Adding an internist to an inpatient psychiatric team improved 12 out of 17
patient care processes without increasing hospital charges or length of stay,
according to a randomized controlled trial by University of Vermont
A second study found that Medicaid psychiatric outpatients in Ohio used
medical services at a higher rate than the general population, but received"
dismal" levels of preventive care. Usage rates differed by
psychiatric diagnosis, said researchers from Ohio State University, so
assistance programs ought to vary accordingly.
The two reports appear in the April Psychiatric Services.
General medical care for psychiatric patients has received increased
research attention in the last decade, commented Benjamin Druss, M.D., the
Rosalynn Carter chair in mental health at Emory University. Druss was not
associated with either study.
"Medical care for the mentally ill has been an orphan issue over the
years," said Druss. "Mental health researchers have focused on
mental health, while primary care people haven't looked at this patient
In the Vermont study, a board-certified internist developed a needs
assessment documenting nonpsychiatric medical problems and medication use on
admission, wrote Alan Rubin, M.D., an assistant professor of general internal
medicine at the University of Vermont College of Medicine, and four
colleagues. He also advised the patients' primary care providers about health
maintenance care on discharge.
"Adding the internist made for wise ordering, a more complete data
base for preventive services, and prompt handling of problems as they came
up," Rubin told Psychiatric News. "We believe the savings
came from fewer unnecessary tests in general and a half day less length of
stay, although this finding was not significant."
Others have proposed giving psychiatrists more training in internal
medicine or creating combined medical-psychiatric units to meet the need for
general medical care for psychiatric inpatients, wrote Rubin. The staff
internist working on the two 24-bed psychiatric units provided comprehensive
services during otherwise open time in the patients' daily schedule.
In the study, 272 patients were admitted from March 2001 to January 2002 to
the psychiatric units of Fletcher Allen Health Care in Burlington, Vt. Twelve
were screened out for prespecified medical reasons, and 121 refused to
participate in the trial. Those who were ineligible or who refused were
significantly older (43.3 years versus 37.2 years) and had more comorbid
medical conditions than patients who agreed to join the study.
The researchers were concerned about the many eligible patients who,
possibly because of "fatigue or suspicion," refused to participate
in the study.
"It is not clear whether these patients would have refused medical
attention by the internist if it was offered in a nonresearch, nonacute
setting," they said.
Eventually 55 patients were randomized to the intervention group, and 84
received usual care. The unequal group sizes resulted from an administrative
error, but this did not violate randomness or introduce bias, said the
researchers. About 39 percent of the usual-care group and 45 percent of the
intervention group were male. There were no significant differences between
the groups in age, sex, diagnosis, and functioning. Most patients did not have
comorbid nonpsychiatric medical conditions, although those in the intervention
group had slightly more (p=0.023).
Patients in both groups had physical examinations and had lists of physical
problems, psychosocial issues, family risk factors, allergies, and
environmental problems updated. However, significantly more of the
intervention group had their medication lists reviewed, had higher
needs-assessment summary scores, and had a risk plan created to reflect any
family history of inheritable diseases like heart disease, breast cancer,
prostate cancer, or colon cancer that call for earlier screening.
Significantly more intervention-group patients received alcohol or tobacco
risk-reduction plans, stool tests, and lipid screenings. In the intervention
group, 90 percent of eligible patients received mammograms, 80 percent had Pap
tests, 75 percent had digital rectal exams or PSA tests, 59 percent got
tetanus vaccine, 58 percent had flu shots, and 46 percent got pneumonia
vaccine. No patients in the usual-care group got those screening tests or
The internist ordered specialty consultations as needed, managed acute and
chronic nonpsychiatric illnesses during the stay, attended daily rounds, and
communicated with the patient's primary care physician at discharge.
Length of stay for the usual-care group was 11.5±9 days compared
with 10.9±7.3 days for the intervention arm. Total hospital costs
averaged $8,527±6,512 for the usual-care group and $8,558±5,703
for the intervention group.
"This is a fairly inexpensive intervention, since the internist is
already working in the hospital," said Druss. "It's important to
do, and this is a good opportunity to do it because it is relatively
inexpensive compared with total inpatient costs."
In the Ohio study, researchers looked at medical records of 669 persons
with severe and persistent mental illness enrolled in Medicaid from 1996 to
1998. Sixty patients were diagnosed with anxiety disorders, 158 with
schizophrenia, 379 with affective disorders, and 72 with paranoid
Nonpsychiatric medical service usage was high across the board but showed
some variation by psychiatric diagnosis, reported Pamela Salsberry, Ph.D.,
R.N., Esther Chipps, Ph.D., R.N., of the College of Nursing at Ohio State
University, and Carol Kennedy, Ph.D., R.N., of the Ohio State Medical Center
For instance, 78 percent of patients with schizophrenia disorders made an
office visit during the study's three years, while 88 percent of those with
affective disorders, 96 percent of those with paranoid disorders, and 100
percent of those with anxiety disorders did so. Over the same period, 69
percent of schizophrenia patients went to the emergency room, as did 83
percent of the anxiety patients. In comparison, 20 percent of Ohio residents
and 21 percent of Medicaid recipients went to the emergency room in
Their findings also pointed to a lower use of cancer screening and dental
and vision services among patients with psychiatric illnesses than in the
general population, a pattern they termed "unacceptable."
"Compared with persons with a schizophrenic disorder, those with an
anxiety disorder were more likely to have had an office-based visit and to
have received vision services, those with a paranoid disorder were more likely
to have used dental services or receive a mammogram, and those with an
affective disorder were more likely to have had a Pap test," the
"This means that programs for improving medical care should be
tailored to the diagnosis or to individual patients," said Druss. For
example, patients with anxiety disorders might get counseling to reduce
overuse of health services, while those with schizophrenia might be helped to
get to their primary care doctor more often.
Vermont's Rubin isn't waiting to act on his study's outcome.
"Since the study, we have added preventive services to the initial
screening, so patients can get better care," he said. "I am proud
of that addition."
"Effects on Processes and Costs of Care Associated With the
Addition of an Internist to an Inpatient Psychiatry Team" is posted
Use of General Medical Services Among Medicaid Patients With Severe and
Persistent Mental Illness" is posted at<http://ps.psychiatryonline.org/cgi/content/full/56/4/458>.▪