Elsevier

General Hospital Psychiatry

Volume 23, Issue 6, November–December 2001, Pages 319-325
General Hospital Psychiatry

Complexity of care and mental illness in medical inpatients

https://doi.org/10.1016/S0163-8343(01)00162-1Get rights and content

Abstract

We investigated the complexity of medical inpatient care to learn it was associated with the presence and type of mental disorders, and with emotional distress and somatization. Six indicators of care complexity, including length of stay (LOS), were assessed for 294 consecutive medical inpatients. Patients rated their own health and physical disability, and medical consultants assessed them for chronic and life-threatening diseases. A subsample of 157 patients was assessed for ICD-10 psychiatric diagnoses by means of an extensive semi-structured interview known as Schedules for Clinical Assessment in Neuropsychiatry (SCAN). With a few exceptions, the indicators of complexity of care were not statistically significantly associated to ICD-10 mental disorders; psychological distress, measured by the SCL-8 rating scale; or somatization, measured by the Whiteley-7 rating scale. On the other hand, four of six complexity indicators were significantly associated with self-rated physical disability or health, or both, when controlling for the severity of the medical condition. In conclusion, complexity of care, including LOS, was substantially associated with the patient’s own health perception but only marginally with the presence of mental illness. This is noteworthy, as previously published results concerning the same patients have shown a clear association of mental illness with utilization of admissions to nonpsychiatric departments, and with utilization of primary care resources.

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

References (32)

  • P Fink

    The use of hospitalizations by persistent somatizing patients

    Psychol Med

    (1992)
  • P Fink et al.

    A study of hospital admissions over time, using longitudinal latent structure analysis

    Scand J Soc Med

    (1993)
  • W Katon et al.

    Depression-medical utilization and somatization

    West J Med

    (1986)
  • G.R.J Smith et al.

    Patients with multiple unexplained symptoms. Their characteristics, functional health, and health care utilization

    Arch Intern Med

    (1986)
  • S.D Fields et al.

    Cognitive impairment. Can it predict the course of hospitalized patients?

    J Am Geriatr Soc

    (1986)
  • J.L Levenson et al.

    Relation of psychopathology in general medical inpatients to use and cost of services

    Am J Psychiatry

    (1990)
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