Estimation of Costs-Savings and Improved Patient Outcomes of Implementing a Consultation-Liaison Service at Health Sciences North

Objective: The study was conducted to assess the implementation of a psychiatric consultation-liaison service (C-L) from the perspective of cost-savings, staff satisfaction, patient satisfaction and to assess the general features of patients referred to the C-L service. Methodology: Cost-savings were evaluated using a large cohort of referrals to the hospital were identified using data derived from the Institute of Clinical Evaluative Sciences (N = 2246); these data were divided into pre and post periods with respect to imitation of the C-L service. To evaluate staff satisfaction, 170 nurses and physicians completed an online survey. Patient satisfaction was assessed through a survey assessing various aspects of their experiences with the C-L service that was completed by each patient (N = 40). Finally referrals to the C-L service (N = 445) were analyzed to discern indicators of the C-L service’s efficacy (i.e. reasons for referral, time to accommodate referral). Results: The data indicated: 1) a reduction in the number of re-admissions and length of stay after the initiation of the C-L service translating into significant cost-savings for the hospital, 2) that increased staff satisfaction was associated with providing confidence, support, and improved communication, and 3) that the C-L service accommodated approximately 90% of patients within 1 day. Conclusion: The results of this study support stakeholders’ decisions to implement C-L services and also indicate areas of improvement that may improve the quality of C-L services within other institutions.


Introduction
Consultant-liaison (C-L) psychiatry refers to services provided to medically-ill patients within a general hospital setting. As summarized by Hamburg [1], these services may have been readily apparent historically dating back to ancient Chinese, Hindu and Egyptian cultures who considered a fundamental "dis-harmonization" of the body and the mind that was curable by rituals and physical operations. Within a modern day setting, these services have demonstrated efficacy with regards to many descriptors that define cost-savings and overall patient health improvement. In general the tasks of the C-L psychiatrist involve rapid consultation with a patient when prompted by another physician and includes assessment and formulation of general recommendations for psychotropic medications and psychological treatment for follow-up.
According to Gomez [2] approximately 30% -65% of medically-ill patients suffer from a co-morbid mental health problem that adversely affects quality of care, adherence to treatment and cost of services [3]. Studies suggest that up to 34% of patients suffering from irritable bowel syndrome also have at least one comorbid psychiatric diagnosis [4]. Patients diagnosed with HIV have co-morbid psychiatric diagnosis in more than 48% of admitted cases [5]. Patients suffering from addictions, in up to 80% of the cases, also suffer with at least one (and often more) psychiatric co-morbidities [6]. It is estimated that 8% of the general population suffer from neurological pain and 29% -47% of them have at least one psychiatric co-morbid condition [7]. In patients suffering from COPD, having co-morbid psychiatric disorders results in significantly poorer prognosis and is seen in a large number of COPD patients resulting from the chronic and debilitating nature of the disease [8]. The incidence of psychiatric co-morbidity and cardiac conditions has been increasingly studied as the prevalence continues to be highlighted. In patients suffering from cardiac conditions, depression is common and is associated with the worst outcomes [9]. It is estimated that there has been an increase from 12.9% to 19% of patients suffering cardiomyopathies with psychiatric co-morbidities over the 10 year period from 2003-2013 [10]. Therefore, given the extensive list of the relationship between physical and psychological co-morbidities, many hospitals have initiated consultant-liaison psychiatric services that have demonstrated reduced length of stay within the hospital and lower re-admission rates which directly influence the costs associated with hospital operations. As summarized in a systematic review by Wood and Wand [11], there is a large body of empirical evidence suggesting the efficacy of implementation of C-L services within general medicine.
Strategies aimed at optimizing patient outcome while reducing cost and wait times are an ongoing priority at Health Sciences North and throughout the Province of Ontario. The C-L service at this hospital was initiated in March 2014 and is directed at supporting patients admitted for a primary medical concern that have co-morbid psychiatric illness, whether previously diagnosed or not.
The service provides primary caregivers the support and psychiatric services necessary to optimize the patients' mental health while they are in hospital receiv-E. Okoronkwo Open Journal of Psychiatry ing treatment for their primary health care issue. While the service is currently in its infancy, its growth will include nursing and allied health care support, which will further improve patient care. It is expected that long term costs will also be reduced, since providing this service will: alleviate wait times for the patient; reduce or prevent internal transfers to psychiatric wards; and provide collaborative support for the primary care physician with respect to medication interaction, therapy options and outpatient support. Further, studies find that patients are more likely to continue to seek care and respond to recovery if the therapy is initiated and organized prior to discharge from hospital [12].
Here we present a detailed examination of the clinical and financial outcomes of implementing a C-L service during the first three years of operation. In the series of studies that follow, we aimed to characterize 1) staff and patient satisfaction with regards to their perceptions of the C-L service, 2) demographics and descriptions of patients that have utilized the service, and 3) overall efficacy of the service.

Staff and Patient Satisfaction Questionnaire
We developed a questionnaire to assess the staff satisfaction with the C-L service and created two versions which represented the two general practices: nursing and physician. These items were uploaded to Survey Monkey and a link containing the questionnaire was e-mailed to the nurses and physicians separately.
Client satisfaction was similarly assessed using a questionnaire which consisted of items which captured overall patient experiences, their willingness to utilize the C-L service in the future, as well as various aspects of their ongoing treatment after consultation with the C-L service. The responses to both staff and patient questionnaires were imported into Excel where frequencies were tabulated for each of the responses.

Clinical Outcomes of the Consult Liaison Service Participants
Clinical outcomes of the consultation psychiatric service were attempted by (N =445) were available for the analysis. For each patient seen by the consultation liaison service, two broad streams of information were obtained from 1) the referring physician who disclosed demographic information, the reason for referral, and observed behaviours, and 2) the consultation liaison psychiatrist who collected information regarding when the referral was received/reviewed, diagnostic impressions, medication review, treatment, recommended interventions, patient care management, and follow up plan at discharge. The data was then consolidated at the Psychiatric Outpatient Clinic and entered into an Excel spreadsheet, coded, and entered into SPSS software for descriptive statistical analysis.

Participants
Participants were individuals between the ages of 18 to 59 years of age, admitted to floors of HSN other than psychiatry for a primary condition other than psychiatry or psychological but were discharged within the three years prior to and following the inception of the C-L service within the study period of April 1, 2011 to March 31 2016. Consequently, participants were categorized into two groups: 1) before C-L service initiation, and 2) after C-L service initiation. All data was extracted and summarized by the Institute for Clinical Evaluative Sciences (ICES). Participants were excluded if they were admitted to HSN floors with a primary psychiatric condition or possessed invalid health card numbers.

Data Extraction
Based on the inclusion and exclusion criteria, the last discharge date of the first episode of care was kept for each person. Using the Registered Persons Database (RPDB) data, baseline characteristics (e.g., age, sex, income quintile, etc.) of the cohort were determined. Using the Discharge Abstract Database (DAD), hospitalization data such as average length of stay and readmissions were pulled for the cohort. To determine Emergency Department visits, the National Ambulatory Care Reporting System (NACRS) data was utilized. When extracting data from NACRS, comorbid psychiatric or psychological illness was defined as having a psychiatric or psychological illness in "other" dx10codes (2-10) whereas primary psychiatric or psychological medical conerns were defined as having psychiatric or psychological illness as the "main" dx10code (1

Data Analysis
All data was pooled and separated into the two groups representing the pre and post-periods of the initiation of the CL service at HSN. Data was then summarized using descriptive statistics (frequency, mean, standard deviation) for the following measures: 1) hospital length of stay, hospital readmissions for both the total period as well as 6 months following the last discharge, patient transfers, emergency department visits, number of outpatient visits with general practitioners/family physicians as well as psychiatrists. These data, particularly the length of stay, formed the basis for calculating an estimated cost-savings of implementing the C-L service.
All ethical clearance for each study was approved by the Health Sciences North Research Ethics Board.

Staff/Physician Satisfaction
There were a total of 170 respondents to the satisfaction questionnaire which included 125 registered and practical nurses as well as 45 physicians. Preliminary one-way analyses of variance on individual items assessing the quality and effectiveness of the CL service indicated that there were no mean differences in how nurses and physicians responded to the items (p > 0.05). Therefore all data was pooled into a single database. A summary of responses to the set of core items assessing the quality and effectiveness of the survey as rated by both the physicians and nursing staff is presented in Table 1.
An exploratory stepwise multiple regression analysis was performed to predict overall satisfaction of the CL service from the discrete survey items assessing various indices of CL service performance as viewed by the physician and nursing staff. Consequently all data was translated along a ratio scale by dividing the responses to the items by the total number of options for each item minus 1; for example the response "Quite dissatisfied" on item 15 would be 0 and very satisfied would be 3/3, or 1. The analysis demonstrated a significant relationship (Multiple R = 0.904, Adjusted R 2 = 0.808) between overall satisfaction which could be predicted by three general constructs listed in decreasing importance as inferred by the beta standardized coefficient: 1) the ability for the CL service to help physicians and nurses treat their patients more effectively, 2) the ability for the CL service to endow confidence with addressing mental health, and 3) the verbal quality of the CL service. The B and standardized beta coefficients are listed in Table 2. A total of 40 patients completed the satisfaction questionnaire at the end of their consultation with the C-L service. A summary of their responses of selected items within the questionnaire are shown in Table 3. According to the data, 67.5% reported that they would take advantage of the C-L service if they were admitted to the hospital once more. In addition, an overall positive rating was received by the C-L service where 65% of patients reported that the care they received was very good and 60% indicated that their recovery was improved through participation in the C-L service.

Time to CL Service and Total Number of Visits Approximately 71 percent of all cases referred to the Psychiatric Consult Liaison
Service were accommodated on the same day as the date of referral. The data indicated 94% of the cases were accommodated within one day. Figure 1(a) displays a histogram of the available data. The majority of patients had one visit (~83%) with a psychiatrist during their participation in the Consultation Liaison Service (Figure 1(b)).

Affected Organ Systems, Diagnoses, and Outcome at Discharge
Descriptive statistics were computed for data consisting of the organ system that was affected by the patient; this data was available for a smaller sample (N = 53).

Baseline Descriptives
During the study period (April 1, 2011 to March 31, 2016) a total of 2246 referrals were admitted to floors of Health Sciences North (HSN) for reasons other than psychiatric or psychological; there were 1267 and 979 referrals before and after the initiation of the C-L service respectively. The average age of individuals identified in the cohort were similar pre (Mean = 42.36, SD = 12.35) and post (Mean = 41.03, SD-12.54) initialization of the C-L service; male (Pre = 50.2%, Post = 49.8%) and female (Pre = 50.46%, Post = 49.54%) proportions were also conserved between the two periods.

Readmission Rates and Length of Stay
The total numbers of hospital re-admissions both before and after the initiation of the CL service were 412 and 231, respectively. When the total sample sizes for the two groups was considered, the percentage of re-admissions to hospitals for both groups were 33% and 24% for the pre and post periods. This data indicated that there was about a 10% decrease in the number of hospitalizations following the introduction of the CL Psychiatric Service at HSN (Figure 3). The average length of stay before and after the initiation of the C-L service was 9.24 days (SD = 35.10) and 7.25 days (SD = 16.88) days respectively (Figure 3).

Discussion
In this paper, a detailed examination of initiating a consultant-liaison psychiatric E. Okoronkwo Open Journal of Psychiatry dits [13] [14]. Survey data collected from staff and physicians indicated that satisfaction was largely a function of 1) helping staff treat their patients more effectively, 2) improving the confidence in staff for addressing mental health issues, and 3) increased verbal communication between the C-L psychiatrist and the staff and physicians of other departments; the linear combination of these three factors accounted for about 81% of the variance in satisfaction. These results suggest that the C-L service may extend its benefits outside of the putative doctor-to-patient care and may have secondary benefits that serve to support physicians and staff who may have limited training in treating individuals with co-morbid psychiatric conditions. An investigation of the patient satisfaction was assessed using a questionnaire which queried various aspects of their experiences with the C-L service. Overall, favourable reviews were reported with respect to the patients' willingness to consult with the C-L service in the future, their positive overall rating of the service, and their overall recovery. Interestingly, a larger proportion of the patients indicated that their own values, preferences and individual needs were respected (80% of respondents) during their consult and 95% of respondents indicated that they felt that they were treated with respect by the C-L staff. Open Journal of Psychiatry It is well-known that depression is a significant psychiatric co-morbidity amongst populations with diverse medical illnesses and has been observed in patients with primary medical diagnosis of type I (12%) and type II (17.6%) diabetes mellitus, chronic obstructive pulmonary disease (42% -57%), myocardial infarction (19.8%), closed head injury (42%) [15] [16] [17] [18] [19]. While primary psychiatric diagnoses were not considered in this manuscript, the data indicated that suicide risk assessment accounted for about 18% of the reasons for referral to the C-L service which matches the approximate figure published by Huyse et al. [20] who reported that deliberate self-harm accounted for about 17% of the referrals which was representative of a European population (N = 14,717) derived from 11 countries treated by 56 participating C-L services.
We evaluated the efficacy of the service using a cohort of patients pre/post the initiation of the C-L service. In this analysis the main objective was to evaluate the numbers of individuals who are re-admitted for psychiatric reasons after being discharged from the hospital with a medical diagnosis other than psychiatric. The analysis indicated that the C-L service was associated with about a 10% decrease in re-admissions when accommodating for the sample sizes of both pre and post cohorts. According to the data published by the Canadian Institute for Health Information [21], the average year length of stay for inpatient hospitalizations in Ontario between 2010 to 2017 was 6.64 days (SD = 0.11). In a recent report [22], they estimated mean cost of a standard hospital stay ($/weighted case) using 4 methods that accommodate 1) simple summation of inpatient-related expenses, 2) pro rata per diem allocation, 3) adjustment based upon differences in databases which produce the estimates, and 4) adjustment of patient stays greater than 365 days. The average cost across all four methods was $6000.80 (SD = 381.86) for fiscal years 2009-2014. Using this data an estimate of the cost of inpatient hospitalization per day was calculated by dividing the average total cost per stay by the average length of stay and was estimated to be $903.73/day for each inpatient. The cost-savings can then be calculated based upon difference in length of stay pre/post the initiation of the C-L service (9.24 days -7.25 days = 1.99 days). Multiplication of the cost/day per inpatient by 1.99 days results in a savings of approximately $1798 per inpatient. When expressed as cost-savings per 100 patients, the amount would be $179,800.
Examination of the chart data indicated that 90% of consultations performed by the C-L psychiatrist were accommodated within 1 day and meets the guidelines outlined by Archinard et al. [23] and O'Keefe et al. [24]. This figure is important when examined within the context of Sockalingam [25] (Table 1) reported consultation within the same temporal period. This discrepancy could be an artifact of memory. Nursing staff and physicians see between 10 -100 patients per day which may prove difficult to track individual cases for accurate reporting during the survey. Alternatively, it may be a logistics error whereby physicians/nurses are not informed (through electronic transfer of consultation dates) that the psychiatrist has already seen the patient and thus the feedback is not provided for an accurate assessment. In either case, the results of this discrepancy may indicate that greater care be taken to report consultations that have been performed so that physicians/nurses can maintain confidence in referring future patients.

Conclusion
The findings presented in this correlative study support the works of others demonstrating the efficacy and cost-savings of implementing consultation liaison psychiatric services from multiple perspectives. Initiation of a C-L service within a rural hospital in Northern Ontario, Canada was associated with lower readmission rates and a decreased length of stay which was estimated to incur significant cost-savings. Future considerations for evaluating the efficacy of the current program in the future may include punctate examination of these figures in concert with nurse/physician feedback to promote a greater quality of care to patients with primarily medical diagnoses [26]. This study also highlights the No endorsement by CCO is intended or should be inferred.
These datasets were linked using unique encoded identifiers and analyzed at the Institute for Clinical Evaluative Sciences (ICES).

Conflicts of Interest
The author declares no conflicts of interest regarding the publication of this paper.