Socioeconomic disparities in patients with psychogenic nonepileptic seizures and their caregivers.

OBJECTIVE: There is no information on disparities of patients with psychogenic nonepileptic seizures (PNES) and their caregivers. The objective of this exploratory study is to compare patients with PNES and caregivers with low socioeconomic status (SES) with those of high SES for disparities in healthcare use, seizures, medication adverse effects, psychosocial impact, and knowledge about epilepsy. METHODS: Patients with PNES and caregivers completed surveys about the aforementioned outcomes during their Epilepsy Monitoring Unit (EMU) admission. Associations were evaluated using SES as a binary independent variable and the patient- and caregiver-related outcomes as dependent variables. RESULTS: Forty-three patients and 28 caregivers were recruited. The majority of patients were on average 36 years old, single women, unemployed, with some college education. The majority had PNES for 8 years averaging 20 seizures per month and were maintained on ≥2 antiepileptic drugs (AEDs) prior to their EMU admission. Most caregivers were first-degree relatives with a mean age of 43 years, married employed women of higher educational attainment, typically cohabitating with the patients. Low SES patients showed poorer knowledge about epilepsy (p < 0.0001) and higher anxiety levels (p = 0.03). Conversely, high SES patients demonstrated poorer social functioning (p = 0.04). High SES caregivers showed higher caregiving burden (p = 0.01). CONCLUSION: There are noteworthy disparities in patients with PNES of different SES and their caregivers. Identification of those disparities is a critical step in the creation of appropriate interventions to address them.

A pilot study of reduction in healthcare costs following the application of intensive short-term dynamic psychotherapy for psychogenic nonepileptic seizures.

PURPOSE: The purpose of this study was to examine preliminary evidence of intensive short-term dynamic psychotherapy (ISTDP) as a treatment option for psychogenic nonepileptic seizures (PNES) in terms of impact on healthcare costs, emotional wellbeing, and somatic symptoms. METHOD: Drawn from a sample of patients treated in a tertiary psychiatric service over a nine-year period, this naturalistic pilot study compared within-group changes from pretreatment with each year up to three years posttreatment, in physician visits, physician costs, hospital admissions, and overall hospital costs. RESULTS: Twenty-eight patients with PNES received ISTDP with average treatment duration of 3.6 sessions. Healthcare costs significantly reduced in follow-up compared with those in baseline, with patient costs falling below the healthy population means, and reductions in healthcare costs compared with those in baseline by 88% in year one, 90% in year two, and 81% in year three. This was accompanied by significant reductions in symptoms and interpersonal problems. CONCLUSION: These preliminary findings indicate the potential for short-term and long-term healthcare savings and improvements in emotional wellbeing, for patients with PNES from the application of ISTDP. Further research evaluating the impact of ISTDP on seizure reduction and comparing this approach with control conditions is warranted.

Evidence for Distinguishable Treatment Costs among Paranoid Schizophrenia and Schizoaffective Disorder.

BACKGROUND: Schizophrenia spectrum disorders result in enormous individual suffering and financial burden on patients and on society. In Germany, there are about 1,000,000 individuals suffering from schizophrenia (SZ) or schizoaffective disorder (SAD), a combination of psychotic and affective symptoms. Given the heterogeneous nature of these syndromes, one may assume that there is a difference in treatment costs among patients with paranoid SZ and SAD. However, the current the national system of cost accounting in psychiatry and psychosomatics in Germany assesses all schizophrenia spectrum disorders within one category. METHODS: The study comprised a retrospective audit of data from 118 patients diagnosed with paranoid SZ (F20.0) and 71 patients with SAD (F25). We used the mean total costs as well as partial cost, i.e., mean costs for medication products, mean personal costs and mean infrastructure costs from each patient for the statistical analysis. We tested for differences in the four variables between SZ and SAD patients using ANCOVA and confirmed the results with bootstrapping. RESULTS: SAD patients had a longer duration of stay than patients with SZ (p = .02). Mean total costs were significantly higher for SAD patients (p = .023). Further, we found a significant difference in mean personnel costs (p = .02) between patients with SZ and SAD. However, we found no significant differences in mean pharmaceutical costs (p = .12) but a marginal difference of mean infrastructure costs (p = .05) between SZ and SAD. We found neither a common decrease of costs over time nor a differential decrease in SZ and SAD. CONCLUSION: We found evidence for a difference of case related costs of inpatient treatments for paranoid SZ and SAD. The differences in mean total costs seem to be primarily related to the mean personnel costs in patients with paranoid SZ and SAD rather than mean pharmaceutical costs, possibly due to higher personnel effort and infrastructure.

Caring for Patients With Functional Neurological Disorders: A Case-oriented Review.

Patients with functional neurological symptoms are commonly seen in neurological practice. They have significant disability that may not improve and their care is costly. This article will use case histories to underline the important aspects of caring for patients with functional neurological disorders, including important features of the history, examination, neurobiology, appropriate investigations, and an approach to treatment.

[Normative-empirical determination of personnel requirements in psychosomatic medicine and psychotherapy]. / Normativ-empirische Bestimmung des Personalbedarfs in der Psychosomatischen Medizin und Psychotherapie.

OBJECTIVES: There is a high degree of misallocated medical care for patients with somatoform disorders and patients with concomitant mental diseases. This complex of problems could be reduced remarkably by integrating psychosomatic departments into hospitals with maximum medical care. Admitting a few big psychosomatic specialist clinics into the calculation basis decreased the Day-Mix Index (DMI). The massive reduction of the calculated costs per day leads to a gap in funding resulting in a loss of the necessary personnel requirements - at least in university psychosomatic departments. The objective of this article is therefore to empirically verify the reference numbers of personnel resources calculated on the basis of the new German lump-sum reimbursement system in psychiatry and psychosomatics (PEPP). METHODS: The minute values of the reference numbers of Heuft (1999) are contrasted with the minute values of the PEPP reimbursement system in the years 2013 and 2014, as calculated by the Institute for Payment Systems in Hospitals (InEK). RESULTS: The minute values derived from the PEPP data show a remarkable convergence with the minute values of Heuft's reference numbers (1999). CONCLUSIONS: A pure pricing system like the PEPP reimbursement system as designed so far threatens empirically verifiable and qualified personnel requirements of psychosomatic departments. In order to ensure the necessary therapy dosage and display it in minute values according to the valid OPS procedure codes, the minimum limit of the reference numbers is mandatory to maintain the substance of psychosomatic care. Based on the present calculation, a base rate of at least 285 e has to be politically demanded. Future developments in personnel costs have to be refinanced at 100 %.

[The significance of the principal diagnosis in Germany's new payment system for inpatient treatment of mental disorders]. / Die Bedeutung der Hauptdiagnose im Pauschalierenden Entgeltssystem Psychiatrie Psychosomatik (PEPP) - Bedeutung und Konsequenzen.

In 2013 Germany implemented a new payment system for the inpatient treatment of mental disorders. Besides perpetuating a per-diem payment, the payment system sets up a classification system that groups cases with comparable costs per diem. The first release of the system reveals the principal diagnosis to be the main grouping variable. Especially in psychosomatic and psychotherapy this approach seems to be at least questionable. Because of the insufficiently precise definition of the assignment of the principal diagnosis in the coding standards - and therefore the expected conflicts between clinics and health insurance funds - this paper discusses the difficulties involved in defining the principal diagnosis. It also formulates recommendations of how the principal diagnosis should be assigned.

[Is there adequate care for patients with psychosomatic disorders in Austria? Analysis of the need and a proposal for a model of quality assurance in Austrian psychosomatic medicine]. / Werden in Osterreich Patienten mit psychosomatischen Storungen ausreichend versorgt? Eine Bedarfserhebung mit Losungsvorschlag zur Qualitats-sicherung fur die Psychosomatische Medizin in Osterreich.

INTRODUCTION: Quality assurance in psychosomatic medicine in Austria is currently based on a voluntary continuing medical education programme in psychosocial, psychosomatic and psychotherapeutic medicine. It is questionable whether psychosomatic care can be sufficiently provided in this manner. In addition, a broadly based proposal to create a subspecialty in psychosomatic medicine in order to facilitate quality assurance, is investigated. METHODS: The necessity to reorganize psychosomatic care was explored through semi-structured qualitative interviews with experts. Data-based analyses probed the labour market of the proposed subspecialty, and the literature was reviewed to look into the cost-benefit ratio of psychosomatic treatment. RESULTS: All experts expressed a need to restructure psychosomatic care in Austria. Examples exist for psychosomatic treatment with an efficient cost-benefit relation in diverse medical settings. CONCLUSION: Establishing a subspecialty in Psychosomatic Medicine seems feasible and could contribute to increased quality assurance and the nationwide provision of psychosomatic care.

Healthcare costs incurred by patients repeatedly referred to secondary medical care with medically unexplained symptoms: a cost of illness study.

BACKGROUND: Some patients are repeatedly referred from primary to secondary care with medically unexplained symptoms (MUS). We aimed to estimate the healthcare costs incurred by such referrals and to compare them with those incurred by other referred patients from the same defined primary care sample. METHODS: Using a referral database and case note review, all adult patients aged less than 65 years, who had been referred to specialist medical services from one of five UK National Health Service primary care practices in a five-year period, were identified. They were placed in one of three groups: (i) repeatedly referred with MUS (N=276); (ii) infrequently referred (IRS, N=221), (iii) repeatedly referred with medically explained symptoms (N=230). Secondary care activities for each group (inpatient days, outpatient appointments, emergency department attendances and investigations) were identified from primary care records. The associated costs were allocated using summary data and the costs for each group compared. RESULTS: Patients who had been repeatedly referred with MUS had higher mean inpatient, outpatient and emergency department costs than those infrequently referred (£3,539, 95% CI 1458 to 5621, £778 CI 705 to 852 and £99, CI 74 to 123 respectively. The mean overall costs were similar to those of patients who had been repeatedly referred with medically explained symptoms. CONCLUSIONS: The repeated referral of patients with MUS to secondary medical care incurs substantial healthcare costs. An alternative form of management that reduces such referrals offers potential cost savings.

Recognition of psychogenic nonepileptic seizures diminishes acute care utilization.

Patients with psychogenic nonepileptic seizures (PNES) frequently use acute health care resources including emergency departments (EDs), resulting in redundant efforts. We asked whether establishing the diagnosis of PNES via video/EEG telemetry reduces subsequent ED use. Twenty-three patients with PNES were studied over a 48-month period surrounding the diagnosis using a provincewide database. There was a 39% reduction in total ED visits and a 51% reduction in ED visits for neurological causes during the 24 months following the diagnosis, and decreased ED use persisted throughout the follow-up period. There was no significant change in ED utilization for psychiatric causes. The proportion of patients with PNES who used ED services once or not at all per year increased from 26% in the 2 years prior to the diagnosis to 57% following the diagnosis. These findings suggest that a definitive, telemetry-based diagnosis relieves diagnostic uncertainties for the patient and physician, but also has quantifiable economic benefits.

Psychogenic nonepileptic seizures: diagnosis and initial management.

Psychogenic nonepileptic seizures (PNES; also known as pseudoseizures, nonepileptic attack disorder) are common. They continue to pose diagnostic difficulties, with mean delays from onset to diagnosis of several years, during which time they are often treated as epilepsy. The literature suggests that clinical diagnosis has limited reliability. However, it may be useful to regard the diagnosis of PNES as having two stages-- that of suspecting the diagnosis and that of confirming it. Clinical features of the history and spells allow the diagnosis of PNES to be suspected in the first place, so that the appropriate expertise and tests can be brought to bear. The diagnosis of PNES is usually confirmed by recording spells using video EEG. A minority of patients also have epilepsy. Once the diagnosis is made, initial management consists of communicating the diagnosis to the patient and carers in a clear and nonpejorative way, as well as withdrawing anticonvulsant medication with appropriate monitoring in patients with no evidence of epilepsy. In many patients, spells will cease without psychological intervention. Emergency healthcare utilization may drop sharply after explanation of the diagnosis, and this may occur even in patients whose spells continue. It is not clear to what degree these positive effects are maintained in the long term.

[Frequency and consequences of financial problems in patients undergoing outpatient psychosomatic treatment]. / Häufigkeit und Folgen finanzieller Schwierigkeiten bei Patienten in ambulanter psychosomatischer Behandlung.

OBJECTIVES: About seven million people in Germany are affected by overindebtedness and insolvency. Being severely in debt is a very stressful situation that can result in social marginalisation, reducted overall activity, and physical and mental illness. The present study investigated the frequency of financial problems and their effects on physical and mental disorders at a university psychosomatic clinic. METHODS: The study included a total of 659 patients. Their mental status was assessed with the Symptom Checklist (SCL-90-R), their physical status with the Gießener Beschwerdebogen (GBB). RESULTS: 37 percent of the subjects reported experiencing financial problems. We found that subjects with financial problems reported more physical and mental disorders than those without financial problems. Furthermore, therapists more often recommended that patients with financial problems receive inpatient therapy than patients without financial problems. CONCLUSION: The study suggests that financial problems should be included in any anamnesis, therapeutic recommendation, and actual therapy of patients in psychosomatic treatment.

Managing complex patients on a medical psychiatric unit: an observational study of university hospital costs associated with medical service use, length of stay, and psychiatric intervention.

OBJECTIVE: Although there is a suggestion that the medical psychiatric unit (MPU) may reduce length of hospital stay (LOS), little is known about costs in terms of medical service use and psychiatric interventions in MPU care. METHOD: A record linkage study was conducted, linking cost data of hospital medical service use, LOS, and hospital psychiatric interventions to patients admitted to the MPU of the Maastricht University Medical Centre (MUMC) between 1998 and 2004. The data set was analyzed to enable comparison between cost changes of the same complex patient population following either MPU index admission or index admissions to reference MUMC medical wards. RESULTS: Comparisons revealed lower costs of medical service use in favor of the MPU (-euro104; 95% CI -euro174 to -euro35; P<.01). However, cost of psychiatric intervention and cost of LOS were higher after MPU admission (respectively, +euro165; 95% CI +euro25 to +euro305; P<.05; and +euro202; 95% CI +euro170 to +euro235; P<.001). Total costs were higher after MPU admission compared to medical ward admission (+euro263; 95% CI +euro68 to +euro458; P<.05). These differences were not moderated by somatic diagnosis or previous pattern of admissions. CONCLUSION: The findings suggest that patients at the interface of psychiatric and somatic morbidity are diagnosed and treated adequately at the MPU, leading to a decrease in medical service use and an appropriate increase in exposure to psychiatric interventions. These results are specifically generalizable to MPUs with a focus on psychosomatic conditions, for instance, somatoform disorders or affective disorders with comorbid somatic diseases. However, failure to show cost savings in terms of LOS compared to medical wards outweighs cost-benefit derived from lower medical service use, suggesting that MPU activities may gain in cost-effectiveness if shifted more to outpatient psychosomatic care solutions.