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ORIGINAL ARTICLES |
From the Department of Microbiology, Preventive Medicine and Public Health (E.L., M.-J.R.), University of Zaragoza, Spain; Department of Internal Medicine, and Department of Social Psychiatry (P.D.J.), University Medical Center Groningen, The Netherlands; Department of Internal Medicine (F.J.H., J.P.J.S.), University Medical Center Groningen, The Netherlands; Department of Psychiatry (A.L.), Hospital Clínico Universitario, University of Zaragoza and Instituto Aragonés de Ciencias de la Salud, Zaragoza, Spain.
Address correspondence and reprint requests to Antonio Lobo, Jefe del Servicio de Psiquiatría, Hospital Clínico Universitario, planta 3, C/ San Juan Bosco 15, 50009 Zaragoza, Spain. E-mail: alobo{at}unizar.es
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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Methods: Three hundred and fifteen consecutive patients were assessed at hospital admission with INTERMED by a trained nurse. At discharge, independent research workers, blind to the previous results, reviewed the medical database and a subsample (n = 144) was assessed for psychopathological outcome. Severity of the pulmonary disease was assessed with the Cumulative Illness Rating Scale (CIRS), and psychopathology with the Hospital Anxiety and Depression Scale, Mini-Mental Status Examination (MMSE) (cognitive disturbances), and CAGE Scale (alcohol abuse). Operational definitions were used for measures of care complexity.
Results: Most patients were in geriatric age, and 78 patients (24.7%) were classified as "complex" by means of INTERMED (IM+). In support of the working hypotheses, IM+ patients scored significantly higher in measures of care complexity (Cumulative Illness Rating Scale, "number of consultations during admission" and "diagnostic count") and on both anxiety and depression. INTERMED was also associated with length of hospital stay (LOS) and with both anxiety and depression after controlling for significant predictors and socio-demographic data.
Conclusions: This is the first report about the ability of INTERMED to predict complexity of care in pneumology patients, and the first to predict a negative psychopathological outcome in any type of medical patients.
Key Words: pneumology • health service research • complexity of care • psychiatric co-morbidity • INTERMED
Abbreviations: APC = ancillary procedures count; B unstand = Beta unstandardized coefficients; CAGE = screen for alcohol abuse; CI = confidence interval; CIRS = Cumulative Illness Rating Scale; COPD = chronic obstructive pulmonary disease; DC = diagnostic count; HADS = Hospital Anxiety and Depression Scale; IM+ = INTERMED positive score; IM– = INTERMED negative score; INTERMED = Interdisciplinary Medicine; LOS = length of hospital stay; MBDS = minimum basic data set; MMSE = Mini Mental Status Examination; NCA = number of consultations during admission; NPD = number of physicians the patient is referred to at discharge; NHS = National Health System.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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Psychopathological and physical symptoms, as well as social problems relate in a complex way in pulmonary patients, together determining poor medical outcomes (8). Functional impairment is an important risk factor for depression (9), and mood disorders have been associated with abnormal medical parameters in different diagnostic groups of pulmonary patients (10), as well as to increased disability (11) and adverse quality of life (6). Patients with higher levels of positive social support have less depression and anxiety (8), therefore a strong social gradient in respiratory mortality and chronic obstructive pulmonary disease has been reported (12). Increased health care utilization has been documented in relation to physical parameters (13), but also to psychopathological problems (14).
Because the high rates of emotional illness complicating the care in pulmonary patients have also been documented in seriously ill, general medical patients (15), it is remarkable that no methods to approach in a systematic way their identification have been widely accepted (16). It is commonly held that improved recognition of psychiatric problems leads to improved patient care in medical patients (17). Specifically, some evidence is available that treatment of psychological problems in asthma (18) or in COPD patients (19), improves outcomes. However, evidence from well-controlled studies is limited (6,20), and interventions aimed to improve social, psychological, or psychiatric functioning are often conducted in an isolated fashion. Elsewhere, we have argued in favor of an integrated patient assessment in the general hospital, focusing on the early detection of patients with vulnerabilities on the social, psychological, and psychiatric domain and proposed that treatment of these vulnerabilities be integrated in regular medical care (21).
The INTERMED method was developed to universally screen at admission to medical wards for complex cases with biological, social, and psychological problems; and to provide a model to communicate these potential problems to the medical staff and to facilitate an early referral (21). Several studies have shown that high scores on the INTERMED predict negative outcomes, such as long hospital stay and poor discharge health status in patients admitted to internal medicine (22), and also in specific diagnostic groups (23). Because many complex cases have long hospital stays, the potential cost-effectiveness of this screening method should be emphasized (24). However, the ability of INTERMED to predict a negative psychopathological outcome has not been tested. Furthermore, this instrument has not been used in pulmonary patients, which is necessary for evaluating the possible advantages of implementing this original method on pneumology wards. We therefore studied whether INTERMED can help the clinician to detect at admission to a pneumology ward patients who will develop negative outcomes at discharge, operationalized as either receiving high levels of care or having high scores in psychopathological measures.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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All consecutive patients admitted to the ward from May 2003 until June 2004 were invited to participate, provided they were older than 17 years and were living in Area III of Zaragoza. Patients admitted for one day or readmitted during the study period were excluded.
Variables and Assessment Tools
Socio-demographic data were recorded after common procedures in medical research.
INTERMED
INTERMED is an observer rated instrument that classifies information from a medical history-taking into four domains related to biopsychosocial and health care aspects of disease (Table 1) (21,25). In each of the four domains five variables, related to "history," "current state," and "prognoses," are rated 0 to 3 according to a manual with clinical anchor points, resulting in a potential score range of 0 to 60. Scoring is based on a review of the medical chart and a patient semistructured interview, which is designed like a medical anamnesis but complemented by psychosocial and health care-related information. Health care professionals need about 20 minutes for the interview.
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A trained nurse can reliably use INTERMED (22). Based on a cut-off score of >20, INTERMED was found to have good inter-rater reliability between two raters, as indicated by a Kappa of 0.85; good test-retest reliability (r = 0.75; 
= 0.60) with a period of one year between two ratings; and internal consistency, with estimates (Cronbach’s 
) ranging between 0.78 and 0.94 in several samples of patients with somatic illness (22). The Spanish version of INTERMED was previously standardized by the authors (26) and was used in this study.
Mini Mental Status Examination (MMSE)
The MMSE is a reliable and valid indicator of cognitive disturbance and probably the test of cognitive function in most widespread use (27). For this study the standardized official Spanish version was used (28).
Hospital Anxiety and Depression Scale (HADS)
The HADS is a self-administered scale, which consists of seven questions relating to anxiety and seven to depression with answering categories ranging from 0 to 3. It is less biased toward symptoms resulting from concurrent medical conditions, as it does not contain items referring to physical symptoms such as sleeping problems and weight loss, and is therefore especially suitable for use in subjects with somatic illnesses (29). The validated Spanish version (30) has been used in this study. The scores were totaled to give a depression score and an anxiety score (range 0–21).
Cumulative Illness Rating Scale (CIRS)
The CIRS is an instrument that was designed to assess impairment due to medical illness in a reliable, brief, and easy-to-use way, and has been successfully used in medical inpatients (31). The validated Spanish version has been used in this study (32). It evaluates 13 categories or systems (heart, vascular, respiratory systems, etc.) each one scored from 0 (no impairment) to 4 (highest possible impairment). For the purpose of this study the severity index based on the total score on the questionnaire was used.
CAGE Scale
The CAGE (acronym for "Cut down" (C), "Annoyed" (A), "Guilty" (G), "Eye" (E)) Scale was standardized by Mayfield (33) and is widely used for the screening of alcohol abuse; it also has a validated Spanish version (34). It includes four items that the subjects are asked to mark yes/no. The threshold used in this study to consider a "probable case" of alcoholism was 2, in correspondence with the literature (35).
Care Complexity
Length of hospital stay (LOS), number of medical diagnoses (diagnostic count, DC), number of ancillary procedures (ancillary procedures count, APC), number of medical consultations during admission (NCA), discharge referral status (number of physicians the patient is referred to at discharge, NPD), which includes the outcome of death, were all extracted from the official discharge database in the hospital (Minimum Basic Data Set, MBDS).
Procedure
The patients were asked to participate in the study by a research nurse in the first three days after admission, unless they were severely ill. They were asked to sign a written informed consent according to Spanish laws. After that, the research nurse reviewed the medical chart and conducted the patient interview (15–20 minutes) necessary to score INTERMED. After the patient’s discharge, independent research workers, blind to the previous results, reviewed the discharge medical reports and collected information from the hospital database (MBDS). Based on this information, the CIRS was scored, and information about LOS, DC, APC, NCA, and NPD was calculated.
For the study of psychopathological outcome, and because of logistical reasons, a sub-sample of the same patients was randomly selected among the consecutive patients admitted to the ward, in such a way that approximately 
of the full sample would be included. In this sub-sample a trained lay-interviewer, blind to the results obtained by the research nurse, administered at the time of the patient’s discharge the MMSE, HADS, and CAGE.
Data Analysis
In order to compare our findings with prior literature, the INTERMED cut-off point (>20) was used to form two groups in the total sample: the "complex" or IM+ (patients scoring above the threshold), and the "noncomplex" patients or IM–. The two groups were first compared with test for differences on basic socio-demographic data. Then, they were compared in variables related to complexity of care, such as LOS, CIRS, DC, APC, NCA, and NPD and in psychopathological variables. Scores on the HADS and MMSE were treated as continuous variables. The CAGE, which was designed as a screening instrument to detect probable cases of alcohol abuse, and not to measure severity, was dichotomized according to the standard threshold in the literature (35). To test statistical significance, 
2 test for categorical data, and Mann-Whitney U tests for not normally distributed, continuous variables were conducted. To study the prospective associations of INTERMED with LOS, anxiety, depression, and cognition, in the presence of several confounders, we applied multivariate linear regression analyses, using the original, continuous INTERMED variable.
A multivariate analysis was conducted to study the independent effect of INTERMED on LOS, controlling for potential demographic confounders (age, sex, and marital status), and other factors that could be correlated with LOS (CIRS, NCA, NPD, DC, and APC). For this, three regression models were tested: a) a model with INTERMED as the sole predictor of LOS, b) a model with all potential confounders (both demographic and nondemographic), and c) this model with INTERMED as an additional predictor. Models were evaluated with respect to explained variance, and Beta unstandardized coefficients were calculated in order to assess the relative importance of the predictors. For these analyses we used the natural logarithmic transformation of LOS, which resulted in an approximately normal distribution (Skewness: 0.1; Kurtosis: 0.9).
Similarly, multivariate analysis was conducted to study the independent effect of INTERMED on variables of anxiety, depression, and cognition, controlling for potential demographic confounders (age, sex, and marital status), and other factors that could be correlated with the variables (CIRS, LOS-log, NCA, NPD, DC, and APC). For this, linear regression models were tested. Models were evaluated with respect to explained variance, and Beta unstandardized coefficients were calculated in order to assess the relative importance of the predictors. For these analyses we used direct measures of the variables, which resulted in an approximately normal distribution. Both original HADS subscales already had approximately normal distributions (Depression: Skewness, 1.3; Kurtosis, 1.5; Anxiety: Skewness, 1.3; Kurtosis, 1.5). To achieve normality for the MMSE scores, we used its square (MMSE2: Skewness, –1.1; Kurtosis, 1.1). In order to enhance the interpretability of our findings, we constructed a new variable by dividing the INTERMED by its interquartile range (i.e., by 7) and to perform additional regression analyses with this variable as predictor. The unstandardized regression weight in this case gives an estimate of the difference in outcome between a typically low scoring patient with a typically high scoring patient on the INTERMED.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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Most patients were of geriatric age, with a mean of 68.3 years (Table 2). Most were men (73.7%), living with partner (68.6%), and were married (70.8%), 3.8% of them were illiterate, and most were retired (54.9%). Close to two thirds of the patients (60.9%) had as a first diagnosis of one of the following: pneumonia (or acute pulmonary infection) 23.9%; COPD 16.8%; lung cancer 12.3%; or asthma 7.5%. Mean LOS was 14.4 days (±10.2). Using the INTERMED’s cut-off point of >20, 78 patients (24.8%) were considered complex (IM+). Compared with IM– patients IM+ patients were significantly younger, and significantly higher proportions were of female gender and were on disability. A significantly lower proportion in this group was retired, probably due to their lower mean age (Table 2).
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In support of the working hypothesis, IM+ patients tended to have higher LOS (p = .053), when compared with IM– patients. Furthermore, IM+ patients scored significantly higher on measures of care complexity, including CIRS, NCA, and DC (Table 3).
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Of the 212 patients who were randomly selected for the psychometric assessment at discharge, 68 were excluded. The remaining 144 patients were assessed at discharge for psychopathological disturbance (Figure 1). Because this group of patients is a sub-sample, we tested to what extent it differed from the rest of the full sample. The proportion of women was 28.3%, mean age was 68.6 (±13.3), and no differences were found in relation to socio-demographic variables. Only LOS was higher in the sub-sample studied for psychopathological outcome (16.9 ± 12.1) when compared with the rest of the full sample (13.2 ± 9.8) (p = .002).
Levels of both anxiety and depression were significantly higher at the time of discharge in IM+ patients, when compared with IM– patients. On the contrary, no significant differences were found in MMSE measures of cognitive deficits or in the proportion of probable cases of alcoholism (Table 3).
The multivariate analysis revealed that INTERMED was significantly associated with LOS (Table 4). In model 2 it is shown that CIRS, NPD, DC, and APC are also positively associated with LOS. In model 3 we found that INTERMED remains associated with LOS after controlling for socio- demographic data and indicators of care complexity.
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Multivariate, regression models also revealed that INTERMED predicts psychopathological variables at the time of discharge (Table 5) independent of care complexity. INTERMED was associated with symptoms of both anxiety and depression, but not cognitive problems. In addition, some variables were associated as expected with psychopathological symptoms, such as age and cognitive deficits; or female sex and anxiety. The multivariate regression analyses in which we used the INTERMED score divided by its interquartile range resulted in unstandardized regression weights to predict HADS-anxiety score of 1.93 (95% CI 1.02–2.84) and HADS-depression score of 1.88 (95% CI 0.96–2.81).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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The finding that IM+ patients are significantly younger was not expected beforehand. An explanation for this might be related to the clinical experience suggesting that older patients are frequently admitted to the pneumology ward because of acute pulmonary diseases, and younger patients tend to be more chronic and/or have severer medical conditions. Although with the data at hand we cannot test the chronicity side of this hypothesis, we have found some support for its severity side: in a secondary analysis we have found that "younger" patients (below the mean age in this sample, 68 years), when compared with the "older" ones (68 years or above) scored significantly higher in the Cumulative Illness Rating Scale (CIRS) (2.30 ± 0.51 versus 2.19 ± 0.41; p = .046). High scores in the CIRS relate to high number of systems diseased and/or severity of impairment, and both may have important weight in the "biological" and "health care" variables of INTERMED (Table 1).
In relation to the second objective, this is the first study giving important support for the hypothesis that INTERMED predicts a negative psychopathological outcome. Notably, significantly higher scores on symptoms of both anxiety and depression were found in IM+ patients when compared with IM– patients. Furthermore, the regression models showed that these differences were independent of significant predictors. However, the magnitude of these differences appears to be relatively modest: typical patients scoring in the upper half of the INTERMED distribution have about 1 to 1.5 times higher HADS anxiety and HADS depression scores at discharge comparing with typical patients scoring in the lower half of the INTERMED distribution, after controlling for potential confounders.
The expected lower scores on cognitive performance in IM+ patients when compared with IM– patients, or the association of INTERMED with cognitive problems were not found in this study. However the low rate of cognitive problems found in this sample precludes a firm conclusion: only 3% of patients in the IM+ group and 2.7% in the IM+ group (p = .92) scored below the threshold considered to be related to moderate/severe cognitive deficit (below 18) in the MMSE (36). Cognitive disturbances have long ago been reported to be common in medical patients (37), but a considerable number of patients initially assessed with INTERMED were excluded because of death, illness severity, or refusal. All these circumstances may lead to the exclusion of patients with cognitive problems because a high death rate has been reported in patients with delirium and delirium with cognitive disturbance is particularly frequent in patients with anoxia (4), such as it occurs in individuals with a severe pulmonary condition. The presence of cognitive disturbances was assessed at the time of discharge from the pneumology ward, and delirium with cognitive disturbance is an acute psychopathological disturbance that usually improves considerably during the hospitalization, unless the patient dies in the first few days. Finally, refusals were more frequent when the patients’ families were aware of the patients’ cognitive problems, with the rational that they might get more confused by the testing.
Some potential limitations of this study should be discussed. Although we cannot claim we have a representative group of patients, the sample is rather typical in a hospital in the National Health System (NHS) in Spain, covering a "health area" with similar socio-demographic characteristics to the rest of NHS general hospitals in the country. The finding that the elderly predominate in medical wards, with the mean age in this study 68 years, is also characteristic of contemporary NHS hospitals in Spain (38).
Because we could not interview at admission the 21 patients who were seriously ill, it might be argued that we did not screen with INTERMED a proportion of patients with high potential for complexity. As expected, the death rate in these patients was significantly higher than in the remaining patients (27.8% versus 6%; p < .001). Although LOS was not significantly longer in the former (17.76 versus 14.89; p = .656), it is still possible that the severely ill are complex patients and, therefore, the survivors may also need the assessment with INTERMED at some point during their hospitalization. However, we believe this possibility does not preclude the main conclusions of the study.
Arguments may also be raised about the use of a subsample for the testing of a negative psychopathological outcome in INTERMED+ patients. Because LOS was significantly higher in this subsample, a flaw in the randomization process might be suggested. However, no differences in LOS were observed between the 212 patients randomized before the exclusion process and the remaining patients (15.09 ± 11.1 versus 13.1 ± 7.9; p = .94). A high LOS in the subsample assessed for psychopathological outcome might be expected, because the psychological testing was programmed at discharge and 22 patients could not be examined because of a shorter stay. Although these patients with a shorter stay might have a less complex hospital care, we believe the results should not be biased in an important way, because it was still possible to show that INTERMED was able to predict among the subsample the patients with higher scores on psychopathological variables.
This study has potential implications for health professionals, which are increasingly confronted with complex patients (1). In this study, a considerable proportion (24.8%) of pulmonary patients was considered to be potentially complex (IM+) and, as expected, complexity of care was confirmed in them. Furthermore, severe psychopathology was also frequent in this sample, particularly among IM+ patients. Functional impairment (9), increased disability (11), adverse quality of life (6), and increased health care utilization (14) are all to be expected as an outcome of this psychopathology. Preliminary findings in a multi-center, national study of comorbid depression in internal medicine and respiratory patients in Spain, which includes patients assessed in this report, suggest that depression is persistent and, at follow-up in primary care, is associated with poor quality of life and higher use of medical services, as well as higher mortality (Lobo A. Meeting of the Royal College of Psychiatrists, Section on Liaison Psychiatry, Barcelona, March 16–18, 2005).
This type of evidence supports our criteria to consider the pulmonary patients with clinically relevant psychopathology to be in need of psychosocial referral and probably treatment, but adequate trials are needed to test the effect of psychosocial interventions in medical settings (6). The literature suggests that an early detection of complex patients is needed to organize an adequate, integrated care plan directed at patient needs, including early referral to appropriate sources (22). INTERMED was designed from this perspective and is intended to reflect a useful evolution in consultation psychiatry, which has been considered to be basically acute crisis management (39). Recently, it has been demonstrated that, compared with usual care, nurse-led interventions based on INTERMED scores resulted in improvements in quality of life at discharge in a sample of general medical patients (24). It remains to be seen if these findings could be confirmed in adequate trials in pneumology patients. In the meantime, it is remarkable that a trained nurse, by means of INTERMED, was able to detect early the complex pulmonary patients and to predict at hospital admission care complexity and negative psychopathological outcomes.
We would like to express our gratitude to Professor Javier Suárez and the medical and nursing staff in the Pneumology ward at the Hospital Clínico Universitario in Zaragoza, for their help in implementing this study, and to the members of the Spanish Research Network on Liaison Psychiatry (REPEP) for their suggestions in different phases of this project. This study has received grant support from Ministerio de Educación y Cultura and Caja de Ahorros de la Inmaculada (CAI) and "Red de Psiquiatría de Enlace (G03/128)", from the Fondo de Investigación Sanitaria (FIS) and Instituto de Salud Carlos III, Spain.
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NOTES |
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DOI:10.1097/PSY.0b013e31802e46da
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