Journal of Adolescent Health
Volume 43, Issue 5 , Pages 417-418, November 2008

Variability in Admission Practices for Teens Hospitalized with Anorexia Nervosa: A Call for Evidence-based Outcome Studies

Chief, Division of Adolescent Medicine, The Marron and Mary Elizabeth Kendrick, Professor in Pediatrics, Lucile Packard Children's Hospital at Stanford, Stanford University School of Medicine, Palo Alto, California

Article Outline

 

See Related Article p. 425

Clinicians have been treating anorexia nervosa since 1694, when the condition was first described by the British physician Richard Morton [1]. Anorexia nervosa is a disease that has its onset in adolescence and is associated with significant medical and psychological morbidity. Despite advances in our knowledge of the morbidities associated with this disorder, there is a paucity of evidence-based literature on effective treatment. In fact, two recent systematic reviews have attested to the limited number of randomized clinical treatment trials in anorexia nervosa and their quality [2], [3]. This issue is important because, despite over 300 years of clinical experience treating the disease, the mortality still remains between 5% and 16% [4], [5], [6], [7], [8], [9], [10]. Approximately 5% of patients diagnosed with anorexia nervosa die per decade of illness [9], and the mortality rate is approximately 12 times that of the general population [10].

In this issue of the Journal, Schwartz et al [11] surveyed 45 adolescent programs in the United States and Canada regarding admission practices and medical management of teens hospitalized with anorexia nervosa. The authors focused on criteria for hospital admission and found marked variations in treatment practices. At first glance, this may seem surprising, because in the year or 2 before the survey was conducted, position papers and treatment guidelines had been published by national societies including the Society for Adolescent Medicine (SAM) [12], the American Academy of Pediatrics (AAP) [13], the American Psychiatric Association (APA) [14], and the American Dietetic Association (ADA) [15]. On deeper reflection, however, these findings are not alarming, because the guidelines and position papers were based on expert opinion and not on rigorous scientific data. The guidelines were established to guide practitioners in their management, but were never intended to serve as standards of care. Since the seminal work of Keys et al [16], there has been a strong body of scientific knowledge about the physiological effects of starvation, the metabolic demands of refeeding, and the dangers of too aggressive refeeding, including sudden unexpected death, the so-called “refeeding syndrome” [16], [17]. Objective signs of medical instability such as bradycardia, hypotension, hypothermia, and orthostasis all reflect adaptive responses to malnutrition, and respond to careful nutritional rehabilitation [18], [19]. We know that with severe malnutrition, there is a “point of no return,” beyond which the risk of death is high. We do not yet know what that point is. There are no data to show that there is a particular degree of malnutrition or a particular heart rate below which morbidity or mortality is increased.

Although the wide variability in treatment practices described in this paper is clear, there also is marked consensus: the majority of respondents used a cutoff of 75% of ideal body weight to admit a patient, consistent with the guidelines of SAM, the AAP, the APA (2000), and the ADA. With regard to bradycardia, the majority of respondents used a cutoff of 40 beats per minute as an admission threshold for an adolescent with anorexia nervosa. Of interest, this cutoff is lower than both the SAM and AAP guidelines, but is more in keeping with the revised (2006) APA guidelines. Not addressed by the paper is the important issue of length of hospitalization and criteria for discharge from inpatient units. There are good data demonstrating that weight at discharge impacts on rate of readmission and on long-term outcome. Several studies have demonstrated that patients discharged at a low weight are rehospitalized at a greater rate than those who achieve their treatment goal weight within the hospital [20], [21]. A recent multicenter study from Europe of 213 adolescents with anorexia nervosa followed for an average of 8.3 years, demonstrated that weight gain during the first admission and a low body mass index (BMI) on discharge predicted readmission to the hospital. Furthermore, subjects who were hospitalized repeatedly had a less favorable long-term outcome and higher rates of persistent psychopathology [21]. Increasing costs of hospitalization and efforts to contain those costs have changed treatment practices. Length of hospitalization for anorexia nervosa in the United States is much shorter than in Canada or Europe. Has this impacted on long-term outcome or rates of rehospitalization? Some units admit patients onto medical units for medical stabilization only, whereas others admit for both medical stabilization and nutritional rehabilitation. Is there a difference in outcome or rates of rehospitalization with the two different approaches? Should patients be discharged when their vital signs stabilize or should they be kept until they reach a certain weight, BMI, or percent of ideal body weight? If so, what is this weight? In the younger adolescent, family-based therapy has been found to be effective and can, in some cases, prevent hospitalization or shorten the length of hospitalization [22]. Does family-based therapy prevent readmission to the hospital or improve long-term outcome?

The article by Schwartz et al [11] is a wake-up call, alerting us to the need for treatment protocols based on solid scientific data. There is a pressing need for well-designed outcome studies to provide the data that practitioners need to make informed treatment decisions for their patients. Such studies are not going to be conducted by a single center alone, but will need to be well-funded, multicenter studies with long-term outcome. Clinicians and researchers need to partner with insurance companies and funding agencies to determine the optimal treatment and the one that is most cost effective. Practitioners have been treating anorexia nervosa since 1694, but outcomes research for this condition remains in its infancy. The work of Schwartz et al [11] is a modest step in the right direction.

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PII: S1054-139X(08)00327-3

doi:10.1016/j.jadohealth.2008.07.013

Refers to article:

  • Variations in Admission Practices for Adolescents with Anorexia Nervosa: A North American Sample , 25 June 2008

    Beth I. Schwartz, Jonathan M. Mansbach, Jenna G. Marion, Debra K. Katzman, Sara F. Forman
    Journal of Adolescent Health November 2008 (Vol. 43, Issue 5, Pages 425-431)

Journal of Adolescent Health
Volume 43, Issue 5 , Pages 417-418, November 2008

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