Consultation-Liaison psychiatric service delivery: results from a European study
Introduction
Despite the world-wide use of consultation-liaison (C-L) services in the general hospital, no study has been published addressing important issues such as consultation rates across services, manpower, type of patients seen, communication patterns with primary care providers, types of assessment, and interventions [1], [2], [3]. To further develop C-L services in a systematic way, such basic information may pave the way for collaborative studies and networks across countries, facilitating evidence-based C-L psychiatry in the future.
This article presents the results of the European Consultation-Liaison Workgroup Collaborative Study (ECLW CS), a method described elsewhere [4], [5], [6]. The primary objective of this article is to document the status of C-L service delivery in the participating European countries. Available literature is biased towards single-site studies and studies from the United States (US). In a US study assessing the volume and clinical characteristics of patients referred to C-L psychiatric services in short-term general hospitals, Wallen and Pincus report a consultation rate of around 1% being lower than the single-site reports from C-L services located in university hospitals (around 3%) [7]. Such a rate (1%) is 10 or more times lower than the prevalence of psychiatric morbidity. This study also reported a longer length of hospital stay for referred patients (7.3 days vs. 16.3 days) and a higher proportion of elderly and female patients. Hengeveld et al. contrasted data from 1814 patients seen in consultation in a Dutch university hospital (Leiden) with findings from 42 mostly US publications [8]. Although they emphasize the striking lack of uniformity in classifications used, their findings seem to be quite comparable with the earlier reported findings. These findings are the following. 1) a greater proportion of female patients seen than male patients and 2) about 15% of the patients over 65 years of age. Between 75 and 80% of the patients are referred from general medicine; referrals from obstetrics/gynecology are most restricted. Main reasons for referral are deliberate self-harm and unexplained physical symptoms (1/3 vs. 1/5 of referrals). In the Leiden sample about 10% are referred for substance abuse, a figure not mentioned in the other literature. Due to the use of different psychiatric diagnostic systems, an appropriate comparison of diagnostic groups was not possible. Affective, organic-psychiatric and substance-use disorders seem to form the main groups, although with extreme variation in the 42 studies used for comparison (for example, 4–62% for affective disorders). Due to the diversity of diagnostic systems, the proportion of somatizers is not clear; however, as reason for referral it consists of a 1/5 to a 1/6 of the referrals [8]. Therefore, the distribution of psychiatric diagnoses in the referred population differs from patients seen in general psychiatric services—to be more specific, there is an emphasis on deliria, substance abuse, and somatoform disorders. About 12.5% of the patients seen are transferred to psychiatry and about 30% are referred to mental health after discharge [8].
European data-based reviews are not available. Reviews based on the opinions of leaders in the field in the different European countries report a wide variation in service delivery, suggesting a haphazard development of the field [2]. C-L patients belong to the group of patients with longer lengths of hospital stay, indicating that they belong to a hospital population of greater complexity [9]. Although liaison constitutes half the name of C-L, the proportion of consults generated by liaison activities—the more preventive and integrated form of service delivery—has never been well established [10].
The focus of this study is to provide the missing European data on the extent and content of C-L services required for health care planning and future research. This study reports univariate analyses.
Section snippets
Method
The general methodology and validation of the patient registration form and psychiatric diagnoses are reported in previous papers [4], [5], [6]. The patient registration form (or RPF) consisted of 68 items. It was developed by the program management group (PMG) and the national co-ordinators after a series of preparatory studies to insure face- and content-validity and pilot testing. Two hundred and twenty consultants, who required 40 h of training and came from 14 different European countries
Hospital characteristics
Of the participating C-L services 59% were located in university hospitals (Table 1). Considerable variation existed among the hospitals’ participating services with regard to their supraregional responsibilities. Hospitals, as can be expected, varied substantially in capacity (mean number of beds. 801; range. 145-1634), the related number of admissions (mean number of admissions. 27.503; range. 7.5–85.0), and the length of stay (LOS) (mean LOS. 9.7; range. 3.2–22.4). Remarkable was the large
Discussion
The objective of the present study is to describe the status of C-L service delivery in Europe based on empirically collected data.
Conclusion
The core function of C-L service delivery is a quick and comprehensive service for patients whose doctors and nurses need diagnostic, ward-treatment and/or discharge management advice. These services are as follows: deliberate self-harm triage, assessment and treatment of evident withdrawal due to acute abstinence resulting from hospital admission or other indications of substance abuse, and the evaluation of patients with psychiatric symptoms and with unexplained physical complaints. The
Acknowledgements
This study is the result of efforts of more than 200 consultants and a large number of people with administrative functions. It is thanks to their dedication that this study was made possible.
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