Lascar R, Letranchant A, Hirot F, Godart N
Faculté de médecine de Nice, UNS Santé, 28, avenue de Valombrose, 06107 Nice, France; Faculté de médecine, université Paris Sud XI, 63, rue Gabriel Péri, 94270 le Kremlin-Bicêtre, France.
Département de psychiatrie, Institut Mutualiste Montsouris, 42, boulevard Jourdan, 75014 Paris, France.
Encephale. 2021 Aug;47(4):362-368. doi: 10.1016/j.encep.2020.11.002. Epub 2021 Mar 19.
The cost of hospital treatment for anorexia nervosa (AN) is very high given its duration. Identifying factors related to length of hospital stay (LOS) would make it possible to consider targeted therapeutic strategies that, by optimizing care, would reduce their duration and costs. The objective of this work is to identify the factors related (predictive and associated) to LOS for AN.
Systematic review of existing literature up to October 2020, based on Pubmed, according to PRISMA recommendations (Preferred Reported Items for Systematic reviews and Meta-Analysis). Factors related to LOS have been described in two categories: factors related to clinical aspects ; and factors related to therapeutic aspects and management modalities. We distinguished predictive factors (identified as pre-hospitalization or contemporaneous with hospital admission) and associated factors (observed during hospitalization) for each category.
Thirteen articles were selected. Samples from the selected studies ranged from 35 to 381 subjects, mostly women with restrictive type AN (R-AN), but some samples included all types of AN, or focused on purging-type forms. The mean age at admission ranged from 13.6 years (Standard Deviation-SD:±1.6) to 30.3 years (SD :±13.9), corresponding to adolescent, adult or mixed samples. Mean body mass indices at admission ranged from 12.3 (SD±1.4) to 16.6 (SD:±2.1). The duration of disease progression ranged from 11.7 months±2.2 to 9.7 years. Mean LOS are short for studies conducted in pediatrics or in medical services (ranging from 13.0 days [SD±7.3] to 22.1 days [SD±9.4]); they are more variable for studies conducted in psychiatry: from 15.6 days (SD±1.0) to 150.2 days (SD±80.8). Among the factors related to an increase in LOS, clinical predictors included: older age at onset or admission; longer duration of the disorder; low minimum body weight during AN; low BMI at admission; purgative form of anorexia nervosa; and high levels of dietary symptoms (asceticism and ineffectiveness dimensions on Eating Disorder Inventory-2). Therapeutic and management modality predictive factors were: a higher number of hospitalizations for AN; the use of enteral nutrition (nasogastric or percutaneous gastric tube) on admission or during hospitalization; the use of intravenous renutrition coupled with oral renutrition; hospitalization far from the patient's home; absence of hospital care in psychiatry after medical stabilization in a somatic unit; compulsory hospitalization. Associated factors were: the presence of psychiatric comorbidities; greater weight gain during hospitalization. Among the factors related to a decrease in LOS, the clinical predictive factor were: greater self-confidence at admission (measured by the Eating Disorder Recovery Self-Efficacy Questionnaire). Therapeutic and management modality predictors included: increased caloric intake of oral renutrition on admission; intake of oral nutritional supplements on admission; and hospitalization in urban areas. The associated factor was: compliance with the weight contract in the adolescent population.
Factors related to an increase in LOS are explained by: higher resistance to treatment, higher severity of the disease, the time required for weight gain in services using cognitive-behavioural therapy, complications associated with renutrition modalities such as parenteral renutrition, difficulties in organising outpatient follow-up which require better consolidation of inpatient treatment and the lack of multidisciplinary care in medical services. Factors related to a decrease in LOS are due to: faster weight gain, the presence of a greater number of outpatient follow-up structures close to the hospital and better adherence to treatment to complete the weight contract.
Taking these factors into account during hospitalization for AN would help optimize care, duration and costs. This situation therefore requires the development of therapeutic trials targeting the identified factors in order to reduce LOS in the treatment of AN.
鉴于神经性厌食症（AN）的病程，其住院治疗费用非常高。识别与住院时间（LOS）相关的因素将有助于考虑有针对性的治疗策略，通过优化护理，减少住院时间和费用。这项工作的目的是识别与AN的LOS相关（预测性和相关性）的因素。
根据PRISMA建议（系统评价和Meta分析的首选报告项目），基于Pubmed对截至2020年10月的现有文献进行系统评价。与LOS相关的因素分为两类：与临床方面相关的因素；与治疗方面和管理模式相关的因素。我们为每个类别区分了预测因素（确定为住院前或与入院同时）和相关因素（住院期间观察到）。
选择了13篇文章。所选研究的样本量从35到381名受试者不等，大多数是限制型AN（R-AN）的女性，但一些样本包括所有类型的AN，或侧重于清除型。入院时的平均年龄从13.6岁（标准差-SD：±1.6）到30.3岁（SD：±13.9），对应青少年、成人或混合样本。入院时的平均体重指数从12.3（SD±1.4）到16.6（SD：±2.1）。疾病进展的持续时间从11.7个月±2.2到9.7年。儿科或医疗服务部门进行的研究中平均LOS较短（从13.0天[SD±7.3]到22.1天[SD±9.4]）；精神病学研究中的LOS更具变异性：从15.6天（SD±1.0）到150.2天（SD±80.8）。在与LOS增加相关的因素中，临床预测因素包括：发病或入院时年龄较大；疾病持续时间较长；AN期间最低体重较低；入院时BMI较低；神经性厌食症的清除型；以及饮食症状水平较高（饮食失调问卷-2上的禁欲和无效维度）。治疗和管理模式预测因素为：AN住院次数较多；入院时或住院期间使用肠内营养（鼻胃管或经皮胃管）；静脉再营养与口服再营养联合使用；住院地点远离患者家；躯体病房医疗稳定后精神病学缺乏住院护理；强制住院。相关因素为：存在精神科合并症；住院期间体重增加较多。在与LOS减少相关的因素中，临床预测因素为：入院时自信心较强（通过饮食失调恢复自我效能量表测量）。治疗和管理模式预测因素包括：入院时口服再营养热量摄入增加；入院时摄入口服营养补充剂；以及在城市地区住院。相关因素为：青少年人群遵守体重合同。
与LOS增加相关的因素可解释为：对治疗的抵抗力较高、疾病严重程度较高、采用认知行为疗法的服务中体重增加所需时间、与再营养模式（如肠外营养）相关的并发症、组织门诊随访的困难（这需要更好地巩固住院治疗）以及医疗服务中缺乏多学科护理。与LOS减少相关的因素是由于：体重增加更快、医院附近有更多门诊随访机构以及更好地坚持治疗以完成体重合同。
在AN住院期间考虑这些因素将有助于优化护理、住院时间和费用。因此，这种情况需要开展针对已识别因素的治疗试验，以减少AN治疗中的LOS。
