ECT and LOS: Reasons To Prescribe Sooner, More Outpatient
Out on PubMed, from researchers at Penn State College of Medicine and Yale School of Medicine, is this study:
Does Electroconvulsive Therapy for Patients with Mood Disorders Extend Hospital Length of Stays and Increase Inpatient Costs?
Adm Policy Ment Health. 2021 Jun 5. doi: 10.1007/s10488-021-01145-3. Online ahead of print.PMID: 34089432
The abstract is copied below:
Although randomized trials have shown that electroconvulsive therapy (ECT) is an effective and underused treatment for mood disorders, its impact on inpatient length of stay (LOS) and hospital costs are not fully understood. We analyzed private insurance claims of patients hospitalized for mood disorders who had continuous insurance for three months prior to an index hospitalization and six months after discharge (N = 24,249). Propensity score weighted linear models were used to examine the association of any ECT use, the number of ECT treatments, and time to first ECT treatment, with LOS and hospital costs adjusting for potential confounders. Three months prior to the index hospitalization, patients who subsequently received ECT had more than double the total healthcare costs and bed days ($12,669 vs. $6,333 and 4.5 vs. 0.92 days, p < .001) of the other group. During their index admission, patients receiving ECT had longer LOS (16.1 vs. 5.8 days, p < .001) and three times greater hospital costs ($28,607 vs. $8,708, p < .001). Analyses adjusted for other group differences showed a dose-response relationship between the number of ECT treatments and LOS and hospital costs. Receipt of ECT was associated with increased LOS by 4 to 29 days depending on the number of ECT treatments and increasing total hospital costs from $5,767 to $52,717. Receipt of any ECT and the number of treatments during hospitalization were associated with markedly increased LOS, hospital admission costs, and post-discharge costs. Cost-effectiveness of ECT may be enhanced by shifting treatments to outpatient settings when possible.
Keywords: Bipolar disorder; Depression; Electroconvulsive therapy; Mood disorder.
And from the text:
In this study of privately insured individuals, after controlling for baseline characteristics and costs, we found a dose–response relationship between the number of ECT treatments received during the index hospitalization and both length of hospital stays and total admission costs. Compared to those who did not get ECT, those receiving ECT had substantially increased length of stay, ranging from 3.6 to 28.5 more days (depending on the number of ECT treatments), with corresponding admission costs ranging from $5767 to $52,717 greater than those who did not receive ECT. Although these differences persisted into the post discharge period, they were somewhat attenuated as those with the longest index lengths of stay had fewer post-discharge inpatient days and correspondingly lower costs than those who received fewer ECT treatments during the index stay. Nevertheless, total costs across all three periods remained considerably higher. Similar to Olfson’s study (Olfson et al., 1998), we found that patients who received any ECT during an inpatient admission had higher hospital costs and longer length of hospital stay than patients not receiving ECT. However, our study adds to the body of ECT literature by examining the incremental effect of the number of ECT treatments on hospital stay and costs which our study reveals to be quite substantial. In addition, our results confirm those found in previous studies (Patel et al., 2019) that initiating ECT treatments earlier reduces costs and length of hospital stay compared to initiating treatments later in the admission.
These results were quite different from those presented in a recent modeling study of the cost-effectiveness of ECT (Ross et al., 2018) which seemed not to take into account costs incurred when ECT is initiated during an inpatient stay, an occurrence that is quite common (Rhee et al., 2020). Consideration of these costs, as examined here, might have shifted the incremental cost-efectiveness ratio in a less favorable direction. Our results also differed from those presented in a study of the impact of ECT on readmission that used an instrumental variables approach and found no differences in length of stay between sites that used varying amounts of ECT (Slade et al., 2017). However, this study was focused on readmission effects, attempting to hold inpatient utilization constant and thus, was not designed to examine natural differences in length of stay and costs between inpatients who do and do not initiate ECT during a hospitalization. An implication of this study for policy and practice is that from a cost or cost-effectiveness perspective, more efforts should be made to provide ECT on an outpatient basis when possible. ECT treatment is typically initiated during inpatient psychiatric stays with patients who require 24-h observation in a safe and secure setting. However, in some instances it may be possible to initiate or continue ECT treatment for individuals with acute illness on an outpatient basis, a clinical issue that the results of this study suggest deserves careful study.
I approached this study with anticipatory boredom and loathing about the results. I was delighted to be wrong; this is such a well-written and presented paper, that it is a pleasure to read! And the conclusions, when taken in context, are just the facts, and do not prejudice against ECT in any way. Again, we are reminded that ECT use remains rare overall: only 2% of this mood disorders inpatient cohort received ECT. The costs of ECT are what they are, but in absolute terms they are miniscule when compared to surgery or cancer treatments.
The message here is clear: for cost savings, whenever appropriate, ECT should be initiated as early as possible in an inpatient stay and, when feasible and safe, done (either from the outset, or transitioned) in an outpatient setting.
For anyone interested in ECT-related healthcare economics, this article is a must-read, ~20 minutes.
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