A Model for Evaluating the Impact of Consultation-Liaison Psychiatry Activities on Referral Patterns

A Model for Evaluating the Impact of Consultation-Liaison Psychiatry Activities on Referral Patterns J. VAZ, M.D., PH.D. MARfA S. SALCEDO, PH.D.

FRANCISCO

A method for evaluating the change ofthe referral patterns in consultation-liaison (C-L) psychiatry is described. The method is applied to the study ofthe 528 requests received by a C -L team for a 2 -year period. following the creation of the C-L service. Five types ofC-L request are isolated and related to DSM-lll-R diagnosis and other clinical variables. Final data show how the referral patterns in a general hospital can change in a positive way as a result of C -L psychiatry activity. moving from a "mending" and secondary view ofpsychiatric work to a collaborative and primary concep(Psychosomatics 1996; 37:289-298) tual model.

T

he structure of modern hospitals, with highly differentiated services, frequent changes in medical and nursing staff, and rapid patient rotation, threatens to deprive patients of global care. Consultation-liaison (C-L) activities could act in such a way to ensure the existence of a multidisciplinary approach to clinical problems; and in this context CoL psychiatry can provide a comprehensive biopsychosocial view of the patient and his or her illness. I.2 Thus, CoL psychiatry can be seen as the clinical expression of psychosomatic medicine, in the most extensive meaning of the term,3 that is, as a field of knowledge that can articulate and integrate different logical components (biologicaVpsychologicaVpsychosocial) to explain illnesses and to design therapeutic processes. Several epidemiological studies have shown that, while the real incidence of psychiatric disorders in the general hospital population is between 30% and 40%,4-9 in only a tenth of the cases is a psychiatric consultation requested, with high levels of psychopathology VOLUME 37 • NUMBER 3 • MAY - JUNE 1996

detected in patients who do not receive psychiatric attention. l o- 15 Since the need for psychiatric care in the general hospital population is so evident, CoL psychiatry must prove not only its usefulness for providing appropriate answers to patients' clinical problems,I6-22 but also its capacity to improve clinicians' ability to detect psychopathological symptoms and to bring about a change in physician attitudes toward psychiatric illness. 23-26 The clinical effectiveness of CoL psychiatry services must result in positive changes in patterns ofpatient remission with the passing of time,27 changes that might reflect a more precise and rapid detection of psychopathological symptoms, more appropriReceived Febrwuy 4, 1994; revised March 4. 1994; accepted May 20. 1994. From the Department ofPh.annaco1ogy and Psychiatry. University of Extremadura Medical School. and the Psychiatric Unit, Infanta Cristina University Hospital. Badajoz. Spain. Address reprint requests to Dr. Vaz. C4tedra de Psiquiattia, Facullad de Medicina de 18 Uex. Av. de E1vas sin. 06071 Badajoz. Spain. Copyright e 1996 The Academy of Psychosomatic Medicine. 289

Impact of C-L Psychiatry on Referrals

ate symptom management, and a progressive decrease in psychological and physical complications associated with hospitalization. The necessity of introducing evaluation criteria to determine the effectiveness of C-L psychiatry activities has been advocated by a number of authors. 19.24.23.28.29 Nevertheless, as Houpt has observed, the evaluation of C-L activity is not always easy because it produces a number of phenomena of a very different nature. Thus, while consultation processes usually provide better clinical care for patients, liaison activities induce positive changes in the attitudes and behavior of medical staff. 30 A method to evaluate the change of the referral patterns in C-L psychiatry is described here. The method does not focus on the characteristics ofthe referred patients but on the characteristics of the requests themselves and, in the authors' opinion, it can be used in the evaluation of the impact that C-L psychiatry activities have on referral patterns. Our conceptualizations have some points in common with others described before in literature. 28•31 The method has been partially described elsewhere,32 and its reliability in clinical work has been proved. It has shown high test-retest reliability (r =0.89) and interrater reliability (r =0.94) when applied in clinical practice. Here it will be applied to the requests received by a C-L psychiatry team over a 2-year period (1990-1992), following the creation of the C-L service. Our results will show how the referral patterns can change in a positive way, moving from a "mending" and secondary view of psychiatric activity to a collaborative and primary conceptual model. As such, the proposed method could be a useful index of the teaching dimension of C-L psychiatry in the hospital context. METHODS Our results came from the analysis of 528 consecutive consultation requests. The first step of the study was the classification of the consultation requests, taking into account the following circumstances: 1) the existence/absence of psychopathological symptoms at admission; 290

2) the existence/absence of psychopathological records; 3) the existence/absence of psychopathological symptoms at the time when the C-L intervention was requested; and 4) when psychopathological symptoms really exist, their relationship with the problem that had motivated the hospital admission. These four items were articulated in a decision tree, which permitted the definition of five basic types of request (see Figure I). The five types of isolated C-L request will be described. "Complementary" Requests (CR I) Under this classification, those requests made for patients who showed psychopathological manifestations associated with the problem that had conditioned their hospital admission (metabolic, neurological, endocrinological, and other similar diseases) were grouped. An example might be the request made for an epileptic patient showing behavioral disturbances or for a person with alcohol hallucinations being cared for in a medical service because of a chronic liver disease. CR I usually require close collaboration between the service that made the request and the C-L psychiatry team. Both services must function as a single multidisciplinary team searching for a common solution. The "liaison" activities here are very important, and both services must clearly define their reciprocal positions, responsibilities, limits, and competencies to avoid the dysfunctional invasion of the others' field on the one hand, and on the other, indiscriminate delegation of responsibility. The advantage of proper planning at this level is the enlargement of the field of clinical knowledge and also cost savings (by avoidance of unnecessary duplication of examinations, complementary tests, treabnents, etc.). The final result will be a quicker, enlarged diagnosis, a shorter hospital stay, and, above all, better care for patients. "Parallel" Requests (CR2) In this group, all those consultation requests made for patients with psychopathologiPSYCHOSOMATICS

Vaz and Salcedo

FIGURE 1.

Types or request

Consultation Request

MlsdlagnoalsConciltIoMcI Request

Initial contad with the physician attending the patient

C5

t

1 Are there at this moment psychopathological symptoms that justify the psychiatric intervention'

Yes

No

No

Does the patient have a psychiatric history' Yes

Were the symptoms present when the patient was admitted'

C3

No

Mending Request

C4 AntecedentConditioned Request

Yes

~

Are the psychiatric symptoms related to the illness that has led to the admission of the patient'

!

Yes

f--+

Cl Complementary Request

No

C2 Parallel Request

cal disorders initially not associated with the problem that had brought them to hospital were placed. An example may be that of a surgical patient with a detected paranoid disorder. It is not the case of those patients in whom the existence of previous psychiatric disorders in their clinical backgrounds led the physician to request the intervention of the psychiatrist, but rather of those who present psychopathological symptoms diagnosed by the attending physician. In CR2, both services (referent and referee) could act with relative methodological VOLUME 37 • NUMBER 3 • MAY - JUNE 1996

independence. although care should be taken to avoid unnecessarily lengthening of the patient's hospital stay. In all cases, the work of referent and referee must run close to each other. Thus, it is important to establish not only the different interventions made for the patient, but also the time and sequence of these. The psychiatric intervention could be started during hospitalization, or delayed until after discharge; it could be developed by the CoL team itself or by other colleagues working in outpatient settings. 291

Impact of C-L Psychiatry on Referrals

"Mending" Requests (CR3) Under this classification, those requests made for patients who showed psychopathological manifestations that had appeared during their hospital stay were grouped. Usually, the symptoms were iatrogenic, since they had appeared as a result of the incidence in the patient of negative institutional factors (isolation, lack of information, communication problems with staff, etc.) or by the lack of appropriate preventive measures (alcohol or drug withdrawal after admission, lack of appropriate external stimuli, or surgery with anesthesia in patients with organic brain disorders, etc.). With reserve, an attempt was made to classify the CR3 into one of the following two categories: "physical" complications (CR3a), disorders basically associated to biological factors, and "psychological" complications (CR3b), disorders basically of a psychosocial nature. CR3 are very frequent and not very difficult to prevent. They can be viewed as important obstacles in the patient's treatment and, if possible, they must be neutralized. The psychiatrist has, in these cases, a double task: I) to treat the patients' present state, and 2) to instruct the staff accordingly to prevent similar problems in the future. Each case must be a reason for reflection and one step on the way to prevention, aimed at creating a more positive and therapeutic hospital atmosphere. "Antecedent-Conditioned" Requests (CR4) Under this classification, the requests that were not motivated by the state of the patient, but by the doctor's prejudices, were grouped. In these cases, the requests were conditioned by the existence of psychiatric records. The psychiatric antecedents led doctors to request the collaboration of psychiatrists for the management of patients defined a priori as "problematic," "dangerous," or "unpleasant," without an appropriate prior evaluation of their present mental state. Thus, psychiatric antecedents acted as a stigma that induced in the doctor a defensive response: the attempt to place the 292

patient in the care and custody of the psychiatrist. For this reason, we have classified these requests as "antecedent-conditioned." The clinical behavior of the psychiatrist under these circumstances is a very important therapeutic element. In our opinion, the main work must be done not with the patient but with the doctor to establish the real need for a psychiatric consultation. Especially dangerous is the automatic transfer of the patient to the psychiatric unit, which could thus be converted into a "ghetto" for especially "problematic patients." "Misdiagnosis-Conditioned" Requests (CR5) In this group, those requests arising from an inaccurate patient evaluation were included. Adaptive behaviors, normal reactions to negative life events, even justified protests, could be interpreted as "signs of a psychiatric disorder." Thus, we use the term "misdiagnosis-eonditioned" to define them. The method used to assign consultations to categories was the following: when the consultation process was over, one of the authors (M.S.S.) blindly assigned each case to one category, whereas the other author (EJ.V.) assigned to each case a DSM-III-R diagnostic category in the context of a clinical session. As mentioned earlier, the main purpose of this investigation was to determine whether the existence ofa C-L psychiatry team could induce therapeutic modifications in referral patterns. When the 528 requests were analyzed and classified following the criteria described before, 4 consecutive periods of 6 months were identified (Periods 1~) to determine the changes that might be produced with the passage of time. For each case, the following data were considered: I) sex; 2) age; 3) the service making the request; 4) the reason that justified the consultation, if this was consigned on the request form; 5) the urgency of the request; 6) the DSMIII-R diagnosis of the patient; and 7) the type of request according to the previously defined categories. Qualitative data were compared by using the chi-square test. Data were grouped for PSYCHOSOMATICS

Vaz and Salcedo

analysis, and the continuity correction factor was introduced when necessary. For the statistical treabnent of quantitative data, a one-way analysis of variance was perfonned. RESULTS The number of subjects studied was 528 patients (255 male/273 female) who were initially attended during the 2-year period. However, a move to a new hospital building in the middle of the second 6-month period made the distance between pediatric/obstetric services and the central medical/surgical hospital (where C-L psychiatric service was located) significantly greater; therefore, it was necessary to divert most of the obstetric/pediatric patients to other psychiatric services. For this reason, we have not considered here these consultations, and we have analyzed only the 508 remaining requests (254 male/254 female) that came from medical and surgical services. The most relevant general data are contained in Table I. The mean ± SO age of the patients was 44.03 ± 21.3 years, with a maximum of 93 and a minimum of 8. The distribution of frequency shows nonnal distribution, with a peak between 20 and 25 years. Requests for medical services and surgical services were 352 (69.3%) and 156 (30.7%), respectively. Of these, 107 (21.0%) were urgent requests. "Depression" (18.3% of the cases), "agitation" (14.3%), "family problems" (7.7%), "no organic fmdings" (7.5%), "disruptive behavior," and "drug/alcohol-related problems" (both with the same frequency, 6.3%) were the main reasons for a psychiatric consultation request. The most frequent OSMIII-R diagnostic category was "organic mental disorder" (23.0%), followed by "mood disorder" (21.3%), and "personality disorder" (12.0%). "Somatofonn disorder" (9.2%) was the fourth most detected pathology. Thirtyseven patients (5.3%) were, after consultation, transferred to the psychiatric unit to receive their specific psychiatric treabnent. Of the 220 requests, 43.7% were classified as CR1; 101 (29.5%) were identified as CR2; 85 cases (16.7%) were classified as CR3; 53 being VOLUME 37. NUMBER 3. MAY - JUNE 1996

CR3a (10.4%); and 32 CR3b (6.3%). In 33 cases (6.5%), the request was specifically conditioned by the existence of psychiatric antecedents (CR4), and, fmally, 18 (3.5%) cases were identified as CR5 (i.e., as diagnostic mistakes or unjustified requests). Table 2 shows the relationship between the OSM-III-R diagnosis and the consultation request type. It can be seen that the "complementary" request (CRI) category highly correlates with "organic mental" (18.5%), "mood" (16.7%), "personality" (14.8%), and "somatafonn" (13.9%) disorders. The most frequent diagnosis in "parallel requests" (CR2) is "mood disorder" (37.3%). For CR3a, that is, those consultation requests derived from a physical complication arising in the course of hospitalization, the main diagnostic category is "organic mental disorders" (73.6%). For CR3b (psychological complications), we fmd four basic diagnostic categories: "organic mental" (21.9%), "mood" (15.6%), "adjustment" (15.6%), and "personality" (12.5%) disorders. "Antecedent-conditioned requests" (CR4) are basically associated with "organic mental disorders" (21.2%), "mood disorders" (18.2%), and "personality disorders" (15.1 %). Finally, "misdiagnosis-conditioned requests" (CR5) are related above all with the "no diagnosis" category (55.6%). Returning to Table I, we can observe the evolution of the data over the four isolated periods. We can see how the total number of requests increases progressively from the first to the fourth period (91 requests in the fmt period, 105 in the second one, 130 in the third one, and 182 in the last period). The male/female rate remains quite stable, without significant variations. The mean age of the patients also shows very small changes, with a maximum of 46.04 years and a minimum of 42.29 years. Medical service requests always clearly predominate over surgical service requests (with a percentage that oscillates between 65.38% (4th period) and 75.38% (3rd period). No significant changes are detected at this level. There is an important (but not significant) 293

Impact of C-L Psychiatry on Referrals

TABLE 1.

General data referring to the four Isolated periods

Gender. % Male Female Age. years Mean values Requesting Service, % Medicine Surgery Emergency, % Urgent requests Patients' Transfer. % Transfer psychiattic unit Main Reason for Consultation, % Agitation Anxiety Depression Suicidal behavior Disruptive behavior Psychosis AlcohoVdrugs Antecedents No organic findings Family problems Sexual probIerns Unspecified Consultation Type, % CRI CR2

CR3a CR3b CR4 CRS DSM-m-R Primary Diagnosis Qilldladolescent disorders Organic mental disorders Psychoactive substance use Schizophrenia Paranoid disorders Other psychotic disorders Mood disorders Anxiety disorders Sornatofonn disorders Impulse control disorders Adjustment disorders Psychological factors affecting... Personality disorders No diagnosis Total Requests

lSI Period

2nd Period

Jrd Period

4th Period

Totals

r

53.85 46.15

48.57 51.43

50.00 50.00

48.9 51.1

50.00 50.00

NS NS

45.49

43.27

46.04

42.29

44.03

NS

68.13 31.87

69.52 30.48

75.38 24.62

65.38 34.62

69.29 30.70

NS NS

26.37

26.67

17.69

17.58

21.06

NS

10.99

11.43

3.85

5.31

0.001

18.68 8.79 24.18 6.59 6.59 2.2 2.2 9.89 4.4 7.69 0 8.79

13.33 3.81 24.76 6.67 9.52 2.86 11.43 0 16.19 1.9 1.9 7.62

13.85 3.85 13.85 2.31 2.31 2.31 3.85 5.38 5.38 9.23 0 37.69

13.19 4.4 14.84 4.4 7.14 3.3 7.14 0.55 5.49 9.89 0.55 29.12

14.3 4.92 18.30 4.72 6.29 2.75 6.29 3.34 7.48 7.67 0.59 23.22

NS NS 0.0417 NS NS NS 0.0318 0.0001 0.0022 NS NS 0.0001

34.07 28.57 8.79 12.09 9.89 6.59

42.86 29.52 7.62 11.43 3.81 4.76

46.92 26.92 13.08 1.54 8.46 3.08

46.7 31.87 10.99 3.85 4.95 1.65

43.70 29.52 lQ.43 6.29 6.49 3.54

NS NS NS 0.0008 NS NS

5.49 20.88 0 3.3 0 2.2 16.48 7.69 16.48 1.1 5.49 1.1 13.19 6.59 91

1.9 26.67 5.71 1.9 0.95 0 20 1.9 8.57 0 6.67 0 22.86 2.86 105

5.38 26.15 6.15 3.08 0.77 6.15 21.54 6.15 6.92 0 0.77 1.54 10 5.38 130

9.34 19.78 12.64 2.75 1.65 0 24.18 6.04 7.69 0 7.14 0 6.59 2.2 182

6.10 23.03 7.28 2.75 0.98 1.96 21.29 5.51 9.25 0.19 5.11 0.59 12.00 3.93

NS NS 0.0014 NS NS 0.0005 NS NS NS NS NS NS 0.0006 NS

0

50S

Note: NS = not significant.

294

PSYCHOSOMAnCS

<

~I ~I

i

I TABLE 2.

I

.

Re"dOD.b1p betweeD type 01 request aDd DSM·m·R primary d....osls Type 01 CoDsuitadoa,,, (~)

Cl

Dlaposls

C2

W 1M

Child/adolescent disorders

21 (9.4)

7 (4.6)

~

Organic mental disorders

41 (18.4)

23 (15.3)

Psychoactive substance use

15 (6.7)

8 (5.3)

Schizophrenia

5 (2.2)

4 (2.6)

Paranoid disorders

1 (0.4)

Other psychotic disorders

0( I

~ i

C5

C4

Totals

31 (6.1)

1 (3.0)

1 (5.5)

39 (73.5)

7 (21.8)

7 (21.2)

0

10 (18.8)

1 (3.1)

2 (6.0)

1 (5.5)

37 (7.2)

0

2 (6.2)

3 (9.0)

0

14 (2.7)

1 (0.6)

0

2 (6.2)

1 (3.0)

0

5 (0.9)

8 (3.6)

2 (1.3)

0

0

0

0

10 (1.9)

Mood disorders

37 (16.6)

56 (37.3)

2 (3.7)

5 (15.6)

6 (18.1)

2 (11.1)

Anxiety disorders

12 (5.4)

11 (7.3)

0

3 (9.3)

2 (6.0)

0

28 (5.5)

Somatoform disorders

31 (13.9)

9 (6.0)

1 (1.8)

2 (6.2)

3 (9.0)

1 (5.5)

47 (9.2)

0

117 (23.0)

108 (21.2)

Dissociative disorders

0

0

0

0

0

0

0

Sexual disorders

0

0

0

0

0

0

0

Factitious disorders

0

0

0

0

0

0

0

Impulse control disorders

0

1 (0.6)

0

0

0

0

1 (0.001)

Adjustment disorders

9 (4.0)

11 (7.3)

0

5 (15.6)

1 (3.0)

0

26 (5.1)

Psychological factors affecting...

3 (1.3)

0

0

0

0

3 (0.5)

<

1 (1.8)

4 (12.5)

5 (15.1)

3 (16.6)

61 (12.0)

§

0

0

2 (6.0)

10 (55.5)

20 (3.9)

CI.l

33 (100)

18 (100)

50S (100)

No diagnosis Totals

I

Ob

1 (3.1)

Persooality disorders

~I

Oa

-

0

33 (14.8)

15 (10.0)

6 (2.7)

2 (1.3)

222 (100)

150 (100)

---- -

--- -

-----

--

53 (100)

32 (100)

~

0-

eo (")

20

Impact of C-L Psychiatry on Referrals

decrease in the number of urgent requests over the four isolated periods. The numbers fall from 26.37% in the first period to 17.58% in the last one. that is. almost 30% less in relation to initial values. There are also some interesting changes in consultation request types. It can be seen that there is an increase in CR I and a decrease in CR4 and CR5. There is a highly significant decrease in CR3b (X2 = 16.694. df = 3. P 0.00(8). whereas CR2 and CR3a remain basically stable. We fmd other significant differences when the variations in the number of patients transferred from their original service to the psychiatric unit are analyzed. In the first and second periods. about II % of the patients were transferred to the psychiatric unit in the course of their hospitalization. In the third period. this procedure was applied in less than 4% of the cases. and in the last period no patients were transferred. all of them receiving psychiatric treatment (when necessary) in the original service ( X} = 24.394. df = 3. P = O.(XH). When the reasons invoked to justify the request are analyzed. we find significant changes in five of them. We can observe how "depression" ( X2 = 8.218; df = 3. P = 0.0417) and "antecedents" (X2 =8.814. df=3. P= 0.0318) are less frequent. On the other hand. we can see how "alcohoVdrugs" (X2 = 21.754. df = 3. P = 0.0001). "no organic findings" (X2 = 14.624. df = 3. P = 0.(022). and "unspecified" (X2 = 43.777. df = 3. P = 0.00(1) are more frequent. In the DSM-III-R diagnosis chapter. we fmd three items with significant changes: "psychoactive substance abuse" (X2 = 15.502. df = 3. P = 0.(014). "other psychotic disorders"
=

DISCUSSION As mentioned at the introduction. the basic question that determined our investigation was the following: Do C-L psychiatric activities really modify the dynamics of a general hospital in a positive way? We think that our results 296

made an afftrmative answer to this important question possible. We shall now attempt to justify this assertion. The first fact that attracted our attention is the progressive increase in the number of consultation requests. We have already referred to some studies that have demonstrated how a great proportion of psychiatric disorders existing in the hospital population are undiagnosed or generally ignored. We do not have exact data on the necessity of psychiatric assistance in our clinical population. but we consider that the increase in the number of requests reflects an increasing capability by physicians to detect psychiatric problems in their patients and to provide them with a more appropriate and global treatment. In our study. the number of requests in the fourth 6-month period is twice the number of requests from the flfSt period. and this fact leads us to assert that after a working period of 2 years the C-L psychiatry team has. at least. generated a growing sensibility in physicians toward the psychiatric problems existent in their patients. With regard to psychiatric diagnosis. our results replicate those of other similar studies. 3:l-3S Like ours. these studies showed a prevalence of medical over surgical services in the total number of requests. "Organic mental disorders" and "mood disorders" seem to be the most frequent diagnoses in general hospital populations. not only in our case but in the greater part of the similar studies. 3:l-3S We consider that in our case C-L psychiatry activities have produced some positive changes in referral patterns. If we return to the characteristics of each type of consultation request. we can affirm that a positive change will imply the progressive increasing ofCI ("complementary") and C2 ("parallel") requests. and a gradual decrease in CR3. CR4. and CR5 requests (that is. essays of repairing iatrogenic complications. requests motivated by prejudices about the mentally ill. as, well as errors in the evaluation of the patients' needs). Our data show such a change: we can observe an increase. over the 2-year period. in "complementary" requests. as well as a decrease in the number of "mending." PSYCHOSOMATICS

Vaz and Salcedo

"antecedent-conditioned," and "misdiagnosisconditioned" requests. The decrease of CR3b (psychological complications of hospitalization) seems to be especially important, and it could reflect the gradual incorporation of more therapeutic attitudes and procedures in clinical work. As we can see in Table 2, a number of CR3b-related problems are associated with mental organic disorders (isolation of elderly patients, lack of appropriate environmental stimuli, fear of medical tests, etc.), adjustment and reactive mood disorders; and personality disorders (difficulties in adapting to the hospital environment, rejection of the situation, anoma-

lous behavior, etc.). We think that the CR3b decrease indirectly speaks of an increased degree of tolerance in the attending staff, a greater concern for psychological aspects of hospitalization, and a progressive integration of therapeutic attitudes and patient-staff relationship patterns. The greater tolerance toward mentally disordered patients is also reflected in the decrease in the number of requests motivated by the existence of psychiatric antecedents, in the decrease in the number of urgent requests, and in the notable decrease in the number of patients moved from their admittance service to the psychiatric unit.

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