Models of care for eating disorders: findings from a rapid review

Abstract

Background Delayed diagnosis, gaps in services and subsequent delays in specialist care and treatment lead to poorer health outcomes for individuals with eating disorders (EDs) and drive significant government healthcare expenditure. Given the significant disease burden associated with EDs, it is imperative that current implementation research is summarised to identify gaps in care and enable refinement for optimal patient outcomes. This review aimed to provide an updated synthesis on models of care for EDs in developed healthcare systems. Methods This paper was conducted as part of a series of Rapid Reviews (RRs) to be published in a special series in the Journal of Eating Disorders. To provide a current and rigorous review, peer-reviewed articles published in the English language between 2009 and 2021 across three databases (ScienceDirect, PubMed and Ovid/Medline) were searched, with priority given to higher level evidence (e.g., meta-analyses, large population studies, Randomised Control Trials (RCTs)). The current review synthesises data from included studies investigating models of care for people with EDs. Results Sixty-three studies (4.5% of the original RR) were identified, which included several diagnostic populations, the most common being Anorexia Nervosa (AN) (30.51%). Across EDs, specialist care was found to improve patient outcomes, with many patients effectively being treated in outpatient or day programs with multi-disciplinary teams, without the need for lengthy inpatient hospitalisation. Few studies investigated the interaction of different ED services (e.g., inpatient, community services, primary care), however stepped care models emerged as a promising approach to integrate ED services in a targeted and cost-effective way. Issues surrounding low treatment uptake, underdiagnosis, long waiting lists and limited hospital beds were also evident across services. Conclusion Findings suggested further research into alternatives to traditional inpatient care is needed, with partial and shorter ‘hospitalisations’ emerging as promising avenues. Additionally, to tackle ongoing resource issues and ensure timely detection and treatment of EDs, further research into novel alternatives, such as active waiting lists or a greater role for primary care clinicians is needed. Plain English summary This paper is part of a larger Rapid Review series carried out to guide Australia’s National Eating Disorders Research and Translation Strategy 2021–2031. Rapid reviews aim to thoroughly summarise an area of research over a short time period, typically to help with policymaking in this area. This Rapid Review summarises the evidence relating to how we care for people with eating disorders in Western healthcare systems. Topics covered include inpatient/hospital care, residential care, day programs, outpatient/community care, and referral pathways. Findings suggested specialist eating disorder services may enhance detection, referral, and patient care. Stepped care models presented as a cost-effective approach which may help with linkage between different eating disorder services. There was a trend towards shorter hospital stays and approaches which allow for greater connection with the community, such as day programs. Evidence was also found of treatment delays, due to system issues (long waiting lists, lack of accurate assessment and diagnosis) and patient-related barriers (stigma, recognition). Upskilling and involving primary care clinicians in diagnosis and referral as part of a stepped care model may help to address some of these concerns. Further efforts to improve mental health literacy and de-stigmatise help-seeking for eating disorders are needed.

Expectations of a new eating disorder treatment and its delivery: Perspectives of patients and new therapists

“…This led them to feel more confident and better equipped to properly address ED symptoms in their consultations. This is similar to findings from other studies, where training healthcare professionals in EDs and the treatment they provided improved access to care in community settings (Johnson et al, 2022; Pehlivan et al, 2022). Specifically, studies suggest that upskilling primary care clinicians or health professionals in diagnosis and stepped‐care models may help reduce stigmatization, and improve detection rates and treatment access (Pehlivan et al, 2022).…”

Understanding the scope of preventable acute care spending among patients with eating disorders

“…Moreover, care coordination and improved access to primary care and disease prevention, particularly related to diabetes, may help prevent the occurrence of some acute care. For example, other work suggests that primary care clinicians could play a greater role in service delivery as part of a stepped care model (Allen & Dalton, 2011), which has shown to improve patient outcomes, while being cost‐effective (Pehlivan et al, 2022). Although acute care (i.e., acute medical hospitalizations and emergency department visits) made up 15% of total costs among individuals with eating disorders, the largest share of total costs (i.e., 31%) were due to acute psychiatric hospitalizations.…”

“…Moreover, care coordination and improved access to primary care and disease prevention, particularly related to diabetes, may help prevent the occurrence of some acute care. For example, other work suggests that primary care clinicians could play a greater role in service delivery as part of a stepped care model (Allen & Dalton, 2011), which has shown to improve patient outcomes, while being cost-effective (Pehlivan et al, 2022)…”

“…The idea behind these types of strategies/interventions is that the implementation of high‐quality outpatient care may help reduce unnecessary acute care for these patients. For example, research suggests that stepped care models, where primary care clinicians play a greater role in service delivery, may be an option to improve patient outcomes in a cost‐effective manner (Pehlivan et al, 2022). However, it is unclear whether any costs can be reduced, and if so which, especially among patients who require costly care.…”

Non‐suicidal self‐injury among individuals with an eating disorder: A systematic review and prevalence meta‐analysis

“…However, it strengthens the ability of findings to inform clinical practice as it more closely reflects individuals receiving treatment. Given the high prevalence of diagnostic crossover within EDs (i.e., switching from one ED diagnosis to another ED diagnosis; Miskovic‐Wheatley et al, 2023), identifying the longitudinal relation between ED diagnosis and NSSI throughout disease and treatment course is an important future research direction to determine whether NSSI or the ED appears first.…”