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Psychosomatics 44:499-507, December 2003
© 2003 The Academy of Psychosomatic Medicine

A Systematic Review of Studies of the Cost-Effectiveness of Mental Health Consultation-Liaison Interventions in General Hospitals

Paola Bruno de Araujo Andreoli, M.Sc., Ph.D., Vanessa de Albuquerque Citero, M.D., M.Sc., and Jair de Jesus Mari, M.D., Ph.D.

Received Oct. 17, 2002; revision received March 14, 2003; accepted March 31, 2003. From the Mental Health Department, Albert Einstein Hospital, São Paulo, Brazil; the Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil; and the Conselho Nacional de Desenvolvimento Cientifico e Technológico (CNPq) (the Brazilian Research Council), São Paulo, Brazil. Address reprint requests to Dr. Andreoli, Av. Albert Einstein 627/701, 05651-901, São Paulo, Brazil; paola{at}einstein.br (e-mail).
This study was developed as part of the fulfillment of the doctoral degree requirements of Dr. Andreoli. Supported by grant 98/12424-8 from Fundação de Amparo à Pesquisa do Estado de São Paulo (the State of São Paulo Research Funding Council) and by CNPq.


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
A systematic review of cost-effectiveness analyses of mental health consultation-liaison interventions in general hospitals was conducted. Few studies have evaluated the cost-effectiveness of consultation-liaison interventions, and only two articles met the criteria for inclusion in the review. The comparable variable was length of the hospital stay. It could not be concluded that psychiatric consultation had an effect on the duration of hospital stays. In one of the studies, the group that received psychiatric consultation showed improvement in depressive symptoms. Additional studies would have been relevant to this review if they had replicated clinical practice by using a naturalistic research design.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Limited resources are available for allocation to fulfill health care demands. Over the past 20 years, this fact has become more evident due to the rapid increase in costs, pressure from health maintenance organizations to systematize the supply of services, and the proliferation of increasingly expensive and sophisticated technologies.1 One of the consequences of the pressure exerted by the market in its search for greater effectiveness at a minimum cost is the widespread acceptance of the term cost-effectiveness.2,3 Most studies of mental health, particularly those dealing with consultation-liaison interventions, have mentioned an association between psychiatric comorbidity and prolonged hospital stays, thus attesting to the economic feasibility of these interventions in the general hospital.4–10 The effectiveness of these services has also been measured in terms of the consulting medical staff's compliance with the recommendations made by the consultation-liaison service.11–17 In consultation-liaison programs, it is important to assess whether the cost of this modality of care is associated with clinical benefits that would justify its implementation. This article reports the results of a systematic review of studies examining the cost-effectiveness of mental health consultation-liaison interventions in general hospitals.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
The following criteria were used to select the studies to be included in this systematic review: 1) the study patients were admitted to a general hospital, 2) the interventions were defined as psychiatric consultation-liaison interventions, and 3) a randomized clinical trial design was used. The clinical outcome variables could include 1) direct costs (cost of materials, staff services, admission, and procedures), 2) indirect costs (evaluation of quality of life, informal caregiving burden, and disability), and 3) measures of the effect of the intervention (measures of comorbidity, symptom improvement, compliance with recommendations, physical and/or emotional well-being, functional level, etc.).

The studies considered for this review were identified from an electronic search of articles published as of 1998 and included in the following data bases: EMBASE, MEDLINE, LILACS, ADSAUD, PsycLIT, and SCISEARCH. References included in the bibliographies of the articles identified in the search were retrieved, and additional relevant Brazilian authors publishing in the area of consultation-liaison psychiatry were contacted.

The quality of the clinical trials was evaluated by using the Jaddad scale18 and the criteria described in the Cochrane collaboration reviewers' handbook.19 The quality of the data presented in the cost-effectiveness analyses was evaluated according to six basic analytic principles proposed by Udvarhelyi et al.3

Procedure
The articles were reviewed separately by two researchers to verify the feasibility of the established criteria. The studies that met with the preestablished criteria were fully reviewed and were included in the analysis after both of the researchers had arrived at a consensus. The possibility of including the studies in a meta-analysis was assessed by means of a qualitative evaluation of the methods and economic analyses used in the selected articles.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
The electronic search for articles led to identification of 95 potential studies. On initial examination 87 articles were discarded either because they failed to meet the inclusion criteria or because the subjects were not inpatients at a general hospital. In 73 articles, the intervention tested was not a consultation-liaison intervention;5,20–91 in seven articles, the subjects were not inpatients;92–98 and in seven other articles, the study was not a clinical trial.11,99–104 The eight remaining articles were reviewed in their full versions and evaluated further according to the inclusion criteria.7,8,105–110 The rate of concordance between both researchers for selection of articles was adequate (kappa=0.79). A search of the references of the selected articles and consultation with researchers in this area resulted in identification of 25 additional articles. These articles were not included in the final selection because 1) 12 studies did not meet the requirements of a consultation-liaison intervention;4,111–121 2) one study was considered quasi-experimental;9 3) eight articles were either reviews or editorials;122–129 4) two studies that met the inclusion criteria failed to report the intrahospital cost-effectiveness analysis;130,131 5) one study had outpatients as subjects;132 and 6) one study was a pilot study,133 and the results had been given in an article already included in the review. Of the eight articles that were reviewed in their full versions, one involved an intervention that was not considered a consultation-liaison intervention,105 four were either quasi-experimental110 or were not considered clinical trials,7,8,108 and one met the inclusion criteria but was excluded because a cost-effectiveness analysis was not presented.106 Only two articles were included for the extraction of data.107,109

The study by Hengeveld et al.107 was a double-blind, randomized clinical trial that was performed at a general university hospital with 933 beds and approximately 23,000 admissions per year. The object of the study was to evaluate the cost-effectiveness of a psychiatric consultation-liaison intervention in two groups of patients, an experimental group (N=33) and a control group (N=35). The patients were included in the study if their score on the Beck Depression Inventory was higher than 13. The patients in the experimental group were seen at the psychiatric service and interviewed for anamnesis, psychiatric diagnosis, and an indication as to the form of treatment, which may or may not have included psychotropic medication. The patients in the control group were not seen in the psychiatric service, and control group patients who required psychiatric treatment during their stay in the hospital were excluded from the analyses. The two groups were compared on the use of psychotropic medication or analgesics, the number of laboratory procedures and diagnostic tests, the number of consultations requested for other specialties, and the length of the hospital stay. The analysis included adjustments for the effects of the severity of the patients' disorders and of the patients' prognoses and functional conditions.

No statistically significant differences between groups were found in gender, marital status, number of previous hospital admissions or outpatient consultations, severity of the disorder, or prognosis. The average age of the experimental group was lower than that of the control group (52 years versus 61 years) (p>=0.05).

The groups showed no statistically significant differences in length of hospital stay; number of consultations for other specialties; and number of diagnostic procedures and laboratory tests, with exception of other blood tests, for which the number of tests was higher in the experimental group than in the control group (p>=0.05).

In the experimental group, the measures of depressive symptoms showed significant improvement from baseline to discharge (p>=0.002). In the control group, the improvement in depressive symptoms from baseline to discharge was not statistically significant (p>=0.10). The experimental group was also less likely than the control group to use psychotropic or analgesic medication (17% and 39%, respectively) (p>=0.05). The authors, nevertheless, concluded that the cost savings due to less use of medication in the experimental group was surpassed by the cost of the consultation-liaison intervention ($341 and $1,000, respectively), and thus, the intervention was not cost-effective.

One of the main problems in evaluating the results was a significant loss of subjects by the time of the reevaluation of the depressive symptoms at hospital discharge (10 subjects in the experimental group and 16 in the control group). Another important problem was that an analysis of morbidity and cost variables was not made, and it was therefore impossible to make a full cost-effectiveness analysis.

Levenson et al.109 carried out a randomized, double-blind clinical trial in a general university hospital. The cost-effectiveness of psychiatric consultation-liaison interventions was evaluated. Patients were assigned to the experimental group (N=256) or a concomitant control group (N=253). The study included a third group, called the basic control group, which was made up of subjects selected during the 6 months before the experimental period. A comparison was made between the subjects in the experimental period (experimental group and concomitant control group) and the subjects in the control period (basic control group) to verify whether the study was carried out under routine conditions. This comparison attested to the reliability of the phenomenon that was evaluated in the experimental phase. Thus, subsequently reported analyses considered only the experimental group and the concomitant control group, which was thereafter referred to as the control group.

Patients were included if they had a high score in a screening inventory for depression, anxiety, mental confusion, and pain (the scales that compose the Medical Inpatient Screening Test). The patients were not randomly selected, but randomization was performed in selecting the practitioners whose patients were screened.

The evaluated measures were the length of hospital stay, number of procedures during the hospital stay, expenses, and hospital costs. The baseline measures were the severity of the patients' depression, anxiety, mental confusion, and pain (as measured by the Medical Inpatient Screening Test) and the severity of the disorder as measured by a score that took into account the diagnostic related group classification used for reimbursement and the score on the TOTSCALE, a comprehensive scale that considers other diagnoses apart from the diagnostic related group and calculates the severity of the disorders.

The postdischarge measures included 1) functional status measured in terms of activities of daily living, 2) the number of outpatient clinic consultations, 3) the number of primary care consultations, 4) scores for depression and anxiety, 5) the number of subsequent hospital admissions, 6) the time elapsed until the next hospital admission, 7) the cumulative length of hospital stay, 8) the cumulative number of procedures, 9) total expenses, and 10) total hospital costs.

No differences between groups were found in the distribution of demographic variables, psychopathology scores, and extended diagnostic classifications.

The experimental group spent a significantly greater mean number of days in the hospital than the control group (11.3 versus 10.2 days) (p=0.02). Compared with the control group, the experimental group also had a significantly greater mean number of hospital procedures (2.3 versus 1.9) (p=0.04), greater mean expenses ($11.109 versus $8.465) (p=0.005), and greater mean hospital costs ($8.160 versus $6.358) (p=0.02).

The experimental group had higher levels of severity of disorder, compared to the control group (severity as measured by diagnostic related group: p=0.02; severity as measured by the TOTSCALE: p=0.04). Consequently, whenever severity of disorder was controlled in subsequent analyses, all of the previously mentioned differences disappeared. When the data for patients with very short or very long hospital stays (less than 4 days or more than 30 days) were excluded, no significant differences between the groups were found, even when the analysis controlled for the severity of disorder.

In the 6–12-month follow-up after hospital discharge, no significant differences between the groups were found for depression and anxiety scores, number of subsequent hospital admissions, cumulative length of hospital stay, cumulative number of hospital procedures, and total hospital cost. Also during the follow-up period, the experimental group had less time between hospital discharge and readmission, compared to the control group (p>0.04), although this difference disappeared when the severity of disorder was controlled.

Severity of disorder was a confounding variable in the comparison between groups in both studies, making it difficult to evaluate the effectiveness of the consultation-liaison interventions. In both of the studies, the short duration of the consultation-liaison interventions could have reduced the likelihood of finding differences between the groups (the average length of the consultation was 2.2 days in the first study and 1 day in the second study). In addition, both studies used intentional samples, and the data for patients for whom a consultation-liaison was not requested could have contributed to a finding of less effectiveness. The characteristics of the two studies are described in Table 1.


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TABLE 1. Characteristics of Two Randomized Controlled Trials Examining the Cost and Effectiveness of Psychiatric Consultation-Liaison Interventions in General Hospitals



The quality of the study design was low in both studies, according to the criteria of Udvarhelyi et al.3 for evaluating the quality of the cost-effectiveness studies (Table 1). Flaws were found in the description of the randomization procedures,107,109 in the description of the blind test107 (including the lack of a description of the blind test109), and in the exclusion of dropouts from the analysis.107 The economic analysis was also considered inadequate because the analyzed costs were not described,107 the description of the benefit to be analyzed was faulty,107,109 and both a sensitivity analysis and measures of effectiveness were omitted.107 ,109

In assessing the feasibility of a meta-analysis of these data, we found that the variety of measures used to assess psychiatric morbidity, costs, expenses, and the number of procedures, made it impossible to include a comparison of such results in a meta-analysis. The only variable that could be compared was the length of the hospital stay, although this comparison was also be prejudiced because of the omission of means and standard deviations for this measure for both groups in one study.107

Examination of the results was nevertheless useful for evaluating the effects of consultation-liaison interventions on the patients' length of hospital stay. In the comparison of the experimental and control groups, neither study showed a decrease in the length of hospital stay for the experimental group. On the other hand, in the study by Levenson et al.,109 the experimental group had a longer mean length of stay than the control group, and the difference between the groups was statistically significant. However, in view of low number of studies reported in the literature, it cannot be concluded that a psychiatric consultation-liaison intervention has any effect on the duration of patients' stay in the hospital.


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
The inclusion of patients with high psychopathology scores as subjects in these studies of psychiatric consultation-liaison interventions complies with two important requirements for such research: 1) the subjects' characteristics are similar to those of patients for whom consultation-liaison services are requested134 and 2) this design facilitates random assignment of the subjects to study groups without presenting the ethical problem of not providing care to all patients for whom a consultation-liaison intervention was requested.135 However, the results cannot be generalized, because no formal request was made to the consultation-liaison team for the groups studied.

Cost-effectiveness studies provide relevant results when they closely resemble clinical practice, and this goal can be accomplished in studies that have naturalistic features.136,137 The procedures with which clinical trials are carried out, including randomization, blindfolding, taking measures to ensure or to increase the use of interventions, cause significant alterations in the routine conditions of clinical practice. In these circumstances, it is difficult to evaluate effectiveness, which should be grounded in conditions that are as close to routine as possible.136,138 Only two clinical trials with the goal of evaluating the cost-effectiveness of psychiatric consultation-liaison were found. The studies that use appropriate experimental methods are thus scarce, and they included a considerable number of measures of the primary outcome.

The need for effective consultation-liaison interventions, evaluated according to the benefits brought about by the minimization (or remission) of patients' psychopathological symptoms, is emphasized by the physicians who request consultation-liaison services.139–141 Improvement of the patients' symptoms is an important factor in the evaluation of the consultation-liaison's effectiveness.9,93,95,106,107,109,130,131,142,143 Research evaluating mental health services in the general hospital can, nevertheless, be misleading when traditional hospital evaluation measures are used exclusively. A focus on morbidity and mortality tends to overlook the global care extended to patients, their families, and the medical staff in the context of consultation-liaison interventions.144 Quality of life, social factors, and the family's and medical staff's caregiving burden, as well as estimates of indirect costs, are important in the evaluation of the economic and clinical effects of consultation-liaison interventions.

A frequently adopted measure in cost-effectiveness studies is the length of the hospital stay.9,107–110,145 Its variation is influenced by the severity of the patient's disorder and/or by social problems,10,146 provided that randomization of the sample is efficient. Should the consultation-liaison intervention be the cause of a shorter hospital stay, the use of the intervention would be easier to justify from a cost perspective. On the other hand, if extended hospital stays are associated with consultation-liaison interventions, the pendulum would swing back to the clinical benefits of the intervention (and not to the costs). Evaluation of the outcome would depend on whether considerable gains could be reflected in quality of life, resulting in a lower risk of readmission. This possibility would justify use of a research design with a follow-up period of 6 months to 1 year after hospital discharge. The length of the hospital stay is an important factor in cost-effectiveness studies,107 although one cannot overlook the true objective of psychiatric consultation-liaison services, which is to provide clinical benefits for the patients' mental health.145,147

The inclusion of only a few clinical trials in this review and the low quality of these studies made it impossible to form any conclusions about the cost-effectiveness of consultation-liaison interventions. The authors nevertheless believe that further clinical trials of a naturalistic character, including an adequate economic analysis, are required.

Cost-effectiveness studies in psychiatry that meet acceptable methodological standards can be found in comparisons assessing the costs and benefits of use of atypical antipsychotics, mainly clozapine.148,149 Moreover, guidelines for economic analyses have been developed, and they should be applied in future research in this area.150,151

At present it cannot be stated that mental health consultation-liaison interventions exert any influence either on the duration of the hospital stay duration or on the effects of psychiatric morbidity, since only one of the studies considered here used this clinical measure. In this case, there was a reduction in the depression scores in the experimental group but not in the control group.

The results suggest that it is not yet possible to establish clinical guidelines for cost-effectiveness of mental health consultation-liaison interventions. Further improvement of experimental studies, including the development of new criteria and measures, is required so that more information on the clinical and economic effects of consultation-liaison interventions can be obtained and models of overall mental health policy in general hospitals can be assessed.


  REFERENCES

 
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 DISCUSSION
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V. de Albuquerque Citero, P. B. de Araujo Andreoli, L. A. Nogueira-Martins, and S. B. Andreoli
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