RESUMEN
BACKGROUND: Inpatient treatment of anorexia nervosa can be lifesaving but is associated with high rates of relapse and poor outcomes. To address this, the Oxford service has adapted the enhanced cognitive behavioural treatment (CBTE) model, first developed for inpatients in Italy to a UK national health service (NHS) setting. In this study, we compared the outcomes from treatment as usual (TAU), integrated CBTE (I-CBTE), and alternative treatment models in routine UK clinical practice. METHODS: This is a longitudinal cohort study, using routinely collected data between 2017 and 2020 involving all adults with anorexia nervosa admitted to specialist units from a large geographical area in England covering a total population of 3.5 million. We compared TAU with (1) I-CBTE (13 weeks inpatient CBTE, restoration to a healthy weight, combined with 7 weeks day treatment followed by 20 weeks of outpatient CBTE; (2) standalone inpatient CBTE (due to insufficient resources since the pandemic; and (3) 6-8 weeks admission with partial weight restoration as crisis management. Primary outcome measures (min. 1 year after discharge from hospital) were defined as: (1) good outcome: Body Mass Index (BMI) > 19.5 and no abnormal eating or compensatory behaviours; (2) poor outcome: BMI < 19.5 and/or ongoing eating disorder behaviours; (3) readmission; or (4) deceased. Secondary outcomes were BMI on discharge, and length of stay. RESULTS: 212 patients were admitted to 15 specialist units in the UK depending on bed availability. The mean age was 28.9 (18-60) years, mean admission BMI was 14.1 (10-18.3), 80% were voluntary. At minimum 1-year follow up after discharge, 70% of patients receiving I-CBTE and 29% standalone inpatient CBTE maintained good outcomes, in contrast with < 5% TAU and crisis management admission. Readmission rates of I-CBTE were 14.3% vs ~ 50% (χ2 < 0.0001) in the other groups. The main predictors of good outcome were reaching healthy BMI by discharge, I-CBTE and voluntary status. Age, psychiatric comorbidity and length of stay did not predict outcomes. BMI on discharge and length of stay were significantly better in the CBTE groups than in TAU. CONCLUSIONS: Our main finding is that in a real-life setting, I-CBTE has superior short- and minimum 1 year outcomes as compared with alternative inpatient treatment models. Dissemination of I-CBTE across the care pathway has the potential to transform outcomes of inpatient treatment for this high-risk patient population and reduce personal and societal costs.
Outcomes for adults requiring inpatient treatment for anorexia nervosa are poor. The aim of this work was to evaluate a recently introduced Integrated Cognitive Behavioural Therapy (I-CBTE) in Oxford, adapted from a model first developed for inpatients in Italy, compared with alternative inpatient treatment programmes in the UK. I-CBTE is an innovative approach which combines a time limited, planned admission of 13-weeks with the goal of full weight restoration, 7-weeks day treatment and ongoing outpatient CBTE. Treatment as usual includes an eclectic multidisciplinary approach, which is often unplanned and poorly coordinated across the care pathway in routine practice.Between 2017 and 2020, we systematically analysed routinely collected data for patients admitted to 15 specialist units from a population of 3.5million in England. We looked at outcomes between admission and discharge, and at one year follow up. 70% of patients receiving I-CBTE, maintained healthy weight at one year after discharge from hospital (without binging or purging), in contrast with less than 5% of those in alternative programmes that result in partial weight restoration. Readmission rates were 14.3% and ~ 50% respectively. Partial weight restoration resulted in high readmission rates and therefore should be discouraged.Our findings show that continuity and consistency of the I-CBTE approach are fundamental for maintaining good outcomes.
