Research: Early Liaison Psychiatry Consultations and General Hospital Readmission: A retrospective cohort study

Author: Victoria Lanvin, et al.

Abstract: In this retrospective study conducted in a general Parisian hospital, earlier psychiatric consultation was associated with fewer 30-day and seven-day readmissions.

“Interventional studies are needed to show that proactive C-L Psychiatry teams could help general hospitals to improve quality of care and make significant economic savings,” say the authors.

All adult inpatients referred for the first time to C-L Psychiatry from January 2008 to December 2016 were included in the study.

The objective was to determine whether the timing of psychiatric consultations is associated with 30-day and seven-day readmissions.

A total of 4,498 inpatients (51.1% women) were referred to C-L Psychiatry. Adjusting for age, sex, place of residence, year of admission, type of ward, psychiatric diagnosis and disease severity, later consultation was associated with higher 30-day and seven-day readmission rates.

Importance: Readmissions are under growing scrutiny as an indicator of quality of care as much as a potential source of savings. Patients with comorbid psychiatric conditions are more likely to be readmitted, so C-L Psychiatry may play a role in lowering readmission rates.

Availability: Published in General Hospital Psychiatry

Research: Prophylactic Use of Ramelteon for Delirium in Hospitalized Patients: A systematic review and meta-analyses

Author: Vanessa Dang, MD, et al.

Abstract: This systematic review and meta-analyses of five randomized placebo-controlled trials, which included data from recent studies, did NOT find that ramelteon was effective in reducing delirium incidence in adult hospitalized patients.

The review follows smaller studies, case reports, and randomized placebo-controlled trials and previous meta-analyses that have shown that ramelteon, a melatonin agonist, may reduce the risk of developing delirium.

This latest research assessed current evidence by including data from larger (> 100 subjects) and more recent trials since the most recent meta-analyses were published in 2019.

“Current evidence suggests that ramelteon is ineffective as a prophylactic drug in reducing the incidence of delirium in hospitalized patients,” say the authors.

Importance: Delirium is associated with longer lengths of hospitalization, higher rates of mortality, and subsequent cognitive decline over a 12-month period. The financial burden of delirium in postoperative elderly patients can reach as high as an additional $44,000 per-patient-per-year.

Management of delirium includes identifying and correcting the underlying etiology, ameliorating sleep-wake disturbances, and managing behavioral manifestations, including agitation. Both pharmacologic and non-pharmacologic interventions are used, although not consistently in all patients, such as reducing use of medications capable of inducing or worsening delirium, re-orientation via verbal and visual cues (e.g., with nursing support, clocks, calendars, bright light exposure, and the use of family photos and/or visits), optimizing hearing and vision (e.g., with hearing aids, ear plugs, and glasses), and ensuring adequate hydration and nutrition.

A recent Cochrane review of non-pharmacologic interventions for delirium, however, found low quality evidence in support of probable reduction of delirium incidence, and possible reduction of hospital length of stay and delirium duration. Current pharmacologic interventions do not appear to shorten the duration of delirium or reduce its sequalae.

Ramelteon is used as an agent to prevent the onset of delirium—but, it seems, that too has little effect.

Availability: Pre-publication in the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP)

Research: The Role of Health Care Systems in Bolstering the Social Safety Net to Address Health Inequities in the Wake of the COVID-19 Pandemic

Author: Rita Hamad, MD, et al.

Abstract: For hundreds of years, US health has been characterized by vast inequities in health achievement across groups. For example, at least since the 1800s, disparities in tuberculosis were known to be associated with overcrowded housing, poor ventilation, and malnutrition. The earliest evaluations of the Framingham Heart Study documented disparities in cardiovascular disease by educational attainment.

Today, advantaged groups in the US have a 20-year greater life expectancy than disadvantaged groups, while racial and ethnic minority populations and those with lower income and education (among other types of disadvantage) have a greater burden of disease than more advantaged groups.

As the scholarship examining these health outcomes has evolved, it has become clearer that these inequities are caused by foundational social and structural forces, stemming from historical structural conditions that carry to the present day.

Despite this understanding, the US is unique among high-income nations in approaching disease as a problem to be solved almost exclusively by health care systems. This has resulted in an underinvestment in resources to address social and structural determinants such as poverty and housing, such that the US spends more on health care than any high-income country but has the least to show for it in terms of health.

Not only does the US have worse outcomes on average than other high-income nations, but also greater inequities between those of higher and lower socioeconomic position.

Historically, the national health care conversation has sidestepped addressing the broader social conditions in which patients live, seeing these conditions as outside the remit of what health care systems can achieve. In the past two years, however, the COVID-19 pandemic has further brought to light and exacerbated socioeconomic and racial disparities in disease, pushing organizational leaders in the health care system and academic medicine to recognize that the usual approaches need to change, and greater attention must be paid to social and structural determinants.

Detailing proposals to address this phenomenon, the authors say: “Ultimately, the most effective of these proposed solutions may require health care systems to encourage the shifting of dollars to government budgets outside of the health care system. This would require great humility from health care systems, recognizing that a society in which health care is less needed because of a shift toward a more holistic view of health is a better society in which to live. Such a view would also recognize that overall health and health inequities are inseparable from the social and structural factors that have been recognized for decades but in which the US has long underinvested.”

Importance: Nearly 20% of people in the US do not see a physician in a given year, and it may not be feasible for clinicians to address social needs in their limited time during health care visits. Consequently, and particularly for larger health care systems and academic medical centers that are anchor institutions in their communities, engagement with nonprofit organizations is needed, say the authors, to invest in communities at a population level rather than on an individual basis.

Availability: Published by JAMA Network