Transcript Identifying Medically Unexplained Symptoms among

Identifying Medically Unexplained Symptoms
among Frequent Attenders to the Emergency
Department: Research to inform Service Design
Dr Rebecca Jacob
Consultant Psychiatrist and CLAHRC Fellow
CPFT
Dr Cecily Morrison,
Research Associate, EDC, Engineering Dept,
University of Cambridge
Background
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MUS are defined as physical symptoms which are not
or insufficiently explained by somatic disease.
Symptoms include chest, abdominal, or back pain,
tiredness, dizziness, headache, ankle swelling,
shortness of breath, insomnia and numbness.
Fink P, Toft T et al 2007, Nimnuan C, Hotopf M et al 2000
Functional Somatic Syndromes
according to medical specialty
Medical specialty
Functional somatic
syndromes
Gastroenterology
IBS
Rheumatology
Fibromyalgia, chronic back pain
Cardiology
Non cardiac chest pain
Neurology
Non-epileptic Seizures, tension
headache
ENT
Globus syndrome
Infectious Disease
Chronic Fatigue Syndrome
Psychiatry
Somatoform, conversion disorders
Henningsen P, Fink P et al 2011
Relationship between MUS and
frequent attendance at ED
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Patients with MUS frequently attend primary and
secondary care health services, including ED.
Hotopf et al (2002) in cohort of 400 FA’s to the
ED:17% had at least two medically unexplained
consultation episodes, higher referrals to secondary
care and > invasive tests.
Older age patients also frequent attenders but
research shows attendance often appropriate with
Medically ‘Explained’ Symptoms. Aminzadeh F, Dalziel WB. 2002
‘Frequent Attender’
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Overt meaning numeric or statistical, and majority of
studies suggest attendance at ED’s >4 times/year.
More covert/pejorative meaning, refers to patients
perceived by health professionals as taking up
disproportionate amount of consultation time and/or
burden on resources.
Hodgson P, Smith P et al, 2005
CLAHRC Fellowship study of
Frequent Attenders
FA to the ED:
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proportionally on the increase.
can be subdivided into Extreme FA (EFA) (>20) and
Moderate FA (MFA) (<20/year).
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EFA’s had less urgent conditions, more mental
health/alcohol problems, were less likely to be admitted
(and are being targeted by ‘FACE’.)
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Wong M, Morrison C et al, 2011
Moderate Frequent Attenders
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Approximately 97% of FA population locally, had
more cardiovascular problems, more often required
admission.
Abdominal complaints predominant presentation in
those re-attending the ED within 7 days.
Questions raised by this project
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Do MFA’s include those with MUS and are their
service needs being met?
Would designing a service improve the health
outcomes and reduce health costs of this group?
Will proposed RAID model encompass this patient
group?
Characterisation of FA’s and
Service Evaluation
Project
Research Questions
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Amongst a sub-group of patients who frequently
attend the ED (>4/year), how many suffer from
MUS/mental disorders/both?
What is their current service provision?
What are low cost methods of identifying this patient
group amongst FA’s to the emergency department?
Study Design
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Setting: The emergency department at
Addenbrooke’s hospital, CUHFT.
Service design under the auspices of NIHR CLAHRC,
(EDC) which has enabled a working relationship
between CPFT and the University of Cambridge
Methods: Stage 1
Characterisation of FA’s
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Case note review of 100 consecutive patients
attending the ED >4 times in a period of 12 months.
Demographics, No of ED attendances, clinical
impression of MUS, invasive tests, OP visits, mental
health diagnoses, service pathways and mental
health input.
Analysis considered proportion of FA’s with
MUS/mental health, specialist mental health input,
factors related to clinical impression of MUS, current
service provision for MUS
Method: Stage 2
Designing Service for MUS
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ED clinicians requested to give all FA’s attending the
ED >4 times a year, two rating scales:
Patient Health Questionnaire (PHQ15)
Hospital Anxiety and Depression Scale (HADS)
For each FA filling questionnaire case note review to
be conducted.
Stage 2: Planned Analysis
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The proportion of FA’s with mental health
needs/MUS based on case note review
Relationship between FA’s with clinical recognition of
MUS and high PHQ scores
Relationships between high HADS score and clinical
recognition of depression and anxiety.
Results will be used to inform service design
Results:
100 FA’s attending ED
Age range of sample 17-95 years
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65% had mental health symptoms/disorders
(mentioned in notes)
71% of this group (46/65) had both MUS and mental
health problems.
15% of total sample had significant alcohol problems.
Proportion of FA’s with MUS
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45% had a clinical diagnosis of MUS
Clinical dx by any specialist reporting Non-epileptic
seizures, Chronic Fatigue, Fibromyalgia, IBS, MUS in
medical notes
Common symptoms related to ED presentation:
abdominal pain, chest pain, SOB, back pain,
dizziness.
MUS and Age
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Mean Age of patients with MUS- 36.8/ Median 32
years.
87% (39/45) with MUS under 65 years
MUS associated significantly younger age (p<0.001)
but not with gender (>0.05)
Older age more likely to have positive test results or
medically ‘explained’ symptoms (p=0.004)
MUS and Frequency of ED
Attendance
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Number of ED attendances not significantly different
for those with/out MUS (p>0.05)
MUS were ‘MFAs’ as hypothesised, 36/45 were
Moderate Frequent Attenders ( p<0.001)
Service provision
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41/45 patients with MUS (91%) had invasive
tests/procedures requested by multiple specialities.
All patients with MUS were seeing >1 OP speciality,
average was 5 specialist clinics.
32/45 had MUS and MH symptoms (71%)
15/32 of those with both MUS/MH had specialist
mental health input (47%).
Only 4% (2/45) had specific psychiatric input
for MUS
Results: Service Design
Only 4 forms returned
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ED busy environment, staff work shifts
Administrative staff available; clinicians rarely,
Staff ‘ drowning in paperwork’
Changes in ED’s physical structure during project
ED one dept. however has multiple domains
Staff spoke of frustration with FAs, keen to have
service BUT research/service evaluation not a priority
when clinical commitments are high.
Case Vignette 1
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35 year old man, married with 2 children, 9 ED
attendances/year for back pain, SOB, chest pain
No psychiatric history, ‘stress’ reported.
Referred by ED /GP to Cardiology, Rheumatology,
Medicine, Trauma Respiratory, Infectious Disease
OPD’s
Multiple tests: X-rays/ECHO/MRI unremarkable
Dx: MUS suspected by Medicine, I D team report
‘post viral fatigue’, Cardiology ‘non-cardiac chest
pain’.
Case Vignette 2
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91 yr. old widowed lady, 7 ED attendance /year for
recurrent falls, UTI, often admitted.
GP treating for anxiety with SSRI’s
Referred by ED/GP to Geriatric Medicine, Gynecology,
Dermatology, Rheumatology, General medicine
Multiple tests: biopsy/MRI/ECHO/Chest X-ray
Diagnoses: Squamous cell Carcinoma hand,
polymyalgia, cerebrovascular disease, Giant cell
arteritis, Ischemic Heart Disease, Hysterectomy
(fibroids)
Case Vignette 3
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24 year old female, 13 ED attendances in the last
year. ED and GP referred to Surgery, Ophthalmology,
Hepatology, Gastroenterology
Dx with Cholecystitis: cholecystectomy
Invasive tests post surgery:
US/OGD/Laparoscopy/Colonoscopy
Postoperative ED visits with multiple medically
unexplained symptoms, chest pain, abdominal pain,
double vision, headache
Gastroenterologist: Irritable Bowel Syndrome?
Clinical Implications
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MUS is a common presentation amongst FA’s to the
ED
Multiple specialist clinic visits and multiple invasive
tests in those with MUS, clinical and cost implications.
Older age FA’s more often showed Medically
Explained symptoms and appropriate use of ED,
replicating other studies.
Design Implications
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ED is a useful hub for identifying patients with MUS
ED Clinicians alone are unlikely to be able to identify
and signpost this patient group
However involvement of primary/secondary care at
the ED interface may be an ideal focus for service
design.
Designing service with an age focus may narrow
down cohort
Future studies
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Designing, delivering and evaluating the planned
pathway of care for patients with MUS within the ED.
Health economic study to estimate the cost savings
of creating a service for patients with MUS,
evaluating whether or not there is a tangible
reduction in ED attendance.
Challenges encountered
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Study plans had to be changed-and more than once!
Whilst ED staff were enthusiastic about developing a
service, they were not keen/able to be part of the
service evaluation project i.e. distributing PHQ/HADS
questionnaires to all FA’s
Everything takes significantly more time than
projected on the GANTT chart
What I Learnt
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MUS: a heterogeneous group (with/out MH
symptoms) posing a clinical and financial challenge
for health services locally.
The importance of robust data when planning service
development
Value of CLAHRC’s cross cutting themes
(Psychiatry/EDC); provides different, objective
perspectives.
Acknowledgements
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Dr. Cecily Morrison, EDC, Dept of Engineering, University of
Cambridge
Dr. Peter Watson, Senior Statistician, MRC Cognition and Brain
Sciences Unit, Cambridge
Dr. Catherine Hayhurst, Consultant ED Physician, ED Dept,
Addenbrooke’s Hospital
Dr. Cathy Walsh, Consultant Psychiatrist, Dept of Liaison
Psychiatry
Professor Peter Jones, Dr.Belinda Lennox, Dr. Christine Hill:
CLAHRC
References
1. Fink P, Toft T et al .Symptoms and syndromes of bodily distress: An
exploratory study of 978 internal medical, neurological, and primary
care patients. Psychosomatic medicine 2007; 69:30-9
2. Nimnuan C, Hotopf M et al. Medically unexplained symptoms: how often
and why are they missed? QJM Monthly Journal of the Associations of
Physicians 2000;93
3. Aminzadeh F, Dalziel WB. Older adults in the emergency
department: a systematic review of patterns of use, adverse outcomes,
and effectiveness of interventions. Ann Emerg Med. 2002;39:238-247.
6. Hodgson P, Smith P et al Stories from frequent attenders: Qualitative
Study in Primary Care. Ann Fam Medicine 2005: 318-23
7. Wong W, Morrison C. A service design approach to frequent attendance
in the ED. CLAHRC Fellowship Report, 2011.