Reprinted from Eating Disorders Review
January/February 2004 Volume 15, Number 1
©2004 Gürze Books
There is a continuing tug of war between clinicians and managed care groups over the design and duration of inpatient care for treatment of persons with anorexia nervosa. As a result, the chance that a patient with anorexia nervosa will be hospitalized often depends more on circumstances than on scientifically based factors, according to Dr. Walter Vandereycken, of Catholic Hospital, Leuven, Belgium (Int J Eat Disord 2003;34:409).
After reviewing the literature, Dr. Vandereycken found that increasing economic restraints through managed care policies limit the length of inpatient treatment, which creates an unhealthy cycle: Early discharge at a lower-than-ideal body weight leads to a higher likelihood of readmissions, which leads to increasing costs. Challenged by the reality of health care costs, therapists who work with seriously ill anorectic patients have to face difficult decisions, clinically and ethically, for which few clear-cut evidence-based guidelines exist. The author points to several crucial questions that remain to be answered. Some of those questions concern admission criteria for care, length of hospitalization, rate of weight gain, and guidelines for discharge.
When should a patient be treated in the hospital?
The American Psychiatric Association guidelines propose a list of criteria for 5 levels of care—the type of care is based on clinical judgment and availability of care. One problem is the clinician’s perception of the cost/benefit of an inpatient treatment regardless of the financial implications. Of the 5 levels of care proposed by the APA guidelines, inpatient hospitalization is considered the last resort. The selection of treatment setting should depend on the priority and/or combination of goals/criteria. In addition, the availability of modes of care will be both a guiding and limiting factor.
Weight gain: how much and how quickly?
Low body weight at the beginning of treatment may predict poor outcome, and as several researchers have found, the speed of weight gain, especially in patients showing rapid weight increase in the hospital, indicates rapid loss of weight after discharge. The amount of time provided for weight stabilization is also important because the time of readmission was significantly related to the length of time that patients had maintained their target weight up to discharge. The shorter the stabilization time, the more likely the patient had to be readmitted within a short time (usually within 9 months after discharge.
When is the patient ready for discharge?
As the author notes, Japanese researchers have found that the duration of inpatient treatment is greatly affected by the severity of the disease and factors such as lower body weight, longer duration of illness, more previous hospitalizations, and older age at admission. In a German multisite study of 1,200 eating disorders patients treated in specialized centers, the median duration of hospitalization was 10 weeks, but most of the shorter-term inpatient programs were more intensive and expensive (Treasure and Kordy, 1998).
Israeli clinicians introduced a 4-step program in which the following occurs: 1) patients are given gradual and increasing exposure to daily activities in the community as they increase weight and return to the treatment unit overnight. 2) The patients undergo intensive group therapy that continues during all the stages of the inpatient treatment, day treatment, and follow-up. 3) After discharge, patients participate in a follow-up program conducted at the eating disorders unit itself with the same patients who were part of their group therapy while they were hospitalized. Nutrition counseling and psychiatric follow-up are provided at these sessions. 4) Attending an individual psychotherapy program as an outpatient is a prerequisite for admission to the follow-up sessions. After Fennig and colleagues added the new procedures, the relapse rate fell from 30% to 15% (General Hospital Psychiatry 2002;24:87).
Preplanning improves success
According to Dr.Vandereycken, the experience of hospitalization for patient, family, and clinician will be influenced by the decision-making process before admission. Ideally this process will involve the patient and her family, with frank discussion of the proposed treatment, reflecting a caring approach. It will make a huge difference if the hospitalization is perceived as a supportive part of recovery and not as evidence of failure on the part of the patient, her family, or the therapists.
Finally, too often most specialized inpatient programs for eating disorders use an integrated approach that is a preprogrammed package of components rather than one more suited to the individual’s needs. One more improvement would be more flexible programs that better match individual patient variables (such as length and severity of illness and previous treatment history).