Electronic Letters to:
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eLetters: Electronic letters published:
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The benefits of specialist outpatient care.
- Mark Berelowitz (28 November 2007)
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Readiness for treatment in Anorexia Nervosa
- Lalana K Dissanayake, Dr Akim Sule, Consultant Psychiatrist (28 November 2007)
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Mark Berelowitz, Consultant Child and Adolescent Psychiatrist Royal Free Hampstead NHS Trust
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mark.berelowitz{at}royalfree.nhs.uk Mark Berelowitz
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Dear Editor I was heartened to read the latest contribution by Gower’s group to the discussion of the effectiveness and cost effectiveness of inpatient treatment for adolescent Anorexia Nervosa. It seems increasingly clear that medium term or long term inpatient treatment has relatively little to offer to patients in terms of real health gain, or to PCT’s in terms of value for money. However, I wonder whether Gower’s group might have taken their challenge to the status quo even further than they have already done. I note that within their study, about 28% of “outpatients” were admitted, and these admissions accounted for over 80% of the £3.7 million spent on treating 110 patients. At the Royal Free we run an intensive specialized ambulatory outpatient service for children and adolescents from 7 PCT’s. We see about 90 new patients a year, and the service has in total treated more than 1100 patients, most of whom have Anorexia Nervosa or EDNOS. There have been no serious untoward events, and no deaths. There have been three complaints, two of which came from parents who had a relatively fixed view, at the time of initial referral, that their child needed long term inpatient care, and one from parents whose child had previously had long term inpatient treatment elsewhere, which had brought about short term weight gain but no psychological change. The key point is that our admission rate is close to 3%, and if it had not been for one patient who has been an inpatient for 4 years, in 4 different units (which rather proves the point), the average total annual spend from our service on inpatient care would have been less than £200 000. And even when we include that unfortunate patient in our financial analysis, our average annual cost per patient is still less than 25% of that that for the patients in the “general CAMHS” arm of the trial We achieve this by offering an intensive ambulatory service, closely linked to paediatrics and to the general CAMHS team. The treatment modalities offered differ from those in the specialist arm of the trial, in that we offer more whole family therapy, more brief psychodynamic psychotherapy, and somewhat less CBT than Gowers’ group. We are also available all day long on the telephone, and squeeze in emergency appointments whenever they are needed. Of course we have more flexibility with duration of treatment than was possible in the reported clinical trial. Our outcomes are closely audited, and, when compared with those published in the trial, are more than acceptable. So it is certainly possible to run a specialist service with a very low admission rate, without any obvious disadvantage to patients and their families, and with substantial advantages in terms of clinical outcomes, lack of disruption to family life, and cost effectiveness. Dr Mark Berelowitz FRCPsych Consultant Child and Adolescent Psychiatrist Royal Free Hampstead NHS Trust Pond Street, London NW3 2QG Tel: 020 7830 2931; 020 7472 6850 |
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Lalana K Dissanayake, AssociateSpecialist , Dr Akim Sule, Consultant Psychiatrist
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thilak{at}doctors.org.uk Lalana K Dissanayake, et al.
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Article; Clinical Effectiveness of treatments for Anorexia Nervosa in Adolescents. The study of clinical effectiveness of different types of anorexia nervosa brings out interesting issues. The background of not having many adequately powered trials to guide recommendations for treatment is appreciated. In this multi-centre randomised controlled trial, in-patient, specialist out-patient and general CAMH treatment s were compared. However, the patient recruitment strategy for each treatment in the methodology raises doubts in mind. In the study treatment allocation was carried out by an independent randomisation service. But the treatment options such as motivation studies are supposed to be decided on the 'chain', pychological stage the patient is on. Therefore, randomisation of a sample of patients into each category must not have matched to the readiness of the patient at the stage to accept the treatment option offered, thus affecting the outcome. (Ref.) As mentioned in the discussion, it is appreciated that stepped-care approach is advisable in treatment of anorexia-nervosa. Also, family support, motivation for treatment, illness identity and emotional adjustment are amongst of many other factors that can influence the outcome in treatment. In randomisation the patient’s psychological stage does not take these into account. Reference; Stockford K., Turner H., Cooper, M., Illness perception and it’s relationship to readiness to change in the eating disorders, Br J Clin Psychol 2007 Jun; 46(pt2); 139-54 Quiles Marcos Y, Terol Cantero M. C., Romero Escobar C., Paqan Acosta G., Illness perceptionin eating disorders and psychological adaptation, Eur Eat Disorderd Rev. 2007 Sep 15 (5). 373-84 Contact Telephone 07966597078 |
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