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Practice Patterns in Pediatric Consultation–Liaison Psychiatry

A National Survey

Received August 25, 2004; revised January 31, 2005; accepted March 7, 2005. From Stanford University School of Medicine; National Jewish Medical and Research Center; and the UCLA Neuropsychiatric Institute. Address correspondence and reprint requests to Dr. Shaw, Division of Child Psychiatry, Stanford University School of Medicine, 401 Quarry Rd., Stanford, CA 94305-5719. e-mail: rjshaw{at}leland.stanford.edu

ABSTRACT

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The purpose of this survey was to describe the current status of pediatric consultation–liaison (C–L) services in the United States. A total of 144 pediatric C–L programs were surveyed, with a response rate of 33%. Financial and staffing constraints were cited as common problems; 61% of programs reported an increase in consultation requests over the past 5 years, however, 30% of services reported a decrease in funding. Collection rates for professional billings average 30%; 57% of services reported an increase in clinical service demands at the expense of teaching and liaison activities. Discussion includes recommendations based on the results of the survey.

INTRODUCTION

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Although the specialty of pediatric consultation–liaison (C–L) psychiatry is well established in many United States hospitals, changes in health care over the past 10 years have had a significant impact on the nature and delivery of consultation services. Changes in healthcare economics have resulted in increased controls on medical costs that are often associated with decreased levels of financial support for C–L programs. Paradoxically, developments in medical technology have resulted in increased survival rates of children with chronic physical illnesses, as well as increased complexity of problems related to survival and the sequelae of invasive treatment.

Although there have been past surveys of adult C–L programs¹ and one previous study of child and adolescent medical-psychiatric units,² to our knowledge, there have been no recent published surveys of pediatric C–L programs in the United States. Although adult and pediatric C–L programs have had to adapt to many of the same changes in healthcare practices, there are many differences between adult and child psychiatry that require a separate analysis of pediatric C–L programs.³ The impetus for the current survey came out of a desire to better describe the current status of pediatric C–L services in the hope that these data would be useful for program evaluation and planning.

METHOD

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To better understand the current practice patterns in pediatric consultation–liaison psychiatry and the changes over the past 5 years, the Committee for the Physically Ill Child of the American Academy of Child and Adolescent Psychiatry, decided to conduct a national survey of inpatient pediatric C–L programs. The survey was conducted between January and June of 2003. Eligibility criteria included all U.S. hospitals that support psychiatric consultation service for children hospitalized for medical or surgical treatment. Eligible programs were identified by a search of the following databases: 1) HospitalWeb: Index of Hospitals on the worldwide web (URL: http://neuro-www.mgh.harvard.edu/hospitalweb.shtml); 2) the American Hospital Association’s Guide to the Health Care Field; and 3) membership in the Academy of Psychosomatic Medicine.

Questionnaires were sent to all eligible programs. Nonrespondents were contacted by telephone, and a second questionnaire was mailed. The survey questions included inquiry on the following topics: 1) attributes of the hospital; 2) staff composition of the C–L service; 3) administrative structure of the C–L service; 4) sources of funding; 5) level of service activity; 6) practice patterns; 7) frequency of major referral questions; 8) nature of service provided; 9) time spent on C–L activities; and 10) major problems encountered by C–L service. Where appropriate, questions included inquiry into the changes in each category over the past 5 years.

RESULTS

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Of the 144 pediatric C–L programs polled, 48 programs (33%) responded to the survey. Table 1 shows the attributes of the programs that responded to the survey. Respondents to the survey had a greater representation from academic and university programs and from hospitals that described themselves as tertiary-care facilities. Data on Nonresponders suggested that county-funded programs were underrepresented in our survey.

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TABLE 1. Attributes of Hospital

Staff Composition of Service
Table 2 shows the staff composition of the survey respondents. The majority of programs responding to this survey were directed by a child psychiatrist with an average full-time equivalent (FTE) of 0.44 of an attending physician. Table 3 describes the administrative structure of the services: 65% of the programs were directed by a child psychiatrist and 10% by a psychologist, and the remainder comprised consultation services that were not coordinated under a single administrative structure. Programs appeared to be evenly split in terms of increases and decreases in permanent staffing over the past 5 years. Trainee time appeared in most programs to be either unchanged or increased.

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TABLE 2. Staff Composition of Service

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TABLE 3. Administrative Structure of Service

Funding of C–L Services
Table 4 shows the primary sources of funding for the C–L services: 68% of the services were funded by either the hospital or pediatric service in which the service was located or by the psychiatry department; 36% of services reported supplemental funding from professional fees. Collection rates for professional services averaged only 30% of the charges submitted, although there was a large variation in this statistic (0–92%); 30% of C–L services reported a decrease in funding over the past 5 years.

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TABLE 4. Sources of Funding

Service Activity and Practice Patterns
Table 5 shows the average census and number of consultations and referrals to C–L services. The majority of services (61%) reported an increase in the volume of consult requests over the past 5 years. Table 6 shows the average frequency of contact with patients and average response time.

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TABLE 5. Service Activity

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TABLE 6. Practice Patterns

Table 7 shows the approximate frequency of consultation questions. Categories of high-frequency requests included adjustment to illness by both child and parent, differential diagnosis of somatoform disorder, suicide assessment, disruptive behavior, and medication evaluation. Requests for evaluations of delirium and protocol evaluations for pre-transplant assessment were of relatively low frequency.

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TABLE 7. Frequency of Major Referral Questions

C–L Activities
Table 8 describes the nature of services provided by pediatric C–L consultants. Although not ranked in terms of frequency of services provided, the data show the percentage of programs that offer the identified services. Diagnostic evaluation, psychotherapy, medication management, and referral and transfer of patients were offered by the majority of programs responding to the survey. Table 9 provides a breakdown of the major C–L activities and shows that the majority of time is spent in the provision of clinical service, with 57% of programs reporting an increase in clinical service demands over the past 5 years. Only 11% of time is currently being spent in liaison activities, whereas 48% of programs report a decrease in time available for both teaching and liaison activities. Only 4% of time on pediatric C–L services is currently being directed toward research activities.

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TABLE 8. Services Offered by Programs

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TABLE 9. Time Spent on Major Consultation–Liaison Activities

Major Problems Reported By C–L Services
Table 10 describes the frequency of major problems reported by respondents to the survey. Financial concerns and constraints, as well as inadequate staffing, were major concerns for many programs. Other issues commonly cited included short duration of hospital stays, lack of space, and lack of administrative support.

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TABLE 10. Major Problems for Consultation–Liaison Service

DISCUSSION

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The first comment to make regarding this survey is that the response rate was only 33% of programs polled. Interpretation and generalization of the results must be made with the caveat that many pediatric C–L programs, in particular, those from county-funded programs, were not represented in this survey. There is the possibility of bias in that the findings may overrepresent services whose directors were more motivated or invested in responding to the survey and underrepresent responses from busy or overworked program directors. It is also important to acknowledge that the data were obtained from self-report by program directors and was not based on an objective review of program statistics, thus there is the potential for reporter inaccuracies. Also, the data presented are descriptive in nature, and no statistical tests were used to validate or control for possible confounding variables. However, with these limitations in mind, we offer the following analysis of our findings.

Staff Composition of Service
Data on the staff composition of pediatric C–L services suggests a relatively low staff-to-patient ratio. The average FTE was 0.44 psychiatrists and 0.44 child psychiatry fellows, significantly lower than a survey of adult C–L Fellowship programs, which report an average FTE of 2.4 psychiatrists and 1.6 fellows.⁴ Although pediatric C–L programs are much more likely to have an attending psychologist present (0.27 FTE in this survey), the ratio of pediatric attending C–L staff to number-of-hospital-beds ratio is still relatively low (1:675). This is significantly lower than the ratio of 1:300 recommended by Fink and Oken.⁵ However, the ratio of attending psychiatrists and/or psychologists to trainees appears to be within the guidelines recommended by Gitlin et al.⁶ Many program respondents commented on the presence of nonintegrated competitive services, a finding also reported in adult C–L programs.¹ There was a notable absence of the role of the clinical nurse-specialist in pediatric C–L programs, in contrast to their role on adult services;⁷ 43% of programs reported inadequate staffing to meet the clinical need, and 42% reported difficulties recruiting child psychiatry staff and faculty, consistent with the overall national shortage of child and adolescent psychiatrists.

Funding of C–L Services
Funding issues have been cited as a major problem for both adult and pediatric C–L services. Many program directors commented on the difficulties related to the time-consuming activities devoted to negotiation with managed-care organizations in an effort to obtain reimbursement for psychiatric services. Reimbursement rates in this survey averaged only 30%, which is consistent with the historically low support for C–L work. However, the wide variation in reimbursement rates (0 – 92%) suggests that there may be models and lessons to be learned from programs that have been successful in increasing their collection rates. There is also a need for a cost/benefit analysis of the value of dedicated billing personnel employed to negotiate for reimbursement with insurance companies.

Program directors also commented on the difficulties related to the practice of "carving out" mental health benefits and the reluctance of medical insurance companies to fund what they see as psychiatric care.⁸ Mental health carve-outs have resulted in numerous clinical and administrative obstacles to providing patient care.^7,9 One example of this type of problem is that of psychiatric evaluations for organ transplantation, where insurance companies often deliberately blur the boundary between medical and psychiatric care in an effort to shift financial responsibility from one benefits-sector to another.⁹ Over 60% of programs reported decreased reimbursement rates for both services.

The discussion over who should support hospital-based C–L services has long been debated in the adult C–L literature.⁴ Early surveys indicated that many programs did not receive hospital funding and that cross-departmental financial support for C–L work was rare.¹⁰ Also, 56% of programs we surveyed reported a decrease in funding from the hospital or the home department. Historically, departments of psychiatry do not place a high priority on C–L work and tend to favor funding more traditional psychiatry specialties.⁴ Nonetheless, the overall rates of support from departments of psychiatry for adult and child programs appear to be equal. Recent surveys have suggested that the majority of adult C–L funding (42%) still comes from the departments of psychiatry, which is similar to the 40% reported in our survey.⁴ Funding from patient fees appears to have increased in recent years. In a 1995 survey by Strain et al.,⁴ patient fees contributed only 13% to adult C–L service, in contrast to the 36% in our survey. It is unclear whether this is a trend or a difference between adult and child programs. Nevertheless, this finding suggests that pediatric C–L program directors need to be actively involved in contract negotiations that involve support services for such programs as organ and bone marrow transplantation. Pediatric C–L services often have a tendency toward being overly responsive to the needs of others and of providing unreimbursed services in the effort to establish good relationships with pediatric colleagues. C–L program directors will need to take an active role in educating hospital administrators of the costs of these liaison activities, and also of raising awareness of the direct and indirect benefits of C–L work to the hospital; for example, those of helping reduce staff "burnout."¹¹

Service Activity and Practice Patterns
One clear finding from this survey is that there has been no decrease in the need for pediatric psychiatric consultation. By contrast, the increased level of medical acuity and shorter lengths of stay have led to increased work demands, with over 60% of programs reporting an increase in the volume of consult requests. Pediatric C–L programs appear to be providing both inpatient and outpatient consultation, and many also provide coverage to the emergency room. Most services appear to have a rapid response to the consultation request, and 74% of programs reported a frequency of contact with patients of either daily, or 2 – 4 times/week suggesting a fairly high level of acuity of referred patients. A recent study by Carter et al. suggests that pediatric C–L services are generally perceived as effective and are valued by both referring professionals and the parents of children referred for psychiatric consultation.¹²

Program respondents reported a high frequency of psychiatric referrals for assessment of both suicide attempt and adjustment to illness, which is consistent with findings of previous studies.^12,13 The findings of this study were also consistent with a study by Burket et al.,¹⁴ reporting that the major reasons for psychiatric consultation by pediatricians were behavior problems, suicide evaluation, depression, and reaction to illness.¹⁴ Other categories of consult request that were frequently reported included differential diagnosis of somatoform disorder, requests for medication evaluations, and nonadherence with medical treatment; 71% of programs reported a medium-to-high frequency of requests for parental adjustment to their child’s illness, suggesting that there is increasing recognition of the effect of the child’s illness on parental adaptation. There is also a growing literature that has drawn attention to the importance of looking at the impact of parental coping on the child’s adaptation.^14–16

C–L Activities
Program respondents reported that two-thirds of C–L activity is dedicated to the direct provision of clinical service. A decline in the time available for liaison work was reported by 48% of programs.¹⁷ This finding appears to be closely related to both the increased demands of clinical work and increased financial constraints. These findings are very similar to those of adult C–L programs, where one study reported a 70% reduction in liaison work.¹ These trends are unfortunate, particularly, since programs that integrate liaison as part of their practice have been shown to increase the number of informal referrals as well as greater utilization of the service.¹⁸ Specific activities most commonly practiced by pediatric C–L programs were psychotherapy, psychopharmacology, and triage and referral, similar to activities of adult C–L services, although pediatric consultation also commonly includes family therapy, preparation for procedures, and behavioral modification.¹⁹ These high-intensity services that are needed as part of effective intervention in child and adolescent psychiatry, in general, are also factors that limit the ‘financial efficiency" of the pediatric psychiatric consultant.

Only 28% of programs reported referral to a medical-psychiatry program as one of their activities. It is likely that this statistic reflects the lack of suitable treatment programs. Medical-psychiatric programs are typically viewed by managed-care companies as high cost centers because of the intensity of treatment and staffing and longer duration of stays.⁸ However, it is important to note that patients with medical and psychiatric comorbidity often have longer lengths of medical stay, and their psychiatric issues often add to their overall cost of health care.^8,20

Future Directions
Pediatric C–L programs have been described as being in an excellent position with regard to the managed-care environment, since they have traditionally focused on consultation, differential diagnosis, psychopharmacology, and short-term therapy, all of which are preferred by managed care, and which also have competitive advantage when compared with generalist psychiatric services.^8,9,15 Goldberg et al.⁸ have also suggested that one of the strengths of this specialty is the ability to integrate the medical, psychiatric, and behavioral aspects of the patient’s care. Our impression is that services integrating the skills of both pediatric psychiatrists and psychologists have a particular advantage in their ability to integrate multiple treatment modalities that are generally required in the management of children with complex medical issues.

There have been a number of studies demonstrating the direct benefit of C–L intervention with regard to both medical outcome and healthcare costs. For example, Smith et al.^21,22 were able to show that a brief written protocol for primary-care physicians resulted in decreased utilization of medical services, as well as a reduction in their annual median cost of medical care. Additional costs associated with medical–psychiatric comorbidity have also been demonstrated in nonadherent adolescent organ-transplant recipients and for patients with somatoform disorders, who are subjected to multiple, often unnecessary diagnostic evaluations. Saravay et al.²³ have also been able to demonstrate a relationship between psychiatric comorbidity and length of hospital stay.²³

Given these findings, it appears that pediatric C–L programs should be in a strong position to effectively advocate for support within both the hospital and insurance communities. Our study, however, suggests a wide discrepancy among programs in terms of levels of both funding and staffing. It seems clear that C–L program directors will need to work assertively with departments of pediatrics and hospital administration to provide input on what is an acceptable rate of reimbursement for their services.⁹ Bundling services—for example, in negotiations about the true costs of organ and bone marrow transplantation—may be one way to carve psychiatry back into the financial agreements.^7,24 Pain services, in particular, appear to have developed an effective model of negotiating joint care in the medical setting, perhaps because of the recognition of both the role of psychological factors in patients with chronic pain, as well as the need to utilize psychological techniques in their management. It may also be profitable to explore whether screening patients for psychiatric illness might allow medical diagnostic coding to increase rates of hospital reimbursement. Analysis of managed-care databases may also be useful in demonstrating the added value of pediatric C–L services.

A number of researchers have referred to the "hidden mental health-network of psychiatric patients," who are treated within the medical sector.^8,25 C–L programs can make their services more attractive to pediatric providers by providing outpatient care as part of the continuum of care, with the goals of preventing unnecessary hospitalization, and co-managing high-utilization outpatients.⁷ Primary-care settings have been noted to provide excellent learning experiences for trainees in child and adolescent psychiatry.^4,26

In conclusion, pediatric C–L is a growing aspect of psychiatric services in academic medical centers, providing training for psychiatry and psychology trainees, clinical care for children and families, and support for pediatric staff. Further study is needed to understand how to best support these important services within the rapidly changing healthcare environment.

REFERENCES

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1. Cavanaugh S, Milne J: Recent changes in consultation-liaison psychiatry: a blueprint for the future. Psychosomatics 1995; 36:95–102[Abstract/Free Full Text]
2. Wamboldt MZ: Current status of child and adolescent medical-psychiatric units. Psychosomatics 1994; 35:434–444[Abstract/Free Full Text]
3. Fritz GK: Consultation-liaison in child psychiatry and the evolution of pediatric psychiatry. Psychosomatics 1990; 31:85–90[Free Full Text]
4. Strain JJ, Easton M, Fulop G: Composition and funding: consultation-liaison psychiatry services. Psychosomatics 1995; 36:91–94[Free Full Text]
5. Fink PA, Oken D: The role of general psychiatry as a primary-care specialty. Arch Gen Psychiatry 1976; 33:998–1003[Medline]
6. Gitlin DF, Schindler BA, Stern TA, et al: Recommended guidelines for consultation-liaison psychiatric training in psychiatry residency programs: a report from the Academy of Psychosomatic Medicine Task Force on Psychiatric Resident Training in Consultation-Liaison Psychiatry. Psychosomatics 1996; 37:3–11[Free Full Text]
7. Bourgeois JA, Hilty DM, Kelin SC, et al: Expansion of the consultation-liaison psychiatry paradigm at a university medical center: integration of diversified clinical and funding models. General Hosp Psychiatry 2003; 25:262–268
8. Goldberg RJ, Stoudemire A: The future of consultation-liaison psychiatry and medical-psychiatric units in the era of managed care. General Hosp Psychiatry 1995; 17:268–277
9. Gonzales JJ, Randel L: Consultation-liaison psychiatry in the managed-care arena. Psychiatr Clin North Am 1996; 19:449–466[CrossRef][Medline]
10. Anders TF: Child psychiatry and pediatrics: the state of the relationship. Pediatrics 1977; 60:616–620[Abstract/Free Full Text]
11. Zarr ML: Patient dynamics, staff burnout, and consultation-liaison psychiatry. Physician Executive 1991; 17:37–40[Medline]
12. Carter BD, Kronenberger WG, Baker J, et al: Inpatient pediatric consultation-liaison: a case-controlled study. J Pediatr Psychol 2003; 28:423–432[Abstract/Free Full Text]
13. Olson R, Holden EW, Friedman A, et al: Psychological consultation in a children’s hospital: an evaluation of services. J Pediatr Psychol 1988; 13:479–492[Abstract/Free Full Text]
14. Burket RC, Hodgin JD: Pediatricians’ perceptions of child psychiatry consultations. Psychosomatics 1993; 34:402–408[Abstract/Free Full Text]
15. Knapp PK, Harris ES: Consultation-liaison in child psychiatry: clinical findings. J Am Acad Child Adolesc Psychiatry 1998; 37:17–25[CrossRef][Medline]
16. Knapp PK, Harris ES: Consultation-liaison in child psychiatry: research on treatment approaches and outcomes. J Am Acad Child Adolesc Psychiatry 1998; 37:139–146[CrossRef][Medline]
17. Lipowski ZJ: Consultation-liaison psychiatry: an overview. Am J Psychiatry 1974; 131:623–630[Abstract/Free Full Text]
18. Rothenberg MB: Child psychiatry-pediatrics consultation-liaison services in the hospital setting: a review. General Hosp Psychiatry 1979; 1:281–286[CrossRef]
19. Ramchandani D, Lamdan RM, O’Dowd MA, et al: What, why, and how of consultation-liaison psychiatry: an analysis of the consultation process in the 1990s at five urban teaching hospitals. Psychosomatics 1997; 38:349–355[Abstract/Free Full Text]
20. Simon G, Ormel J, VonKorff M, et al: Healthcare costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry 1995; 152: 352-357
21. Smith GR, Monson RA, Ray DC: Psychiatric consultation in somatization disorder. N Engl J Med 1992; 344:1407–1413
22. Smith GR, Rost K, Kashner M: A trial of the effect of a standardized psychiatric consultation on health outcomes and cost in somatizing patients. Arch Gen Psychiatry 1995; 52:238–243[Abstract]
23. Saravay SM, Lavin M: Psychiatric comorbidity and length of stay in the general hospital: a critical review of outcome studies. Psychosomatics 1994; 35:233–252[Abstract/Free Full Text]
24. Thompson TL, Folks DG, Silverman JJ: Challenges and opportunities for consultation-liaison psychiatry in the managed-care environment. Psychosomatics 1997; 38:70–75[Abstract/Free Full Text]
25. Schurman RA, Kramer PD, Mitchell JB: The hidden mental health network. Arch Gen Psychiatry 1985; 42:89–94[Abstract]
26. Fritz GK, Bergman AS: Consultation-liaison training for child psychiatrists: results of a survey. General Hosp Psychiatry 1984; 6:25–29

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