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Psychiatric comorbidity in cardiovascular inpatients: Costs, net gain, and length of hospitalization

https://doi.org/10.1016/j.jpsychores.2010.09.010Get rights and content

Abstract

Objective

Although psychiatric comorbidity often goes undetected and untreated in cardiovascular patients, it is not clear whether the costs for a special treatment of psychiatric comorbidity are appropriately reflected in the reimbursement system. To investigate the economic impact of psychiatric comorbidity, we compared costs, returns, net gain, and duration of hospitalization in cardiovascular inpatients with and without psychiatric comorbidity.

Methods

For a period of 2 years, we analyzed costs, net gain, and other outcome variables according to the diagnosis-related group (DRG) system for cardiovascular inpatients of a German university department (n=940). Psychiatric disorders were diagnosed by the treating physicians based on clinical criteria and results from the Patient Health Questionnaire (PHQ). With respect to the outcome variables, we compared patients with and without a psychiatric disorder, controlling for sociodemographic characteristics.

Results

The average total costs of hospitalization (mean±S.E.) for cardiovascular patients without psychiatric comorbidity and for patients with psychiatric comorbidity differed significantly (€5142±210 vs. €7663±571; d=0.39). The increased costs for patients with psychiatric comorbidity were related to elevated returns, but the net gain for patients without psychiatric comorbidity was €277±119. In contrast, the treatment of internal medicine patients with psychiatric disorders resulted in a net loss of −€624±324 (overall group difference, d=−0.25).

Conclusion

Psychiatric comorbidity in cardiovascular inpatients leads to higher costs that are not reflected in the current reimbursement system in Germany. The inappropriate reimbursement of psychiatric comorbidity in cardiovascular inpatients may result in a serious undertreatment of these patients.

Introduction

The introduction of diagnosis-related groups (DRG) in Germany has led to an increasing pressure on hospitals to focus on the costs of treatment. Despite higher expenses for patients with somatic disorders and psychiatric disorders [1], [2], [3], no international studies exist which focus on the consequences of psychiatric comorbidity on the real costs of inpatient treatment. A recent study gave evidence that patients with psychiatric disorders are more expensive to treat than patients without psychiatric disorders [4]. This finding is relevant because the reimbursement system is generally independent from the length of stay and forces the care providers to minimize the duration of hospitalization. Because it is known that psychiatric diagnoses are associated with prolonged hospitalization [5], [6], [7], poorer compliance [8], more complications [9], and increased mortality [10], the question arises whether the treatment of patients with psychiatric comorbidity is appropriately reflected.

Psychiatric disorders in internal medicine patients increase the costs for inpatient treatment [1], [2], [3], and patients with internal disorders have an elevated risk of psychiatric disorders [11], [12], [13]. While the prevalence of depressive disorders is 6.6% in the general population [14], it is estimated to be 35–70% in inpatients with chronic heart failure [15]. Additionally, there is a strong correlation with the quality of life [16] and the NYHA grade: with increasing NYHA grade, the fraction of depressive patients rises significantly [17]. Moreover, depression is a strong predictor of short-term worsening of heart failure symptoms [18], since psychological distress adversely affects the prognosis in coronary patients [19]. The rate of rehospitalization of patients with chronic heart failure (CHF) triples within 1 year if a depressive comorbidity is diagnosed [20]. Depressive patients with CHF utilize medical emergency admission services twice as much as CHF patients without depression [21] and show an eightfold higher risk of mortality after 30 months [22]. Besides the subjective restrictions, depressive patients with CHF caused a 29% increase in costs compared to nondepressive patients with CHF [23]. These findings show how crucial it is to detect depressive symptom patterns in cardiovascular patients. In addition, it is crucial to account for the financial aspects of treating depressive patients with CHF in the event that the reimbursement system does not adequately reflect the additional costs associated with treating psychiatric comorbidity. Therefore, in this study, we investigated the relationship of psychiatric disorders and costs, returns, net gain, and duration of hospitalization in cardiovascular inpatients to find out whether treatment of psychiatric comorbidity in these patients is appropriately reflected in the reimbursement system with the DRG.

Section snippets

Methods

For a period of 2 years, we analyzed costs, net gain, and other outcome variables according to the German DRG system for cardiovascular inpatients of a university department (N=1063). Psychiatric disorders were diagnosed by the treating physicians based on clinical criteria and results from the Patient Health Questionnaire (PHQ). With respect to the outcome variables, we compared patients with and without psychiatric disorders while controlling for sociodemographic characteristics.

Sociodemographic data

Of 1063 cardiovascular inpatients, 940 patients (86.9%) were not diagnosed with a psychiatric disorder. In 123 patients (13.1%), one psychiatric disorder was diagnosed. Ninety-three patients (8.75%) had one diagnosis of a psychiatric disorder, 22 (2.07%) had two psychiatric disorders, and 8 (0.75%) had more than two psychiatric disorders (Table 1).

Under the psychiatric disorders, the following diseases were diagnosed (simple and multiple diagnosis): 61 (37%) depressive disorders, 17 (10%)

Discussion

Our analyses show as a major finding that psychiatric comorbidity in cardiovascular patients leads to higher costs of treatment that are not even rudimentarily reflected in the German system of diagnoses-related groups. While the treatment of cardiovascular patients without psychiatric comorbidity results in a net gain for the hospital, the treatment of cardiovascular patients with psychiatric comorbidity can even lead to a net loss for the hospital. Although the variances of costs, gain, and

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