Complexity of care and mental illness in medical inpatients
Introduction
Epidemiological and clinical studies have shown that persons with mental disorders are frequent users of nonpsychiatric health care resources [1], [2], [3], [4], [5], [6]. In a previous paper it was shown that mental disorders in internal medical inpatients were strongly associated with increased utilization of nonpsychiatric admissions, and of primary care services, during recent years up to the index admission [7].
However, apart from the number of admissions, it is important to study how comorbid mental disorders influence inpatient care. Increased average length of stay (LOS) has been found for general hospital inpatients with cognitive impairment [8], [9], [10], [11], [12], [13], and similar results have been reported for anxiety, depression, and psychological distress [14], [15], [16], [17], though doubted by other studies [9], [11], [18], [19].
LOS is only one aspect of health care utilization associated with a hospital admission, and other factors may contribute to an integrated assessment of complexity of care given during hospitalization, particularly by adding information on the “density of care”, i.e. the work the patients cause for the care deliverers during hospitalization. In the Biomed1 Risk Factor Study (European consultation Liaison Workgroup, ECLW) [20], [21], [22], a concept of care complexity was developed, offering a more detailed description of the utilization of hospital services during admission. This concept was adopted in the present study. Care complexity was measured by counting the number of days on which there were laboratory- and diagnostic tests, the number of medications and nurse interventions, and the number of consultants involved during hospital stay.
Hence, it was the objective of the study to determine whether mental illness altered complexity of care and to identify simple case finders for patients in need of inter-disciplinary care. Currently, referral of complex patients to psychiatric consultation is based on a subjective decision, presumably biased toward those patients presenting (behavioral) problems to the health care professionals. In this article, two brief screening instruments for mental illness were applied and examined for associations with care complexity.
The purpose of the present study was to investigate among internal medical inpatients, whether complexity of care is associated with: a) ICD-10 non-cognitive mental disorders; B) the SCL-8D scale for anxiety and depression; C) the Whiteley-7 scale for somatization; and D) the patient’s own perception of health and physical disability.
Section snippets
Study population
The study population consisted of consecutive inpatients aged 18 or older who were admitted to the department of internal medicine at Silkeborg Central Hospital, Denmark, during a three month period in 1997. The department provides all medical services for the catchment area. Each patient was included only once. In all, 547 patients were admitted during the study period.
Descriptive statistics
Table 1 shows the frequencies of all variables discussed in the present article.
High complexity and mental disorders
Among females, the presence of a mental disorder, and the presence of an anxiety/depressive disorder, showed significant associations with a high number (≥9) of different non-psychotropic medications (ORmental disorder = 5.8 (95% C.I. = 1.3–26.9); ORanx/dep = 7.3 (95% C.I. = 1.5–36.6). In men, the corresponding odds ratios were not significant. Neither mental disorders combined nor did a diagnosis of
Complexity and health perception
The variables studied in this article most clearly associated to complexity of care were the ones concerned with the patients’ health perception. Table 2 illustrates that there was a trend in the association between several of the complexity indicators and the self-rated variables. As health ratings were done by admission, this association probably shows that the way patients experience their own health has an impact on how complex their care will be in the hospital, even after adjustment for
Acknowledgements
The investigation is part of the Biomed1 Risk Factor Study (European Consultation Liaison Workgroup, ECLW) [20], [21], [22]. The authors would like to thank Thomas Herzog, MD (Germany), Professor Antonio Lobo, MD (Spain), Prof. J. P. J. Slaets, MD (The Netherlands), Graca Cardoso, MD (Portugal) and Prof. Marco Rigatelli, MD (Italy). Lene Søndergaard, MD, senior registrar, Dep. of Psychiatry, Vejle Hospital made contributions as to design and as a SCAN interviewer. Marie-Louise Oxhøj, MD, was
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