Psychosomatics 45:470-476, December 2004
© 2004 The Academy of Psychosomatic Medicine
Factors Affecting the Relationship Between the Timing of Psychiatric Consultation and General Hospital Length of Stay
Yasuhiro Kishi, M.D.,
William H. Meller, M.D.,
Roger G. Kathol, M.D., and
Susan E. Swigart, M.D.
Received May 19, 2003; revision received Oct. 19, 2003; accepted Jan. 30, 2004. From the Department of Psychiatry, University of Minnesota. Address reprint requests to Dr. Meller, Department of Psychiatry, University of Minnesota, F282/2A West Building, 2450 Riverside Ave., Minneapolis, MN 55454; melle001{at}umn.edu (e-mail).
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ABSTRACT
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The purpose of this study was to examine the factors affecting the timing of psychiatric consultations and length of stay in the current managed care era. It also assessed the relationships between the timing of consultations and demographic/clinical characteristics. Medical records of 541 consecutive psychiatric consultation patients at a university teaching hospital in 2001 were reviewed for demographic characteristics, lengths of stay, number of days from admission to consultation, specialty services requesting consultations, reasons for the referral given by the referring physicians, and all five axes of DSM-IV. Earlier consultations independently predicted shorter lengths of stay. Delayed consultations were seen more often in women; surgical patients; those seen with a request to assess depression; and those seen with a diagnosis of adjustment disorder, delirium, or no psychiatric disorder. Delay in psychiatric consultations continues to be associated with longer lengths of stay in the current managed care environment. It is now possible that early detection strategies for high-risk patients with behavioral health problems in the medical setting, such as use of the INTERMED, may lead to reduction in delayed psychiatric consultations and thus shorter lengths of stay.
Key Words: hospital treatment
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INTRODUCTION
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Several studies in the United States have reported the relationship of the timing of consultation to patients' outcomes. In the 1980s, Lynos et al.1 reported that earlier consultations predicted shorter lengths of stay. These findings were supported by Ackerman et al.2 in depressed medical patients and Ormont et al.3 in general medical patients with schizophrenia. Studies in Australia4 and the Netherlands5 also confirmed that early psychiatric consultation improves outcome, as measured by length of stay internationally.
Factors that may influence the timing of psychiatric consultation are discussed by de Jonge et al.5 Their study showed that patients with high scores for psychiatric dysfunction are referred early, while patients with high scores for social vulnerability are referred late. They reported that patients who are prone to late referral are older and suffer from delirium or a mood disorder. Patients referred for these reasons had a poor prognosis, i.e. 30% died in the hospital, and 40% were placed in nursing homes. A report by Handrinos et al.4 corroborated the predictions of de Jonge et al. since they found that depressed patients were typically referred late while those with personality disorder were referred early. This study re-examines factors affecting the timing of consultation and the lengths of stay in the managed care environment.
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METHOD
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Study Group and Setting
The study included a consecutive series of patients referred to the psychiatric consultation-liaison service of Fairview-University Medical Center at the University of Minnesota between Jan. 1, 2001, and Dec. 31, 2001. The hospital is at a public university located in the 15th largest metropolitan area in the U.S., with approximately 3 million people (approximately 15% of whom are non-Caucasian minorities).6 During the study year, the hospital had 17,629 admissions to the general hospital wards. A total of 3.1% (541 patients) were evaluated by the psychiatric consultation team. The consecutive consults were performed by a team, including an attending psychiatrist, psychiatric residents, and medical and pharmacy students.
The following information was recorded for each consultation: patient demographic characteristics, the date of admission, the date of consultation, the specialty service requesting the consultation, the reason for referral given by the referring physician, and all five axes of the DSM-IV diagnostic system,7 based on the consultation interview. The number of days each of the patients stayed in the hospital for the episode in which the consultation occurred was obtained from the main hospital computer system. The specialty services requesting the consultations were divided into five groups: medicine, surgery, intensive care, family practice, and other. Medicine included internal medicine, cardiology, neurology, and oncology. Surgery included general surgery, transplant surgery, cardiac-thoracic surgery, neurosurgery, and orthopedic surgery. Intensive care included all intensive care units. Services, such as ophthalmology, obstetrics and gynecology, otolaryngology, community medicine, radiology, and pediatrics were classified in the category of "other."
Reasons for referrals were divided into 12 categories: 1) suicidal ideation and/or suicidal behavior, 2) depression, 3) psychosis, 4) chemical (alcohol or drug) abuse or dependency, 5) "psychiatric evaluation" (request for the evaluation of psychotropic medications or the assessment of unspecific mental conditions), 6) competence or refusal of treatment, 7) behavioral problems, 8) agitation, 9) anxiety, 10) confusion or delirium, 11) somatic complaints (somatizing, factitiousness, or malingering), and 12) other. A patient could have more than one reason for referral, e.g., chemical dependency and somatic complaints.
Recommendations by the consultation team were divided into eight categories: pharmacotherapy or medication management, psychotherapy, further medical work-up, transferral to inpatient psychiatry, follow-up to outpatient psychiatry, paramedical (e.g., social worker, physical therapy, etc.), consultation, evaluation only, and others.
Active medical conditions were divided into the following 14 categories: status postoverdose, gastrointestinal disease, endocrinological disease, neurological disease, cardiovascular problem, status posttrauma, acquired immunodeficiency syndrome (AIDS) or status of human immunodeficiency virus (HIV) positive, pulmonary disease, liver disease, hematological disease, urological disease, chronic pain, any active cancer, and "other." Most patients had more than one condition.
DSM-IV psychiatric diagnoses were categorized into 13 groups (see Table 3). Depression also included clinical major depression possibly secondary to organic etiologies, such as depression due to a general medical condition and substance-induced depression.
In order to assess the timing of the consultation, it would be inaccurate to study merely the number of days from admission to consult, since this number was confounded by the length of stay itself. For example, patients who are in the hospital longer could potentially receive their psychiatric consultations later. For this reason, several investigators have suggested transforming the timing of referral into one adjusted for the length of the hospital stay (LOS), using the following formula:1,2,4
Referral time (RFtime)=log (numbers of days from admission to consult)/log (LOS).
With this formula, it is the percent of hospital stay occurring before the consultation, rather than the absolute number of days that are used to indicate the timing of consultation. This study was approved by the institutional review board of the University of Minnesota.
Statistical Analysis
Logarithmic transformation was applied to both the number of days from admission to consult and the length of stay, since both variables were positively skewed. To investigate the association of the length of stay and several factors, such as recommendations by the psychiatric team or physical and psychiatric conditions/diagnoses, stepwise multiple regression analysis was performed. To investigate the association of referral time with background characteristics, reason for referral, and DSM-IV psychiatric diagnoses, univariate analysis was used. The recommendations by the psychiatric team were not included in these analyses since those recommendations were determined after the psychiatric referral. For comparison of parametric data in these two groups, t tests were performed. One-way analysis of variance in combination with Bonferroni tests was used for comparison of parametric data in three or more groups. To document correlations between continuous variables, the Pearson product-moment test was used. Final associated factors were identified by an analysis of covariance (ANCOVA), including variables with a p value <0.10 in the univariate analysis. All p values were two-tailed. All data analyses were conducted by using Statistical Product and Service Solutions (SPSS) statistical software 10.0.
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RESULTS
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Characteristics of the Consultation Patients
Table 1 summarizes the background characteristics of the patients. In 2001, the mean length of stay for all patients admitted to the hospital was 5.7 days. The average length of stay for all patients receiving the psychiatric consultation was 17.91 days.
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TABLE 1. Demographic and Clinical Characteristics of 541 Patients Referred to Psychiatric Consultation-Liaison Services in 2001
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The main reasons for referral were for the evaluation of depression and chemical dependency (Table 2). Mood disorder was the primary diagnosis in over 60% of the referrals. Alcohol-related disorders were present in a quarter and delirium in a fifth of the patients (Table 3). Both health-related and socioeconomic stressors were often present.
Referral Time and Length of Stay
Logarithmic transformation of the length of stay correlated with the referral time (r=0.51, p<0.001), accounting for 25.7% of the variation in the length of stay, indicating that the earlier consults predicted a shorter length of stay.
A stepwise multiple regression analysis showed that 10 factors predicted length of stay best (R=0.603, R2=0.364; F=28.24, df=10, 494, p<0.001). Referral time was the most predictive (ß=0.415; t=10.68, df=1, p<0.001), followed by alcohol-related disorders (ß=–0.134; t=–3.65, df=1, p<0.001), drug-related disorders (ß=–0.135; t=–3.66, df=1, p<0.001), postoverdose status (ß=–0.121; t=–3.22, df=1, p=0.001), no psychiatric diagnosis status (ß=0.108; t=3.00, df=1, p=0.003), anxiety disorder status (ß=–0.110; t=–3.05, df=1, p=0.02), pulmonary disease status (ß=0.095; t=2.61, df=1, p=0.009), hematological disease status (ß=0.091; t=2.51, df=1, p<0.02), urological disease status (ß=0.082; t=2.23, df=1, p<0.03), and psychotic disorder status (ß=–0.075; t=–2.07, df=1, p<0.04).
Factors Related to Referral Time
An ANCOVA (F=6.10, df=17, 471, p<0.001) revealed that referral times were delayed in women (p=0.006); those on surgical units (p<0.001); those seen with a request to assess depression (p=0.04); and those with a diagnosis of adjustment disorder (p=0.01), delirium (p=0.05), or no psychiatric diagnosis (p=0.05). Of interest, 23% of the patients seen with a request to assess depression did not receive a diagnosis of depression by a psychiatrist. Among those, 52% were given a diagnosis of adjustment disorder, and 21% were given a diagnosis of delirium by a psychiatrist. Patients with suicidal ideation and/or behavior (p=0.001) and those with drug-related disorders (p=0.05) had significantly shorter referral times.
Two consultation recommendations predicted shorter lengths of stay, transfer to inpatient psychiatry (ß=–0.289; t=–6.72, df=1, p<0.001) and follow-up in outpatient psychiatry (ß=0.126; t=–3.09, df=1, p=0.002), while a recommendation of pharmacotherapy (ß=0.242; t=5.68, df=1, p<0.001) predicted longer length of stay. Even when these variables were controlled, a stepwise regression analysis (R=0.612, R2=0.374; F=60.31, df=5, 504, p<0.001) showed that referral time was the best predictor of length of stay (ß=0.435; t=11.85, df=1, p<0.001), followed by transfer to inpatient psychiatry (ß=–0.233; t=–5.70, df=1, p<0.001), follow-up in outpatient psychiatry (ß=–0.134; t=–3.59, df=1, p<0.001), and pharmacotherapy (ß=0.145; t=3.37, df=1, p=0.001).
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DISCUSSION
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This study suggests that delayed psychiatric consultation remains associated with a longer length of stay in the current managed care era. Even when there was control for the medical condition, the psychiatric reason for referral and diagnosis and the interventions recommended, the timing of the psychiatric consultation predicted length of stay. This suggests that a more timely psychiatric consultation could potentially improve outcomes and cost through concurrent and coordinated psychiatric and general medical management during early hospitalization for psychiatric patients in the medical inpatient setting. Analyses from this study also indicate that clinical factors, such as female gender, surgical ward admission, and those perceived as depressed by their physicians could be used to identify high-risk patients for delayed referral time. Patients with suicidal ideation and/or behavior and substance abuse disorders, consistent with the findings of Handrinos et al.,4 are at less risk of delayed consultation.
The findings in this study raise questions about the wisdom of continuing with the conventional reactive approach to psychiatric consultation. Patients with blatant psychiatric symptoms, such as suicidal ideation and drug problems, posed little threat for treatment delay associated with late consultation. On the other hand, women and patients with adjustment disorders or nonpsychiatric disorders, which require more psychosocial intervention rather than "psychiatric" intervention, are at greater risk for delayed assistance since these patients often have less impressive symptoms.
Recent publications suggest that a new approach to the identification of patients appropriate for psychiatric assistance and/or referral might be worth considering. Since there are too few consultation psychiatrists to deliver services to the many medically ill patients with behavioral disorders,8 an innovative group of psychiatrists and nonpsychiatrists in the Netherlands have developed a collaborative proactive biopsychosocial screening instrument, the INTERMED, to identify those in need of psychiatric assistance early in the course of medical hospitalization. Using this tool and a collaborative care approach, at-risk patients receive targeted intervention from health professionals, including consultation psychiatrists, based on the expertise needed.9,10 This early detection strategy, coupled with behavioral and general medical accountability for patients who have psychiatric need, now have data suggesting that clinical outcomes improve and lengths of stay shorten.11
Relationship of Clinical Factors
It is not surprising that fewer patients with suicidal thoughts and/or behavior have consultations later in hospitalization than others. For instance, a survey completed by surgeons and general physicians at a teaching hospital in London in 2001 revealed that over 60% of these physicians felt responsible for ensuring that patients with suicidal ideation or behavior were assessed and treated. Only 30% felt the same for patients with depression.12 Doctors' attitudes toward psychological problems as identified in that study might help explain why our suicidal patients had timely consultations, while they were delayed in patients who were thought to have depression.
Consultations that require physicians' ability to understand patients, i.e., empathy, may contribute to the delay in certain consultations. For example, patients with depression or the stress of adjustment disorder may be delayed, while those who have attempted suicide or are using drugs, i.e., blatant behaviors, would receive timely consultations. Doctors in people-oriented specialties, such as internal medicine, emergency medicine, psychiatry, and internal medicine subspecialties have higher measures of empathy than those in technology-oriented specialties, such as anesthesiology, surgery, and the surgical subspecialties.13,14 These factors might help explain why the patients on the surgical wards had delayed consultations. It has been pointed out that empathetic physicians have a better ability to understand their patients, which leads to several beneficial clinical effects in patient care, including patient satisfaction and outcomes.15
There is no easily identifiable explanation why the female patients had delayed consultations. Other studies have also found gender differences in consultations for depressed nursing home residents,16 for detection of alcohol abuse,17 and for referral to cardiac rehabilitation programs after revascularization.18 In each of these studies, men were referred more often. Further studies are necessary to identify the factors relating to gender difference in the timing of psychiatric consultations.
More than two-thirds of physicians consider themselves responsible for the treatment of delirium.12 As a result, they may delay psychiatric consultations for delirious patients until they can no longer deal with the symptoms by themselves. In addition, detection of delirium is poor.19–21 In fact, a large number of patients who remain delirious are discharged as incapable of caring for themselves. Feelings of responsibility for treatment and impaired detection thus appeared to be the reason for delayed timing of consultations in delirious patients. Even in terminally ill patients, delirium is reversible in 50% of episodes by intervention.22 Identification of risk factors for delirium and the institution of prophylactic measures, which could become a basic part of a proactive psychiatric consultation, similar to that described for the INTERMED, have been associated with reduction in the occurrence of delirium in up to a third, with significant cost savings.23–26
Although our data show that the delayed timing of consultations had a relationship with longer length of stay, it is important to acknowledge that this does not mean the earlier consultations reduce the length of stay. Several prospective controlled trials of screening and treatment for psychiatric disorders in general hospitals have failed to show that routine screening for psychiatric disorder leads to benefit in clinical (health status) or economical (e.g., resource use and length of stay) outcomes.27–30 This suggests that psychiatric screening alone is not enough for consultation psychiatry to improve care. Although some trials show that the liaison psychiatry model, not the consultation model, reduces the length of stay,31,32 the liaison model unfortunately has not shown itself to be feasible economically and practically. A program in which at-risk patients are identified through a multidimensional assessment tool, such as the INTERMED, which focuses on much more than just psychiatric diagnosis, has significantly greater promise for improved outcome and reduced cost.
Study Limitations
It is important to acknowledge the methodological limitations of the study. First, this study represents a retrospective analysis of one university hospital's consultation records. Data represent those of clinicians involved in typical psychiatric consultations. Standardized psychiatric scales and structured clinical interviews were not used in this study. Second, it was not possible to assess the level of medical disease severity. This variable might have added additional information related to both the reasons for a delay in consultation and the patient's length of stay. Finally, the findings in this study may not be applicable to all patients referred for consultation psychiatry service in the U.S, since, as shown in Table 1, the patients in our population were socially vulnerable (nearly 50% were unemployed or disabled, and 74% had a psychiatric history). Furthermore, the study was conducted at a university teaching hospital located in a metropolitan area.
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CONCLUSIONS
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In conclusion, delay in psychiatric consultation remains associated with poor outcomes, as measured by a longer length of stay in the current managed care era. Based on the findings in this study, it is worthwhile to develop early detection strategies for high-risk patients in whom delayed consultation may occur, such as women, surgical unit admissions, those perceived as depressed by their requesting physicians, and those with a diagnosis of adjustment disorder or delirium. Conventional consultation psychiatrists function largely as emergency psychiatrists in inpatient medical settings with limited outcome-changing capability, particularly in patients seen late during hospitalization. A proactive identification system, such as with the multidimensional INTERMED, which provides psychiatrists and other medical specialists with information about patient vulnerabilities and need associated with extended lengths of stay, might be clinically and economically beneficial.
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ABSTRACT
INTRODUCTION
