Reporting psychosomatic consultations in the discharge letter: An examination of communication between inpatient and primary care physicians

The discharge letter is the primary means of communication between the inpatient and the outpatient treatment providers in the German health care system. The inclusion of psychosomatic consultation findings within the discharge letter is a critical step for impacting the psychosocial aspects of patient care following discharge. The present retrospective study measured the extent to which psychosomatic consultations conducted at the University of Heidelberg Medical Hospital were mentioned in the discharge letter during a 2-year index period. Psychosomatic consultations (N = 605) were requested by a total of 101 inpatient physicians and conducted by 9 consultants. Of the 528 discharge letters that were reviewed, 67.8% referenced the psychosomatic consultation. Results from a stepwise logistic regression analysis found that a reason for referral due to “presumed psychiatric etiology of unexplained physical complaints” was the strongest predictor of whether the consultation was mentioned in the discharge letter (odds ratio = 2.27). In contrast, a referral due to “coping and compliance problems” or the identification of psychosocial problems secondary to a somatic illness significantly decreased the chance of communication. The high rate of communication when physicians are confronted with a complex diagnostic picture involving presumed psychiatric comorbidity underscores the perceived usefulness of the consultation. However, consultants may need to take an active role in facilitating the management of psychosocial aspects of care during the inpatient stay and following discharge in an effort to improve concordance.     

精神科住院抑郁症患者自杀预防及护理干预措施专家共识

目的 形成《精神科住院抑郁症患者自杀预防及护理干预措施专家共识》,规范精神科住院抑郁症患者自杀护理干预措施。 方法 运用循证方法及文献分析法提取住院抑郁症患者自杀护理干预措施推荐建议和研究结论,形成共识初稿,通过2轮专家函询及2次专家论证会,结合专家意见,对初稿进行调整、修改和完善,形成共识终稿。 结果 2轮函询专家积极系数均为100%,专家权威系数均为0.924,各指标重要性赋值均数均>3.5分,且变异系数均<0.25,专家肯德尔和谐系数分别为0.182和0.260（均P<0.01）。最终对精神科住院抑郁症患者自杀护理干预操作性定义、自杀风险评估、干预形式、干预时间、干预理论基础、干预一般原则、自杀意念的干预措施、自杀行为的干预措施、特殊人群自杀护理干预要点、干预效果评价及出院后的健康教育计划共11个部分的内容达成一致意见。 结论 该共识为精神科住院抑郁症患者自杀护理干预措施提供指导依据,使精神科住院抑郁症患者的自杀护理干预更规范。     

Psychiatric consultations in a southern university hospital

BACKGROUND: Differences in psychiatric referral rates among demographic groups of general hospital patients between 1995 and 1998 in a southern university setting were studied. The contribution of suicide attempts to referral rates was assessed. METHODS: The study was done by analysis of hospital admission and psychiatric consultation data. RESULTS: Psychiatric consultations were done in 844 (2%) of 41,681 admissions. Among patients without suicide attempts, those between ages 30 and 59, whites, and internal medicine admissions had higher referral rates. Age, race, and admitting service were independently associated with psychiatric referral rates. CONCLUSIONS: Findings support previous research showing that psychiatric referral depends on a variety of factors that may be patient-related, disease-related, and/or physician-related. Physicians' motivations to refer or not, organizational barriers or facilitators, disease-related, and/or patient-related factors (eg, age and race) need to be assessed further as determinants for requesting psychiatric consultation.     

Psychiatric disorders in geriatric medical/surgical patients. Part I: Report of 195 consecutive consultations

We reviewed psychiatric consultations (N = 195) for patients aged 60 years or more from a consecutive series of 1,000 psychiatric consultation requests. Consultations for geriatric patients were requested disproportionately less frequently than for nongeriatric patients and significantly more frequently for elderly women than for elderly men. The most frequent primary psychiatric diagnoses were organic psychiatric and depressive spectrum disorders. The referring primary care physician had either misdiagnosed or failed to recognize an underlying organic psychiatric disorder in more than half the patients with organic psychiatric illness. The study highlights the prevalent psychiatric disorders of the elderly medical/surgical patient, and opines that psychiatric consultants can be of significant assistance in the medical care of these patients.     

Patterns of care in patients utilizing both primary health care and psychiatric care in a Swedish health district

Patterns of care in all patients (N = 546) establishing contact with both primary health care and psychiatric care were studied during 1984 (N = 252) and 1986 (N = 294) in a Swedish health district. Utilization of primary health care was not affected by the sectorization of the psychiatric care organization, while there was a significant increase in utilization of outpatient psychiatric care. Patients with a higher number of visits in outpatient psychiatric care had a lower number of visits in primary health care. The utilization of care was unevenly distributed in the sample; 25% of the patients accounted for almost 60% of the visits in both care organizations. The mental health problems were identified in primary health care in 40% of the patients. This group of patients seemed to be defined as belonging neither to specialized psychiatric care nor to the general practitioner level of primary health care.     

How effective are mental health nurses in A&E departments?

Background

A&E departments are key points of contact for many people with mental health problems. Various models of care have been developed in A&E departments for delivering mental health services, but few have been assessed for effectiveness. The present study aimed to assess the impact of a dedicated A&E psychiatric nurse service on several outcomes relevant to patients and clinicians.

Methods

A crossover design was used to introduce a dedicated psychiatric nurse service (comprising four experienced community psychiatric nurses) into two busy UK A&E departments. Standardised assessments were completed for each patient, and a random sample of these independently assessed for quality. Data were also collected on the number of patients assessed, psychiatric nurse time employed, waiting times, onward referrals, repeat attendances, patient satisfaction, and staff views.

Results

A&E staff referred about a third of patients judged to have mental health problems to the psychiatric nurse service; approximately half of those assessed had a psychiatric history. On average, assessments took 60 min and over 90% of the formulated management plans were judged appropriate by independent assessors. The psychiatric nurse intervention had little impact on waiting times or satisfaction levels for mental health patients, although there was evidence of a change in onward referral patterns.

Comment

Psychiatric nurse assessment services have been introduced in many A&E departments, although the evidence base for the effectiveness of this development is not well established. This study presents evidence that psychiatric nurses can provide an accurate assessment and referral service with advantages for patient care.     

Medical specialists' patient-centered communication and patient-reported outcomes

BACKGROUND: Physicians' patient-centered communication in the medical consultation is generally expected to improve patient outcomes. However, empirical evidence is contradictory so far, and most studies were done in primary care. OBJECTIVE: We sought to determine the association of specialists' patient-centered communication with patient satisfaction, adherence, and health status. METHODS: Residents and specialists in internal medicine (n = 30) and their patients (n = 323) completed a questionnaire before a (videotaped) follow-up encounter. Patients' satisfaction was assessed immediately after the consultation and their self-reported treatment adherence, symptoms, and distress 2 weeks later. Specialists' patient-centered communication was assessed by coding behaviors that facilitate or rather inhibit patients to express their perspective. Patient participation was assessed by determining their relative contribution to the conversation and their active participation behavior. Outcomes were assessed using standard questionnaires. Analyses accounted for relevant patient, visit and physician characteristics. RESULTS AND CONCLUSIONS: Medical specialists' facilitating behavior was associated with greater satisfaction in patients who were less confident in communicating with their doctor. Patient-centered communication was not associated with patients' health status or adherence in general, but facilitating behavior was positively related to the adherence of patients with a foreign primary language. In general, patients appeared to be more satisfied after an encounter with a more-facilitating and a less-inhibiting physician, but these associations diminished when controlling for background characteristics. We conclude that the absence of strong associations between patient-centered communication and patient-reported outcomes may be explained by medical specialists being responsive to patients' characteristics.     

Psychiatric consultation and collaboration

Overcoming resistance to the stigma of psychiatric care is a first step in merging mental health care with primary care. The practitioner's role in socializing clients who could potentially benefit from psychiatric care is vital in gaining acceptance for mental health care. The socialization process should address reasons for mental health care, elaborate on the client's choices in selecting a suitable therapist and reassure the client that the primary care provider will maintain a collaborative relationship with the therapist. For those clients or situations that cannot be referred to a specialist, psychiatric consultation models are useful alternatives for the primary care provider. Regularly scheduled meetings with a psychiatric consultant provide time to discuss clients, assessment techniques, intervention strategies or impediments to the delivery of mental health care. Increased knowledge of mental health practices will improve case finding and implementation of psychotherapeutic plans.     

Writing to patients: a randomised controlled trial

It has been suggested that consultants should consider writing directly to patients with a summary of their outpatient consultation. In a controlled trial involving consecutive new referrals to a haematology outpatient clinic, we randomised patients to receive either a personal letter from their consultant summarising their consultation (n = 77) or a brief note thanking them for attending the clinic (n = 73). Patients were assessed for recall of and satisfaction with the consultation by a single independent observer, using standardised methods. At the second visit to outpatients, the patients' median percentage recall of items discussed during the consultation was 67% (IQ range 50-80%) in the intervention group, versus 57% (IQ range 43-76%) in the control group (p = 0.3). Strongly positive views on the personal letter were expressed by patients and referring clinicians. The findings suggest that although personal letters do not substantially improve recall of the clinical encounter, they are feasible, highly valued by patients and acceptable to referring clinicians.     

Managing somatic preoccupation.

Somatically preoccupied patients are a heterogeneous group of persons who have no genuine physical disorder but manifest psychologic conflicts in a somatic fashion; who have a notable psychologic overlay that accompanies or complicates a genuine physical disorder; or who have psychophysiologic symptoms in which psychologic factors play a major role in physiologic symptoms. In the primary care setting, somatic preoccupation is far more prevalent among patients than are the psychiatric disorders collectively referred to as somatoform disorders (e.g., somatization disorder, hypochondriasis). Diagnostic clues include normal results from physical examination and diagnostic tests, multiple unexplained symptoms, high health care utilization patterns and specific factors in the family and the social history. Treatment may include a physician behavior management strategy, antidepressants, psychiatric consultation and cognitive-behavior therapy.     

The mental health nurse: a valuable addition to the consultation-liaison team

Nurses, particularly those working in non-psychiatric settings, report that they do not feel adequately prepared to meet the mental health needs of patients. The psychiatric consultation-liaison nursing role has arisen in part, as a response to these difficulties and aims to facilitate access to mental health nursing expertise for general hospital patients and staff. The impact of the introduction of a nursing position into an established consultation-liaison psychiatry service was evaluated using an activity audit, a staff attitude survey, and staff focus groups. The findings demonstrated that the addition of the nursing role to the consultation-liaison psychiatry service improved access of general hospital patients to specialist mental health care. It also provided valued expert assistance to staff in the provision of care to this patient group, particularly those with complex problems and significant psychiatric comorbidity. The study found that the nursing consultation was particularly helpful because of its focus on practical and care-orientated interventions. The model of practice that evolved out of this project is described and the findings support the use of both direct and indirect patient interventions as important psychiatric consultation-liaison nurse activities.     

Psychiatric consultation and referral

Over half of patients with psychiatric problems are seen by primary care physicians. Many of these patients will benefit from psychiatric consultation when the diagnosis is unclear or when the patient is not responding to treatment. Good communication between referring physician, consulting physician, and patient are essential to ensure a good result. Specific problems that should lead to consultation include: patient's request, unclear diagnosis, poor results from treatment, and crisis situations such as suicide attempts. Consultation-liaison psychiatry services in the primary care setting are becoming more popular and are an excellent way of improving communication between primary care physicians and psychiatrists. Further development of this role of the psychiatrist in the primary care setting has great potential of improving the quality of care delivered patients with psychiatric problems who seek care from their primary care physician. It appears that the majority of patients continue to seek care for their psychiatric symptoms from their primary care physician. Open communication and ease of consultation with psychiatrists can make the care of these patients even more rewarding to the primary care physician.     

Patients' assessments of consulting a nurse practitioner: the time factor

AIM: This paper reports a study exploring patients' views about consulting with a primary care nurse practitioner. BACKGROUND: United Kingdom based randomized controlled trials comparing the work of doctors and nurse practitioners add considerable weight to the view that patients tend to be more satisfied with primary care nurse practitioner consultations. However, there is a need for qualitative research to explore issues raised by the trials. METHODS: A judgement sample of 10 patients consulting with a primary care nurse practitioner was drawn. In-depth interviews were conducted and analysed thematically. The data were collected in 2000-2001. FINDINGS: The following themes were identified in the data: time spent in the consultation; and time as a commodity in patients' lives. Time matters to patients when they consult on their health, whether it is time to discuss problems or time saved as a result of having issues resolved, thus minimizing further visits. Factors associated with the style and emphasis of consultations are also important. CONCLUSIONS: Understanding the relationship between time, and style and emphasis of consultation may help to explain patients' satisfaction with primary care nurse practitioners.     

Patients' preferences for intensive care.

OBJECTIVES: To determine patients' preferences for intensive care and to evaluate the influence of a recent ICU experience on preferences for future ICU treatment. DESIGN: Survey of nonrandomized patient sample using structured interviews. SETTING: Large, urban, tertiary academic medical center. PATIENTS: Eighty-four adult inpatients discharged from the medical ICU between June and August 1990. MEASUREMENTS: Agreement with life-supportive care under each of four potential outcome scenarios was assessed on a 5-point scale. An overall preference score was created by summing scores for the four items. Patients were also asked about their recent experiences in the ICU. RESULTS: Patients identified sources of stress associated with their ICU stay, yet most (76%) rated their ICU experience positively. Preferences for future intensive care varied with perceived outcome, and were strongest for health restoration and weakest for persistent vegetative states. No significant relationships were found between ICU preferences and any demographic or clinical variable except race. CONCLUSIONS: Patients tolerate intensive care well and desire it to restore health. Most patients modify their desire for intensive care if less favorable outcomes are likely. Patients' preferences for intensive care cannot be predicted from demographic features or previous ICU experiences.     

Older patients with serious mental illness: sensitivity to distance barriers for outpatient care

OBJECTIVES: To inform health services delivery and to demonstrate the appropriateness of understanding access at the individual's level, we evaluated how patient characteristics affect sensitivity to access barriers. We examined one dimension of access: geographic accessibility. We assessed age differences in sensitivity to distance barriers for outpatient psychiatric and nonpsychiatric care among active Department of Veterans Affairs (VA) patients with serious mental illness. METHODS: Among 142,055 VA patients with bipolar disorder, schizophrenia, or other psychoses in fiscal year 2000, separate random intercepts mixed models were estimated (cluster: nearest site) for outpatient psychiatric and nonpsychiatric visit day volume. In addition to distance and age group (<45, 45-65, or >65), covariates included gender, ethnicity, rural location, psychiatric diagnosis type, Charlson comorbidity level, initial treatment location, and psychiatric diagnosis X distance interactions. Differential distance effects by age were assessed using age X distance interaction terms. RESULTS: Among VA patients with serious mental illness, distance limits the volume of VA outpatient visits. For nonpsychiatric outpatient care, patients older than 65 were substantially more sensitive to distance barriers (P < 0.0001). For psychiatric outpatient care volume, patients aged 45-65 had slightly increased sensitivity; however, this difference did not have clinical significance. DISCUSSION: The impact of geographic accessibility barriers depended on personal characteristics of the individual and the outpatient service type. For nonpsychiatric outpatient care, older VA patients were most negatively affected by distance barriers. Results may inform efforts to reduce barriers to health care among patients with serious mental illness.     

The role of psychiatric consultation liaison nurses in ethical decisions to remove life-sustaining treatments

This article proposes a deliberative nursing process for ethical decisions about the withdrawal of life-saving treatments from terminally ill patients. It highlights the role of the psychiatric consultation liaison nurse in facilitating this process and the growing need for an expanded nursing role, presents relevant ethical theory and principles, and introduces a paradigm for such ethical decisions. As medical technology and life-saving equipment continue to proliferate, the psychiatric consultation liaison nurse can become increasingly involved in assisting all health care providers in the essential professional role of helping patients and families to make these ethical decisions.     

Comorbidity of migraine and psychiatric disorders--a national population-based study.

BACKGROUND: Migraine is common, with an estimated lifetime prevalence of 7-17%. Population-based studies have reported an association between various psychiatric conditions and migraine. This is a population-based study exploring the association between migraine and psychiatric disorders in a large cohort and assessing various health-related outcomes. OBJECTIVE: (1) Determine the prevalence of various psychiatric conditions in association with migraine; (2) describe the patterns of association of these comorbidities with a variety of health-related outcomes. METHODS: Data from the 2002 Canadian Community Health Survey were used. This is a national health survey which included administration of the World Mental Health Composite International Diagnostic Interview to a sample of 36,984 subjects. Health-related outcomes included 2-week disability, restriction of activities, quality-of-life, and mental health care utilization. RESULTS: The prevalence of physician-diagnosed migraine (n=36,984) was 15.2% for females and 6.1% for males. Migraine was most common in those between ages 25 and 44 years and in those of lower income. Migraine was associated with major depressive disorder, bipolar disorder, panic disorder, and social phobia, all occurring more than twice as often in those with migraines compared with those without. Migraine was not associated with drug, alcohol, or substance dependence. The higher prevalence of psychiatric disorders in migraineurs was not related to sociodemographic variables. Psychiatric disorders were less common in those over 65 years, in those who were in a relationship, and in those of higher income whether migraine was present or not. Health-related outcomes were worst in those with both migraines and a psychiatric disorder and intermediate in those with either condition alone. CONCLUSION: Migraine is associated with major depressive disorder, bipolar disorder, panic disorder, and social phobia. Migraine in association with various mental health disorders results in poorer health-related outcomes compared with migraine or a psychiatric condition alone. Understanding the psychiatric correlates of migraine is important in order to adequately manage this patient population and to guide public health policies regarding health services utilization and health-care costs.     

Inpatient Specialty-Level Palliative Care Is Delivered Late in the Course of Hepatocellular Carcinoma and Associated With Lower Hazard of Hospital Readmission

ContextLittle is known about receipt of specialty-level palliative care by people with hepatocellular carcinoma (HCC) or its impact on health care utilization.ObjectivesIdentify patient characteristics associated with receipt of specialty-level palliative care among hospitalized HCC patients and measure association with time to readmission.MethodsWe used logistic regression to examine relationships between receipt of inpatient palliative care consultation by HCC patients at an academic center (N = 811; 2012–2016) and clinical and demographic covariates at index hospitalization. We used a survival analysis model accounting for competing risk of mortality to compare time to readmission among individuals who did or did not receive palliative care during the admission and performed a sensitivity analysis using kernel weights to account for selection bias.ResultsOverall, 16% received inpatient palliative care consults. Those who received consults had worse laboratory values than those who did not. In a multivariable model, higher Model for End-Stage Liver Disease Sodium, receipt of sorafenib, and higher pain scores were significantly associated with increased odds of palliative care, whereas liver transplantation and admission to a surgical service were associated with lower odds. For time to readmission (2076 hospitalizations for 811 individuals with 175 palliative care visits), the subhazard ratio for readmission for patients who received consults was 0.26 (95% CI = 0.18–0.38) and 0.35 (95% CI = 0.24–0.52) with a kernel-weighted sample.ConclusionInpatient palliative care consultation was received by individuals with more advanced disease and associated with lower readmission hazard. These findings support further research and the development of HCC-specific programs that increase access to specialty-level palliative care.