Assessment of Emergency Department and Inpatient Use and Costs in Adult and Pediatric Functional Neurological Disorders

Stephen, Christopher D.; Fung, Vicki; Lungu, Codrin; Espay, Alberto J.

doi:10.1001/jamaneurol.2020.3753

Cited by 114 publications

(118 citation statements)

References 22 publications

(40 reference statements)

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“…Indicative costs in our hospital are: for a 2‐night hospital admission to a neurology ward €3076, for routine blood tests €14, for a CT head scan €419 and for a basic MRI of head €982 (total €4491). These significant costs are in keeping with recent data suggesting FND care in the ED and inpatient units costs US$1.2 billion annually in the United States [21].…”

Section: Discussionsupporting

confidence: 87%

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Functional neurological disorders presenting as emergencies to secondary care

Beharry

Palmer

et al. 2021

Euro J of Neurology

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Background Functional neurological disorders (FND) represent a significant proportion of presentations to outpatient adult neurology services. There is little information relating to patients presenting to acute inpatient care. Methods We identified patients presenting as acute admissions with FND to Christchurch Hospital, Christchurch, New Zealand, from 2016 to 2018. We analyzed relevant demographic and clinical data from electronic records and measured incidence of presentation to secondary care and healthcare utilization. Results One hundred sixty‐two patients presented on 173 occasions with FND, representing 9% of all admissions to the neurology service during the 3‐year study period. The mean age was 40 (SD 17) years, 111 (69%) patients were female and the median length of stay was 3 (IQR 2–4) days. A total of 92 computed tomography brain scans, 77 magnetic resonance imaging brain scans and 42 electroencephalograms were carried out. On 22 (13%) occasions, patients were referred for outpatient psychological therapy. In the 3 years prior to each patient's last presentation in the study period, these 162 patients had a total of 671 presentations to the emergency department. Healthcare demand did not decrease after the index admission. The rate of acute inpatient admission for FND was 10 per 100,000 per year for the total Christchurch Hospital catchment, 6/100,000/year in rural areas, and 11/100,000/year in urban areas. Conclusion FND represented almost 1 in 10 acute neurology admissions with significant inpatient healthcare resource utilization.

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Section: Discussionsupporting

confidence: 87%

“…Access to outpatient physiotherapy and occupational therapy is also limited by resource constraints. Low rates of referral for both physical and psychological therapy has been found in other studies [21].…”

Section: Discussionmentioning

confidence: 76%

Functional neurological disorders presenting as emergencies to secondary care

Beharry

Palmer

et al. 2021

Euro J of Neurology

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“…Functional neurological disorder (FND) is a common neuropsychiatric condition resulting in substantial disability and healthcare costs (Espay, Aybek, et al, 2018; Gelauff, Carson, Ludwig, Tijssen, & Stone, 2019; Stephen, Fung, Lungu, & Espay, 2020). After more than 100 years in the medical literature, the pathophysiology of FND remains incompletely understood (Baizabal‐Carvallo, Hallett, & Jankovic, 2019; Bègue, Adams, Stone, & Perez, 2019).…”

Section: Introductionmentioning

confidence: 99%

Individual differences in interoceptive accuracy and prediction error in motor functional neurological disorders: ADTIstudy

Sojka

Diez

Bareš

et al. 2020

Human Brain Mapping

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In motor functional neurological disorders (mFND), relationships between interoception (a construct of high theoretical relevance to its pathophysiology) and neuroanatomy have not been previously investigated. This study characterized white matter in mFND patients compared to healthy controls (HCs), and investigated associations between fiber bundle integrity and cardiac interoception. Voxel‐based analysis and tractography quantified fractional anisotropy (FA) in 38 mFND patients compared to 38 HCs. Secondary analyses compared functional seizures (FND‐seiz; n = 21) or functional movement disorders (n = 17) to HCs. Network lesion mapping identified gray matter origins of implicated fiber bundles. Within‐group mFND analyses investigated relationships between FA, heartbeat tracking accuracy and interoceptive trait prediction error (discrepancies between interoceptive accuracy and self‐reported bodily awareness). Results were corrected for multiple comparisons, and all findings were adjusted for depression and trait anxiety. mFND and HCs did not show any between‐group interoceptive accuracy or FA differences. However, the FND‐seiz subgroup compared to HCs showed decreased integrity in right‐lateralized tracts: extreme capsule/inferior fronto‐occipital fasciculus, arcuate fasciculus, inferior longitudinal fasciculus, and thalamic/striatum to occipital cortex projections. These alterations originated predominantly from the right temporoparietal junction and inferior temporal gyrus. In mFND patients, individual differences in interoceptive accuracy and interoceptive trait prediction error correlated with fiber bundle integrity originating from the insula, temporoparietal junction, putamen and thalamus among other regions. In this first study investigating brain‐interoception relationships in mFND, individual differences in interoceptive accuracy and trait prediction error mapped onto multimodal integration‐related fiber bundles. Right‐lateralized limbic and associative tract disruptions distinguished FND‐seiz from HCs.

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“…Additionally, FD had roughly three times as many ED presentations and six times as many nonelective hospitalizations related to their symptoms, in the 6 months before or after their first clinic visit. Taken together, the greater number of medical and neurological opinions, investigations, greater ED visits/hospitalizations, and medical procedures demonstrate greater health‐care utilization and economic burden 21,52 . Therefore, early diagnosis may save costs, underscoring the potential benefit of our prediction algorithm.…”

Section: Discussionmentioning

confidence: 92%

Functional dystonia: A case‐control study and risk prediction algorithm

Stephen

Perez

Chibnik

et al. 2021

Ann Clin Transl Neurol

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Objective Functional dystonia (FD) is a disabling and diagnostically challenging functional movement disorder (FMD). We sought to identify historical predictors of FD vs. other primary dystonias (ODs) and develop a practical prediction algorithm to guide neurologists. Methods 1475 consecutive new patient medical records were reviewed at an adult/pediatric tertiary‐referral dystonia clinic from 2005 to 2017. Ninety‐nine met criteria for clinically established FD (85 adults and 14 pediatric), paired with 99 age/dystonia distribution‐matched OD. Univariate and multivariate regression analyses were performed to identify predictors of FD and disability. We formed a prediction algorithm, assessed using the area under the receiver operating curve (AUC). Results Multivariate logistic regression analysis investigating independent predictors of FD (P < 0.001) followed by development of a prediction algorithm showed that the most robust predictors included abrupt onset, spontaneous resolution/recurrence, pain, cognitive complaints, being on or pursuing disability, lifetime mood/anxiety disorder, comorbid functional somatic disorders, and having ≥3 medication allergies. The prediction algorithm had utility for both adult and pediatric FD, with excellent sensitivity/specificity (89%/92%) and an area under the curve (AUC) 0.95 (0.92‐0.98). Greater disability (modified Rankin Scale) independently correlated with a number of functional examination features, unemployment/not attending school, number of medication allergies, and younger age of presentation. FD patients were high health‐care utilizers and were more frequently prescribed opiates/opioids and benzodiazepines (P < 0.003). Interpretation This case‐control study provides an algorithm to guide clinicians in gauging their index of suspicion for a FD, with diagnostic confirmation subsequently informed by neurological examination. While this algorithm requires prospective validation, health‐care utilization data underscore the importance and need for more research in FD.

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Assessment of Emergency Department and Inpatient Use and Costs in Adult and Pediatric Functional Neurological Disorders

Cited by 114 publications

References 22 publications

Functional neurological disorders presenting as emergencies to secondary care

Functional neurological disorders presenting as emergencies to secondary care

Individual differences in interoceptive accuracy and prediction error in motor functional neurological disorders: ADTIstudy

Functional dystonia: A case‐control study and risk prediction algorithm

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