Hospital healthcare utilizers with medical and psychiatric claims in the Netherlands: a nationwide study.

BACKGROUND: Psychiatric and medical multimorbidity is associated with low quality of life, poor functioning and excess mortality. Differences in healthcare utilization between those receiving co-occurring medical and psychiatric healthcare (HUMPCs) and those only receiving medical (HUMCs) or only psychiatric healthcare (HUPCs) may indicate differences in care accessibility, help-seeking behavior and the risk patterns of medical illness. We aimed to assess the occurrence of psychiatric diagnostic groups in HUMPCs compared to HUPCs and to compare their medical and psychiatric claims expenditures. METHODS: Using Dutch claims data covering psychiatric and medical hospital care in 2010-2011, healthcare utilization differences between HUMPCs and HUPCs were expressed as differences and ratios, accounting for differences in age and sex between groups. Median claims expenditures were then compared between HUMPCs and HUPCs. RESULTS: HUMPCs had 40% higher median medical cost of claims compared to HUMCs and a 10% increased number of psychiatric claims compared to HUPCs. HUMPCs were more often diagnosed with: organic disorders; behavioral syndromes associated with physiological disturbances and physical factors; mood [affective] disorders; neurotic, stress related and somatoform disorders; and disorders of adult personality and behavior. By contrast, disorders of psychological development, schizophrenia, schizotypal and delusional disorders, behavioral and emotional disorders with usual onset occurring in childhood, and mental and behavioral disorders due to psychoactive substance abuse were less often diagnosed in this group. CONCLUSIONS: Both medical and psychiatric disease become more costly where both are present. For HUMPCs the costs of both medical and psychiatric claims for almost all diagnostic groups were higher than for HUPCs and HUMCs.

Intoxicated persons showing challenging behavior demand complexity interventions: a pilot study at the interface of the ER and the complexity intervention unit.

Intoxicated persons showing challenging behavior (IPCBs) under influence of alcohol and/or drugs frequently have trouble finding appropriate acute care. Often IPCBs are stigmatized being unwilling or unable to accept help. Separated physical and mental healthcare systems hamper integrated acute care for IPCBs. This pilot aimed to substantiate the physical, psychiatric, and social health needs of IPCBs visiting the emergency room (ER) during a 3-month period. All ER visits were screened. After triage by the ER physician, indicated IPCBs were additionally assessed by the consultation-liaison-psychiatry physician. If needed, IPCBs were admitted to a complexity intervention unit for further examinations to provide integrated treatments and appropriate follow-up care. The INTERMED and Health of the Nation Outcome Scale (HoNOS) questionnaires were used to substantiate the complexity and needs. Field-relevant stakeholders were interviewed about this approach for acute integrated care. Alongside substance abuse, almost half of identified IPCBs suffered from comorbid psychiatric disturbances and one third showed substantial physical conditions requiring immediate medical intervention. Almost all IPCBs (96%) accepted the acute medical care voluntarily. IPCBs showed high mean initial scores of INTERMED (27.8 ± 10.0) and HoNOS (20.8 ± 6.9). At discharge from the complexity intervention unit, the mean HoNOS score decreased significantly (13.4 ± 8.6; P < 0.001). Field-relevant stakeholders strongly supported the interdisciplinary approach and ER-facility for IPCBs and acknowledged their unmet health needs. A biopsychosocial assessment at the ER, followed by a short admission if necessary, is effective in IPCBs. This approach helps to merge separated healthcare systems and may reduce stigmatization of IPCBs needing help.

Bisphenol A Inhibits the Transporter Function of the Blood-Brain Barrier by Directly Interacting with the ABC Transporter Breast Cancer Resistance Protein (BCRP).

The breast cancer resistance protein (BCRP) is an important efflux transporter in the blood-brain barrier (BBB), protecting the brain from a wide range of substances. In this study, we investigated if BCRP function is affected by bisphenol A (BPA), a high production volume chemical used in common consumer products, as well as by bisphenol F (BPF) and bisphenol S (BPS), which are used to substitute BPA. We employed a transwell-based in vitro cell model of iPSC-derived brain microvascular endothelial cells, where BCRP function was assessed by measuring the intracellular accumulation of its substrate Hoechst 33342. Additionally, we used in silico modelling to predict if the bisphenols could directly interact with BCRP. Our results showed that BPA significantly inhibits the transport function of BCRP. Additionally, BPA was predicted to bind to the cavity that is targeted by known BCRP inhibitors. Taken together, our findings demonstrate that BPA inhibits BCRP function in vitro, probably by direct interaction with the transporter. This effect might contribute to BPA's known impact on neurodevelopment.

The state of psychiatry in the Netherlands: strength by quality, influence by capabilities.

Psychiatry and mental healthcare in the Netherlands has a long history of institutional care, slowly more adapted to the community, but differentiated from mainstream healthcare in terms of organization and remuneration. It is in a crucial phase of reconsideration. Along with harsh cuts on the budgets in healthcare, the field is in transition where training is concerned. The good news is that in fruitful cooperation the government and all spcialist parties involved in mental healthcare are on the verge of reaching an important agreement that should make mental healthcare more patient centred, affordable and accessible for those who need it. The bad news that needs serious consideration and ongoing action is that mental health problems are still highly stigmatized and that as a result the government could impose an unjust and unfair own financial contribution for users in mental care as a means of lowering the costs in the field.

Organization and Outcomes of Integrated Inpatient Medical and Psychiatric Care Units: A Systematic Review.

OBJECTIVE: The goal of this review was to assess the relationships among aims, designs, and outcomes of integrated inpatient medical and psychiatric care units (IMPUs) and gather the evidence base on the effectiveness of these units. METHODS: Using online searches of Embase, Medline, Web of Science, PsycINFO, Scopus, CINAHL, Cochrane, and Google Scholar, the authors identified and reviewed literature describing the aims and outcomes of specific IMPU designs. RESULTS: The search yielded 55 studies, in which the authors identified 39 IMPUs that focused on patients with mood, psychotic, somatic symptom, substance use, organic, and personality disorders and a broad array of medical diagnoses. Most units were psychiatric-medical units and had medium medical and psychiatric acuity capabilities. The studies reviewed provided little information on the cost-effectiveness of various IMPU designs. Although some comparative studies indicated reductions in hospital length of stay (LOS), these studies were generally of low quality and rarely reported other intended outcomes. CONCLUSIONS: IMPUs may help shorten LOS. IMPUs should focus care on patients with complex conditions and high acuity to maximize health system value. Implementing compulsory admission facilities; qualified psychiatric, medical, and nursing staff involvement; and cross-disciplinary training may improve IMPUs' capacity to treat high-acuity patients. Future research should relate IMPU designs to intended outcomes.

Specialty Psychiatric Services in US Emergency Departments and General Hospitals: Results From a Nationwide Survey.

OBJECTIVE: To explore the handling of psychiatric patients in medical hospitals and emergency departments (EDs) as well as hospital characteristics associated with the availability of psychiatric services in these settings. METHODS: From October 1, 2017, to April 1, 2018, a telephone survey regarding the presence and nature of psychiatric services was attempted among all US registered Medicare hospitals. RESULTS: Of the included 4812 US hospitals, 2394 (50%) were surveyed. Of these hospitals, 1108 (46%) have some psychiatric services available, either in medical EDs or through psychiatric consultation on general medical inpatient wards. If medical ED patients with active psychiatric issues need admission, 59% of hospitals transfer the patient to a different hospital and 28% admit the patient to a medical ward. Exploration by logistic regression analysis of the association of selected variables and available psychiatric expertise suggested that larger hospitals, nonprofit services, or hospitals in urban settings were more likely to have psychiatrists on staff or available for consultation. CONCLUSION: Despite the growing number of psychiatric patients seeking help in medical EDs and general hospitals, more than 50% of the EDs and general hospitals lack psychiatric services. These results suggest that accessibility to psychiatric care in medical settings requires improvement.

Exploring Neurobehaviour in Zebrafish Embryos as a Screening Model for Addictiveness of Substances.

Tobacco use is the leading cause of preventable death worldwide and is highly addictive. Nicotine is the main addictive compound in tobacco, but less is known about other components and additives that may contribute to tobacco addiction. The zebrafish embryo (ZFE) has been shown to be a good model to study the toxic effects of chemicals on the neurological system and thus may be a promising model to study behavioral markers of nicotine effects, which may be predictive for addictiveness. We aimed to develop a testing protocol to study nicotine tolerance in ZFE using a locomotion test with light-dark transitions as behavioral trigger. Behavioral experiments were conducted using three exposure paradigms: (1) Acute exposure to determine nicotine's effect and potency. (2) Pre-treatment with nicotine dose range followed by a single dose of nicotine, to determine which pre-treatment dose is sufficient to affect the potency of acute nicotine. (3) Pre-treatment with a single dose combined with acute exposure to a dose range to confirm the hypothesized decreased potency of the acute nicotine exposure. These exposure paradigms showed that (1) acute nicotine exposure decreased ZFE activity in response to dark conditions in a dose-dependent fashion; (2) pre-treatment with increasing concentrations dose-dependently reversed the effect of acute nicotine exposure; and (3) a fixed pre-treatment dose of nicotine induced a decreased potency of the acute nicotine exposure. This effect supported the induction of tolerance to nicotine by the pre-treatment, likely through neuroadaptation. The interpretation of these effects, particularly in view of prediction of dependence and addictiveness, and suitability of the ZFE model to test for such effects of other compounds than nicotine, are discussed.

Designing an Herbarium Digitisation Workflow with Built-In Image Quality Management.

Digitisation of natural history collections has evolved from creating databases for the recording of specimens' catalogue and label data to include digital images of specimens. This has been driven by several important factors, such as a need to increase global accessibility to specimens and to preserve the original specimens by limiting their manual handling. The size of the collections pointed to the need of high throughput digitisation workflows. However, digital imaging of large numbers of fragile specimens is an expensive and time-consuming process that should be performed only once. To achieve this, the digital images produced need to be useful for the largest set of applications possible and have a potentially unlimited shelf life. The constraints on digitisation speed need to be balanced against the applicability and longevity of the images, which, in turn, depend directly on the quality of those images. As a result, the quality criteria that specimen images need to fulfil influence the design, implementation and execution of digitisation workflows. Different standards and guidelines for producing quality research images from specimens have been proposed; however, their actual adaptation to suit the needs of different types of specimens requires further analysis. This paper presents the digitisation workflow implemented by Meise Botanic Garden (MBG). This workflow is relevant because of its modular design, its strong focus on image quality assessment, its flexibility that allows combining in-house and outsourced digitisation, processing, preservation and publishing facilities and its capacity to evolve for integrating alternative components from different sources. The design and operation of the digitisation workflow is provided to showcase how it was derived, with particular attention to the built-in audit trail within the workflow, which ensures the scalable production of high-quality specimen images and how this audit trail ensures that new modules do not affect either the speed of imaging or the quality of the images produced.

Health-economic outcomes in hospital patients with medical-psychiatric comorbidity: A systematic review and meta-analysis.

BACKGROUND: Hospital inpatients often experience medical and psychiatric problems simultaneously. Although this implies a certain relationship between healthcare utilization and costs, this relationship has never been systematically reviewed. OBJECTIVE: The objective is to examine the extent to which medical-psychiatric comorbidities relate to health-economic outcomes in general and in different subgroups. If the relationship is significant, this would give additional reasons to facilitate the search for targeted and effective treatments for this complex population. METHOD: A systematic review in Embase, Medline, Psycinfo, Cochrane, Web of Science and Google Scholar was performed up to August 2016 and included cross-references from included studies. Only peer-reviewed empirical studies examining the impact of inpatient medical-psychiatric comorbidities on three health-economic outcomes (length of stay (LOS), medical costs and rehospitalizations) were included. Study design was not an exclusion criterion, there were no restrictions on publication dates and patients included had to be over 18 years. The examined populations consisted of inpatients with medical-psychiatric comorbidities and controls. The controls were inpatients without a comorbid medical or psychiatric disorder. Non-English studies were excluded. RESULTS: From electronic literature databases, 3165 extracted articles were scrutinized on the basis of title and abstract. This resulted in a full-text review of 86 articles: 52 unique studies were included. The review showed that the presence of medical-psychiatric comorbidity was related to increased LOS, higher medical costs and more rehospitalizations. The meta-analysis revealed that patients with comorbid depression had an increased mean LOS of 4.38 days compared to patients without comorbidity (95% CI: 3.07 to 5.68, I2 = 31%). CONCLUSIONS: Medical-psychiatric comorbidity is related to increased LOS, medical costs and rehospitalization; this is also shown for specific subgroups. This study had some limitations; namely, that the studies were very heterogenetic and, in some cases, of poor quality in terms of risk of bias. Nevertheless, the findings remain valid and justify the search for targeted and effective interventions for this complex population.

Identifying value-based quality indicators for general hospital psychiatry.

OBJECTIVE: To define generic quality indicators for general hospital psychiatry from the perspectives of patients, professionals (physicians, nurses, and managers), and payers (health insurance companies). METHODS: Quality variables were identified by reviewing the relevant literature. A working. group consisting of patients', professionals' and payers' representatives was mandated by their respective umbrella organizations. The working group prioritized the quality variables that were identified. Core values were defined and subsequently linked to preliminary quality indicators. These were tested for feasibility in ten hospitals in a four-week period. Stakeholder consultation took place by means of two invitational conferences and two written commentary rounds. RESULTS: Forty-one quality variables were identified from the literature. After prioritization, seven core values were defined and translated to 22 preliminary indicators. Overall, the feasibility study showed high relevance scores and good implementability of the preliminary quality indicators. A final set of twenty-two quality indicators (17 structure, 3 process and 2 outcome indicators) was then established using a consensus-based approach. CONCLUSION: Consensus on a quality framework for general hospital psychiatry was built by incorporating the perspectives of relevant stakeholders. Results of the feasibility study suggest broad support and good implementability of the final quality indicators. Structural indicators were broadly defined, and process and outcome indicators are generic to facilitate quality measurement across settings. The quality indicator set can now be used to facilitate quality and outcome assessment, stimulate standardization of services, and help demonstrate (cost-) effectiveness.