characteristics and medical treatment in a large general hospital. M. Brunn, U. ... discharge against medical advice (AMA) was possible or not. Analysis.
Personality disorders in patients referred to consultation-liaison psychiatry: characteristics and medical treatment in a large general hospital M. Brunn, U. Golombek, J.J. Strain, A. Diefenbacher
SUPPLEMENT – FULL METHOS
Design The present study is a retrospective cohort analysis of patients referred to the CL psychiatry service of Mount Sinai Hospital (MSH), New York City, between 1988 and 1997. The cohort includes all patients whose psychiatric consultation was requested by a somatic ward. MSH is a tertiary care university hospital of 1,200 beds and 30,000 inpatient admissions per year during the study period. Since several specialty units (e.g. gerontology, HIV/AIDS) employ their own psychiatrists or psychologists, consultations requests were issued predominantly by general medical or surgical wards. For 158 patients of the cohort, no psychiatric diagnosis was coded. In total, 3032 patients with a diagnosis of Axis I and/or II of the DSM-III-R or DSM-IV classification system between the ages of 17-65, who did not have private insurance (the latter received care through private attending physicians), were included. Data collection Patient characteristics and the data reflecting the consultation process were collected using the MICRO-CARES Consortium Psychiatric Consultation Questionnaire (1). Documentation was performed by the consulting physician only. In order to ensure reliability, residents were supervised by the head of the CL psychiatry service and training was provided using case vignettes. Psychiatric
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diagnosis was made by the consulting physician without the use of structured diagnostic interviews, based on clinical interviews only. Variables Demographic characteristics (age, gender, living situation, job status, psychiatric treatment during the previous year, reason for the consultation) were recorded at the initiation of the consultation, as well as the somatic (based on ICD-9, available for 2848 patients) and psychiatric diagnoses. Because of the small numbers for individual PD diagnoses, such as schizoid PD etc., all PD were grouped into three clusters as defined by the DSM system, as is Cluster A: paranoid, schizoid and schizotypal PD; Cluster B: antisocial, borderline, histrionic and narcissistic PD; and Cluster C: avoidant, dependent and obsessive-compulsive PD. The Karnofsky Index, scaled from 0 to 100 (low values indicate a high need for care), was used to assess general functioning and morbidity during the month preceding the admission. Process variables included the number of reasons by consultee, lag time (time from hospital admission to calling for a psychiatric consultation), number of follow-up consultations, LOS as well as recommendations by the consulting psychiatrist: psychopharmacological medication, psychometric tests, non-medical consultation (physical rehab, dietary, social work), collecting external information, behavioral management (restrain, activate, mobilize), psychological management, change of environment. The consulting psychiatrist also assessed, on request, whether discharge against medical advice (AMA) was possible or not. Analysis For descriptive statistics, the above variables were compared for three groups of patients: those with a disorder on 1) Psychiatric disorders exclusive of PD (Axis I only, [A_I]), 2) PD only (Axis II, [A_2]) or 3) both conditions. Nominal data were analyzed using the Chi²-test. For the analysis of metrical data, the Kolmogorov-Smirnov-test was employed to assess for normal distribution. Since all variables were distributed non-normally, a non-parametric test was used (one-factorial ANOVA after Kruskal-
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Wallis), followed by a post-hoc comparison after Dunn (2). After Bonferroni-correction for multiple testing, statistical significance was accepted at p < 0.003. LOS, as a proxy for outcome of hospital treatment, is particularly prone to be influenced by many factors other than the type of psychiatric disorder. Therefore, in a secondary analysis, we used multiple regression in order to assess whether a PD diagnosis had any impact on LOS. As for 653 patients data on LOS were missing, those were not included in this part of the analysis. A comparison of this cohort of patients with the remainder of those who did have LOS data with regard to sociodemographic characteristics showed no significant differences. In order to reduce the influence of outliers and the skewed distribution of LOS, logarithmic transformation of the data was performed. For 25 patients with a LOS-value of zero, these values were transformed from zero to one in order to include them in the analysis. Independent variables were chosen based on clinical hypotheses derived before the analysis took place. For example, older age and lower general functioning were assumed to lead to longer hospital stays. Then, univariate analysis was performed to assess the linearity of associations. The year of the consultation was managed as a continuous variable in order to account for changes in case-mix and discharge practice over time, in particular the seminal trend towards shorter hospital stays. Finally, backward-selection was used to exclude those variables from the model that were not significant at a level of p < 0.05. All statistical tests were two-sided. All analyses were performed using SPSS version 20. References 1. Hammer J, Lyons J, Strain J. Extensions, enhancements, and computer considerations of a standalone microcomputer system for psychiatry services, MICRO-CARES. Comput PsychiatryPsychol. 1986;16–20 (Part IV). 2. Silva AP, Prado SOS, Scardovelli TA, Boschi SRMS, Campos LC, Frère AF. Measurement of the Effect of Physical Exercise on the Concentration of Individuals with ADHD. Lidzba K, editor. PLOS ONE. 2015 Mar 24;10(3):e0122119.
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