Medical Care Improves When Psychiatrists, Internists Join Forces

Adding an internist to an inpatient psychiatric team improved 12 out of 17 patient care processes without increasing hospital charges or length of stay, according to a randomized controlled trial by University of Vermont researchers.

A second study found that Medicaid psychiatric outpatients in Ohio used medical services at a higher rate than the general population, but received“ dismal” levels of preventive care. Usage rates differed by psychiatric diagnosis, said researchers from Ohio State University, so assistance programs ought to vary accordingly.

The two reports appear in the April Psychiatric Services.

General medical care for psychiatric patients has received increased research attention in the last decade, commented Benjamin Druss, M.D., the Rosalynn Carter chair in mental health at Emory University. Druss was not associated with either study.

“Medical care for the mentally ill has been an orphan issue over the years,” said Druss. “Mental health researchers have focused on mental health, while primary care people haven't looked at this patient group.”

In the Vermont study, a board-certified internist developed a needs assessment documenting nonpsychiatric medical problems and medication use on admission, wrote Alan Rubin, M.D., an assistant professor of general internal medicine at the University of Vermont College of Medicine, and four colleagues. He also advised the patients' primary care providers about health maintenance care on discharge.

“Adding the internist made for wise ordering, a more complete data base for preventive services, and prompt handling of problems as they came up,” Rubin told Psychiatric News. “We believe the savings came from fewer unnecessary tests in general and a half day less length of stay, although this finding was not significant.”

Others have proposed giving psychiatrists more training in internal medicine or creating combined medical-psychiatric units to meet the need for general medical care for psychiatric inpatients, wrote Rubin. The staff internist working on the two 24-bed psychiatric units provided comprehensive services during otherwise open time in the patients' daily schedule.

In the study, 272 patients were admitted from March 2001 to January 2002 to the psychiatric units of Fletcher Allen Health Care in Burlington, Vt. Twelve were screened out for prespecified medical reasons, and 121 refused to participate in the trial. Those who were ineligible or who refused were significantly older (43.3 years versus 37.2 years) and had more comorbid medical conditions than patients who agreed to join the study.

The researchers were concerned about the many eligible patients who, possibly because of “fatigue or suspicion,” refused to participate in the study.

“It is not clear whether these patients would have refused medical attention by the internist if it was offered in a nonresearch, nonacute setting,” they said.

Eventually 55 patients were randomized to the intervention group, and 84 received usual care. The unequal group sizes resulted from an administrative error, but this did not violate randomness or introduce bias, said the researchers. About 39 percent of the usual-care group and 45 percent of the intervention group were male. There were no significant differences between the groups in age, sex, diagnosis, and functioning. Most patients did not have comorbid nonpsychiatric medical conditions, although those in the intervention group had slightly more (p=0.023).

Patients in both groups had physical examinations and had lists of physical problems, psychosocial issues, family risk factors, allergies, and environmental problems updated. However, significantly more of the intervention group had their medication lists reviewed, had higher needs-assessment summary scores, and had a risk plan created to reflect any family history of inheritable diseases like heart disease, breast cancer, prostate cancer, or colon cancer that call for earlier screening. Significantly more intervention-group patients received alcohol or tobacco risk-reduction plans, stool tests, and lipid screenings. In the intervention group, 90 percent of eligible patients received mammograms, 80 percent had Pap tests, 75 percent had digital rectal exams or PSA tests, 59 percent got tetanus vaccine, 58 percent had flu shots, and 46 percent got pneumonia vaccine. No patients in the usual-care group got those screening tests or immunizations.

The internist ordered specialty consultations as needed, managed acute and chronic nonpsychiatric illnesses during the stay, attended daily rounds, and communicated with the patient's primary care physician at discharge.

Length of stay for the usual-care group was 11.5±9 days compared with 10.9±7.3 days for the intervention arm. Total hospital costs averaged $8,527±6,512 for the usual-care group and $8,558±5,703 for the intervention group.

“This is a fairly inexpensive intervention, since the internist is already working in the hospital,” said Druss. “It's important to do, and this is a good opportunity to do it because it is relatively inexpensive compared with total inpatient costs.”

In the Ohio study, researchers looked at medical records of 669 persons with severe and persistent mental illness enrolled in Medicaid from 1996 to 1998. Sixty patients were diagnosed with anxiety disorders, 158 with schizophrenia, 379 with affective disorders, and 72 with paranoid disorders.

Nonpsychiatric medical service usage was high across the board but showed some variation by psychiatric diagnosis, reported Pamela Salsberry, Ph.D., R.N., Esther Chipps, Ph.D., R.N., of the College of Nursing at Ohio State University, and Carol Kennedy, Ph.D., R.N., of the Ohio State Medical Center in Columbus.

For instance, 78 percent of patients with schizophrenia disorders made an office visit during the study's three years, while 88 percent of those with affective disorders, 96 percent of those with paranoid disorders, and 100 percent of those with anxiety disorders did so. Over the same period, 69 percent of schizophrenia patients went to the emergency room, as did 83 percent of the anxiety patients. In comparison, 20 percent of Ohio residents and 21 percent of Medicaid recipients went to the emergency room in 1997-1998.

Their findings also pointed to a lower use of cancer screening and dental and vision services among patients with psychiatric illnesses than in the general population, a pattern they termed “unacceptable.”

“Compared with persons with a schizophrenic disorder, those with an anxiety disorder were more likely to have had an office-based visit and to have received vision services, those with a paranoid disorder were more likely to have used dental services or receive a mammogram, and those with an affective disorder were more likely to have had a Pap test,” the researchers wrote.

“This means that programs for improving medical care should be tailored to the diagnosis or to individual patients,” said Druss. For example, patients with anxiety disorders might get counseling to reduce overuse of health services, while those with schizophrenia might be helped to get to their primary care doctor more often.

Vermont's Rubin isn't waiting to act on his study's outcome.

“Since the study, we have added preventive services to the initial screening, so patients can get better care,” he said. “I am proud of that addition.”

“Effects on Processes and Costs of Care Associated With the Addition of an Internist to an Inpatient Psychiatry Team” is posted online at<http://ps.psychiatryonline.org/cgi/content/full/56/4/463>.“ Use of General Medical Services Among Medicaid Patients With Severe and Persistent Mental Illness” is posted at<http://ps.psychiatryonline.org/cgi/content/full/56/4/458>.▪