is needed.
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RESULTS
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Study Population
The mean age of the psychiatric inpatients included in the study was 39.7 years (standard deviation 14.6, range 13–98 years). Twenty-six patients (2.7%) were <18 years of age, and 75 (7.9%) were >65 years old. Fifty-one percent were female; 58% were black, 40% were white, and the remainder were of other ethnic backgrounds. Table 1 displays the final discharge diagnoses. Because most patients received more than one diagnosis, the numbers in the table add up to more than 100%.
Medical Comorbidity in Psychiatric Inpatients
The attending psychiatrists reported that for 196 of 950 patients (20.6%), medical comorbidity had been a focus of care during the hospitalization. GMHRs were made on 571 patients and are displayed in Table 2, where admission and discharge ratings are cross-tabulated. At the time of admission, slightly more than half were rated to have excellent health, meaning essentially no medical comorbidity. Approximately 15% of patients at admission and 12% at discharge had fair or poor health, implying substantial medical comorbidity. Overall, the admission and discharge GMHRs were similar. Seventy-two patients (12.6%) received a different GMHR at discharge. As seen in the table, most patients (62 of 72, or 86%) at discharge had an improved general health rating.
Relation Between Medical Comorbidity on Admission and Psychiatric Outcomes
Table 3 contains the mean scores at discharge on the PSS, FIR, and GAF, as well as the mean LOS across different admission ratings on the GMHR. It also compares the means on these scales and on LOS for patients for whom medical illness had been a focus of care during the hospitalization. These means were compared using ANOVA. The presence of more serious medical comorbidity (lower ratings on the GMHR) was associated with lower GAF scores and more severe psychiatric symptomatology at discharge. This association between GMHR and discharge GAF or PSS ratings was small but statistically significant.
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TABLE 3. Mean scores at discharge for Functional Impairment Rating, Psychiatric Symptom Severity, Global Assessment of Functioning, and Length of Stay by admission GMHR or by whether medical comorbidity was a focus of care during the hospitalization
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With regard to the significant relation between GMHR and LOS, patients in "fair" health had substantially longer LOS, typically about 6 days longer, than patients with "good" or "excellent" health on admission. The short LOS for patients in "poor" health was in part due to the medical morbidity itself, which necessitated transfer to a medical unit for two patients, and the fact that another three patients were transferred from a medical unit where psychiatric care had already been initiated.
Table 3 displays the relation between whether medical illness was a focus of care during the hospitalization and discharge ratings. With regard to discharge FIR or GAF scores, there was no significant association with this variable. However, the patients for whom medical comorbidity was a focus of care had more impaired discharge PSS ratings. Similarly, for patients whose comorbidity had been a focus of care, LOS was significantly longer by an average of 5.4 days.
Adjustment for Clinical State
Clinical state at admission is intuitively associated both with medical comorbidity and with clinical outcomes at discharge. To confirm an independent relation between medical comorbidity and clinical psychiatric outcomes, we estimated a series of regression models to adjust for the effects of admission clinical state on the relation between medical comorbidity and discharge outcomes. Table 4 displays a summary of the findings in these models. The table shows the unstandardized coefficient (beta) and its associated P value for regression models in which the independent variable was GMHR or whether comorbidity was a focus of care. The dependent variable was discharge PSS, discharge FIR, discharge GAF, or LOS. Each of these models incorporated as an independent covariate the relevant admission rating, which is the admission PSS or FIR or GAF. In the models in which LOS was the dependent variable, we adjusted for the HCFA "Case Complexity Rating." This rating was developed by the Health Care Services Administration to grade case complexity, and is made on all hospital discharges in the United States using a special formula that is too complicated to state in this paper.
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TABLE 4. Regression coefficient (beta) and associated P value of the association between GMHR, or whether medical comorbidity was a focus of care during the hospitalization, and individual discharge outcomes
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To assist the reader with the interpretation of the beta values in Table 4, we offer the following. In the regression models involving GMHR, a beta value can be interpreted as the average change in the outcome measure (e.g., PSS, FIR, GAF, or LOS) for each point increase in GMHR. For example, the beta linking GMHR to FIR is -0.375. This means that for each increase in GMHR, such as going from a score of 2 to a score of 3, there was on average a 0.375 decrease (note the negative sign) in the FIR score at discharge, after controlling for admission FIR. The associated P value for this beta is <0.05, indicating a significant relation between GMHR and discharge FIR. However, the absolute value of the beta indicates that the relation between GMHR and FIR is small.
With the above in mind, after adjustment for admission scale ratings or for HCFA complexity, higher ratings on GMHR (healthier) were associated with lower discharge scores on PSS or FIR (less pathology) and with higher discharge GAF ratings. GMHR was no longer associated with LOS. All of these relations were consistent with small associations between admission GMHR and psychiatric outcomes. Thus, for example, for each point decrease in the GMHR, there was a relative decrease of 2.8 in the GAF at discharge. Or, going from a GMHR score of 4 to a GMHR score of 1 would be associated with an average 10-point difference in GAF at discharge.
Table 4 also shows the results of the regression models estimating the association between medical comorbidity as a focus of care and discharge outcomes. After adjustment for admission scale ratings or for HCFA complexity score, comorbid medical illness as a focus of care was associated with a longer LOS, as well as with higher psychiatric symptom ratings (PSS) and greater psychosocial impairment (FIR) at discharge. Patients for whom medical illness had been a focus of care stayed in the hospital 3.25 days longer than patients for whom medical illness had not been a focus of care, after adjustment for baseline complexity. Similarly, patients for whom medical illness had been a focus of care had an average of 1-point higher symptom ratings on PSS and 0.78-point higher ratings on FIR. Although these findings were statistically significant, the effect of medical comorbidity was small, leading to increases in symptom measures of 10%–15%.
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DISCUSSION
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We report here on the relation between medical comorbidity and psychiatric outcomes from a study of a large sample of psychiatric inpatients. Medical comorbidity that was a focus of treatment during the hospitalization was present in about 20% of patients. In addition, 15% of patients had several active, in some cases unstable, medical problems. More severe medical comorbidity on admission, as rated on the GMHR, seemed to be associated with worse psychiatric symptom ratings, greater psychosocial impairment, and lower GAF ratings at discharge, even after adjustment for clinical status on admission. In addition, when medical comorbidity was a focus of care during the hospital stay, the LOS appeared to be prolonged. Thus, although its effect was small, medical comorbidity appeared to modify psychiatric outcomes during a hospital admission. For some patients, medical comorbidity may have extended LOS in the hospital by an average of about 3.25 days.
Our findings are in line with those of Sloan et al.,5 who reported that medical comorbidity prolonged LOS in depressed patients. They are also in line with those of Kishi and Kathol,6 who reported that care on a Type IV psychiatric-medical inpatient unit, when compared with a traditional psychiatric unit, led to better psychiatric outcomes for medically complex patients. These findings are a broader study of the effect of medical comorbidity on psychiatric outcomes, indicating that this comorbidity influences psychiatric symptomatology and functioning, as well as LOS.
The mechanism of this association, should it be replicated, is unknown. One mechanism may be that medical comorbidity simply increases the amount of patient care that is required during the hospital stay, thus increasing the LOS. This would imply that adjustment for case complexity, which accounts for medical diagnoses, should render the association nonsignificant, which was not the case in this study. As well, this explanation does not account for the presence of more severe psychiatric symptomatology at discharge among those with medical comorbidity. Another explanation is that medical comorbidity and psychiatric comorbidity have a synergistic effect on the outcomes assessed. The whole might be more than the sum of the parts because comorbidity alters the patient's perception of his or her symptoms, both medical and psychiatric. This concept of "symptom amplification"—the amplification of medical symptoms in the presence of psychiatric symptoms—has already been proposed by Walker et al.9 in the context of inflammatory bowel disease.
The high frequency of medical comorbidity in this patient population is consistent with the literature.1 It also reflects the fact that the Johns Hopkins Hospital is a tertiary care center located in an inner-city neighborhood. In fact, in 1999, psychiatric admissions at Johns Hopkins were the most complex of the 30 psychiatric units in the state of Maryland (Jacobson K, personal communication).
What do these results mean? Physicians who pay attention to medical problems in their psychiatric patients also provide good psychiatric care. Certainly, we propose that the link between medical comorbidity and psychiatric outcomes suggests that psychiatrists should redouble their efforts to detect and treat the medical illnesses of their patients. Not only is this good practice, but it also may improve psychiatric outcomes. These results, in light of the study by Kishi and Kathol,6 also raise the question of whether psychiatric patients with more complex medical problems should receive care on subspecialty units with special expertise in medical-psychiatric comorbidity. The answer to this question remains unresolved and will require a randomized trial to settle the matter.
The strengths and weaknesses of this study bear discussion. This was a study of a large sample size, with prospective follow-up, assessed on a number of clinical variables and outcomes. Another strength is use of the GMHR, which is highly reliable and well validated. The GAF is also a widely used global rating. One weakness is the rather select nature of the sample (tertiary care, inner-city location), which was limited to psychiatric units so that patients with more serious medical problems were excluded. Also, we used a subjective question to determine whether medical comorbidity was a focus of care, and there was limited validation of two principal outcome measures, the PSS and FIR. Admission and discharge ratings were not independent of one another. This was a short-term study, investigating only the time interval between admission and discharge to a general hospital psychiatric unit. Finally, we did not have data on the treatment of the comorbid medical illness; this would have allowed us to assess the modifying effects of treatment on the relation between medical comorbidity and psychiatric outcome.
We conclude that medical comorbidity is present in a substantial number of psychiatric inpatients in tertiary general hospital units. This comorbidity has a small but measurable impact on psychiatric outcomes. Under certain circumstances, this comorbidity is associated with prolongation in length of hospital stay. On the basis of this research, we recommend that psychiatrists redouble their efforts to detect and treat the medical comorbidity of their patients. In addition, the issue of whether psychiatric patients with complex medical comorbidity should receive care on specialized medicine-psychiatry units merits further study. The findings could be used as the basis for future randomized controlled trials exploring ways to modify the impact of medical comorbidity on patients who suffer from psychiatric disorders.
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ABSTRACT
INTRODUCTION
