Dr Rebecca Jacob Consultant Psychiatrist and CLAHRC Fellow CPFT Dr Cecily Morrison,

1. Identifying Medically Unexplained Symptoms among Frequent Attenders to the Emergency Department: Research to inform Service Design Dr Rebecca Jacob Consultant Psychiatrist and CLAHRC Fellow CPFT Dr Cecily Morrison, Research Associate, EDC, Engineering Dept, University of Cambridge

2. Background • MUS are defined as physical symptoms which are not or insufficiently explained by somatic disease. • Symptoms include chest, abdominal, or back pain, tiredness, dizziness, headache, ankle swelling, shortness of breath, insomnia and numbness. Fink P, Toft T et al 2007, Nimnuan C, Hotopf M et al 2000

3. Functional Somatic Syndromes according to medical specialty Henningsen P, Fink P et al 2011

4. Relationship between MUS and frequent attendance at ED • Patients with MUS frequently attend primary and secondary care health services, including ED. • Hotopf et al (2002) in cohort of 400 FA’s to the ED:17% had at least two medically unexplained consultation episodes, higher referrals to secondary care and > invasive tests. • Older age patients also frequent attenders but research shows attendance often appropriate with Medically ‘Explained’ Symptoms. Aminzadeh F, Dalziel WB. 2002

5. ‘Frequent Attender’ • Overt meaning numeric or statistical, and majority of studies suggest attendance at ED’s >4 times/year. • More covert/pejorative meaning, refers to patients perceived by health professionals as taking up disproportionate amount of consultation time and/or burden on resources. Hodgson P, Smith P et al, 2005

6. CLAHRC Fellowship study of Frequent Attenders FA to the ED: • proportionally on the increase. • can be subdivided into Extreme FA (EFA) (>20) and Moderate FA (MFA) (<20/year). • EFA’s had less urgent conditions, more mental health/alcohol problems, were less likely to be admitted (and are being targeted by ‘FACE’.) Wong M, Morrison C et al, 2011

7. Moderate Frequent Attenders • Approximately 97% of FA population locally, had more cardiovascular problems, more often required admission. • Abdominal complaints predominant presentation in those re-attending the ED within 7 days.

8. Questions raised by this project • Do MFA’s include those with MUS and are their service needs being met? • Would designing a service improve the health outcomes and reduce health costs of this group? • Will proposed RAID model encompass this patient group?

9. Characterisation of FA’s and Service EvaluationProject

10. Research Questions • Amongst a sub-group of patients who frequently attend the ED (>4/year), how many suffer from MUS/mental disorders/both? • What is their current service provision? • What are low cost methods of identifying this patient group amongst FA’s to the emergency department?

11. Study Design • Setting: The emergency department at Addenbrooke’s hospital, CUHFT. • Service design under the auspices of NIHR CLAHRC, (EDC) which has enabled a working relationship between CPFT and the University of Cambridge

12. Methods: Stage 1Characterisation of FA’s • Case note review of 100 consecutive patients attending the ED >4 times in a period of 12 months. • Demographics, No of ED attendances, clinical impression of MUS, invasive tests, OP visits, mental health diagnoses, service pathways and mental health input. • Analysis considered proportion of FA’s with MUS/mental health, specialist mental health input, factors related to clinical impression of MUS, current service provision for MUS

13. Method: Stage 2 Designing Service for MUS • ED clinicians requested to give all FA’s attending the ED >4 times a year, two rating scales: • Patient Health Questionnaire (PHQ15) • Hospital Anxiety and Depression Scale (HADS) • For each FA filling questionnaire case note review to be conducted.

14. Stage 2: Planned Analysis • The proportion of FA’s with mental health needs/MUS based on case note review • Relationship between FA’s with clinical recognition of MUS and high PHQ scores • Relationships between high HADS score and clinical recognition of depression and anxiety. • Results will be used to inform service design

15. Results: 100 FA’s attending ED Age range of sample 17-95 years • 65% had mental health symptoms/disorders (mentioned in notes) • 71% of this group (46/65) had both MUS and mental health problems. • 15% of total sample had significant alcohol problems.

16. Proportion of FA’s with MUS

17. 45% had a clinical diagnosis of MUS • Clinical dx by any specialist reporting Non-epileptic seizures, Chronic Fatigue, Fibromyalgia, IBS, MUS in medical notes • Common symptoms related to ED presentation: abdominal pain, chest pain, SOB, back pain, dizziness.

18. MUS and Age

19. Mean Age of patients with MUS- 36.8/ Median 32 years. • 87% (39/45) with MUS under 65 years • MUS associated significantly younger age (p<0.001) but not with gender (>0.05) • Older age more likely to have positive test results or medically ‘explained’ symptoms (p=0.004)

20. MUS and Frequency of ED Attendance

21. Number of ED attendances not significantly different for those with/out MUS (p>0.05) • MUS were ‘MFAs’ as hypothesised, 36/45 were Moderate Frequent Attenders ( p<0.001)

22. Service provision • 41/45 patients with MUS (91%) had invasive tests/procedures requested by multiple specialities. • All patients with MUS were seeing >1 OP speciality, average was 5 specialist clinics. • 32/45 had MUS and MH symptoms (71%) • 15/32 of those with both MUS/MH had specialist mental health input (47%). • Only 4% (2/45) had specific psychiatric input for MUS

23. Results: Service DesignOnly 4 forms returned • ED busy environment, staff work shifts • Administrative staff available; clinicians rarely, • Staff ‘ drowning in paperwork’ • Changes in ED’s physical structure during project • ED one dept. however has multiple domains • Staff spoke of frustration with FAs, keen to have service BUT research/service evaluation not a priority when clinical commitments are high.

24. Case Vignette 1 • 35 year old man, married with 2 children, 9 ED attendances/year for back pain, SOB, chest pain • No psychiatric history, ‘stress’ reported. • Referred by ED /GP to Cardiology, Rheumatology, Medicine, Trauma Respiratory, Infectious Disease OPD’s • Multiple tests: X-rays/ECHO/MRI unremarkable • Dx: MUS suspected by Medicine, I D team report ‘post viral fatigue’, Cardiology ‘non-cardiac chest pain’.

25. Case Vignette 2 • 91 yr. old widowed lady, 7 ED attendance /year for recurrent falls, UTI, often admitted. • GP treating for anxiety with SSRI’s • Referred by ED/GP to Geriatric Medicine, Gynecology, Dermatology, Rheumatology, General medicine • Multiple tests: biopsy/MRI/ECHO/Chest X-ray • Diagnoses: Squamous cell Carcinoma hand, polymyalgia, cerebrovascular disease, Giant cell arteritis, Ischemic Heart Disease, Hysterectomy (fibroids)

26. Case Vignette 3 • 24 year old female, 13 ED attendances in the last year. ED and GP referred to Surgery, Ophthalmology, Hepatology, Gastroenterology • Dx with Cholecystitis: cholecystectomy • Invasive tests post surgery: US/OGD/Laparoscopy/Colonoscopy • Postoperative ED visits with multiple medically unexplained symptoms, chest pain, abdominal pain, double vision, headache • Gastroenterologist: Irritable Bowel Syndrome?

27. Clinical Implications • MUS is a common presentation amongst FA’s to the ED • Multiple specialist clinic visits and multiple invasive tests in those with MUS, clinical and cost implications. • Older age FA’s more often showed Medically Explained symptoms and appropriate use of ED, replicating other studies.

28. Design Implications • ED is a useful hub for identifying patients with MUS • ED Clinicians alone are unlikely to be able to identify and signpost this patient group • However involvement of primary/secondary care at the ED interface may be an ideal focus for service design. • Designing service with an age focus may narrow down cohort

29. Future studies • Designing, delivering and evaluating the planned pathway of care for patients with MUSwithin the ED. • Health economic study to estimate the cost savings of creating a service for patients with MUS, evaluating whether or not there is a tangible reduction in ED attendance.

30. Challenges encountered • Study plans had to be changed-and more than once! • Whilst ED staff were enthusiastic about developing a service, they were not keen/able to be part of the service evaluation project i.e. distributing PHQ/HADS questionnaires to all FA’s • Everything takes significantly more time than projected on the GANTT chart

31. What I Learnt • MUS: a heterogeneous group (with/out MH symptoms) posing a clinical and financial challenge for health services locally. • The importance of robust data when planning service development • Value of CLAHRC’s cross cutting themes (Psychiatry/EDC); provides different, objective perspectives.

32. Acknowledgements • Dr. Cecily Morrison, EDC, Dept of Engineering, University of Cambridge • Dr. Peter Watson, Senior Statistician, MRC Cognition and Brain Sciences Unit, Cambridge • Dr. Catherine Hayhurst, Consultant ED Physician, ED Dept, Addenbrooke’s Hospital • Dr. Cathy Walsh, Consultant Psychiatrist, Dept of Liaison Psychiatry • Professor Peter Jones, Dr.Belinda Lennox, Dr. Christine Hill: CLAHRC

33. References 1. Fink P, Toft T et al .Symptoms and syndromes of bodily distress: An exploratory study of 978 internal medical, neurological, and primary care patients. Psychosomatic medicine 2007; 69:30-9 2. Nimnuan C, Hotopf M et al. Medically unexplained symptoms: how often and why are they missed? QJM Monthly Journal of the Associations of Physicians 2000;93 3. AminzadehF, Dalziel WB. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann EmergMed. 2002;39:238-247. 6. Hodgson P, Smith P et al Stories from frequent attenders: Qualitative Study in Primary Care. Ann Fam Medicine 2005: 318-23 7. Wong W, Morrison C. A service design approach to frequent attendance in the ED. CLAHRC Fellowship Report, 2011.