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Background. Anorexia nervosa (AN) is a common eating disorder with the highest mortality rate of all psychiatric diseases. However, few studies have examined inpatient characteristics and treatment for AN.
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Read More »To our knowledge, this was the first study conducted using a large-scale database to demonstrate sex differences in risk factors in patients with AN. These data showed that the in-hospital mortality rate for this patient group was approximately 3%, and the mortality rate for male patients was more than twice that for female patients. This increase was not explained by differences in patients’ baseline characteristics, clinical expression, or other mental disorders. Only one previous study conducted in a single centre showed that the 3-year mortality rate for male AN patients was higher than for female patients [20]. The authors hypothesised that men received less social support after discharge than women. The current study showed that men’s age at first hospitalization was higher relative to that of women. One possible explanation for this finding could be that delayed intervention or insufficient recognition of the severity by both patients and medical staff contributed to the worsening of outcomes. In the subgroup analysis, we demonstrated that men were less likely to be re-admitted relative to women. This result could be explained by sex differences. Male patients could have received inadequate interventions and been hospitalised only when they were in a more fragile state, relative to female patients, for various reasons. The lack of an association between the frequency of hospitalization and higher mortality rates in the main analysis could also explain this. These findings suggest that early and multiple advanced medical interventions could be favourable. AN is relatively rare and clinically atypical in male patients; therefore, it requires careful treatment. We also demonstrated for the first time that treatment at a university hospital exerted a favourable effect on mortality. The management of AN patients is complicated by not only psychotherapy but also supportive care. For example, titration of drug administration is important, as abnormal distribution volumes could cause pharmacodynamics to differ from those observed in healthy individuals, and refeeding syndrome during enteral nutrition could also be a critical problem [21,22,23]. The newest ESPEN guidelines support multimodal nutrition for patients at high risk of preoperative conditioning [24]. From these perspectives, involving several experts in treatment is reasonable, and the lower OR observed for university hospitals, relative to those observed for other hospitals, could have resulted from the involvement of many experts and departments in patient care, which is emphasised by several guidelines and reports [10,11,12,13,14, 25]. The findings of the current study support the notion that multi-professional interventions contribute to better outcomes. The sensitivity analysis showed several treatment risks. For example, critical hypotension, arrhythmia, and blood transfusions were associated with higher mortality, but major operations and general anaesthesia were not. According to the “obesity paradox,” underweight patients are at increased risk of mortality in general surgical procedures relative to patients of a healthy weight [26, 27]. Improvement of the management of these conditions via short-acting drugs or advanced monitoring devices could contribute to better outcomes. The results indicated that when patients require surgical intervention, practitioners should not hesitate to provide this, as there might not be time to hesitate. The study was subject to several limitations. For example, as the DPC database is based on diagnoses recorded by attending physicians, these diagnoses could have been less valid relative to those in prospective studies. Due to the limitation in that we could not access behavioural criteria (i.e. pursuit of thinness or fear of fat) or associated symptoms, our samples might include individuals with avoidant-restrictive food intake disorder as classified in DSM-V or other low weight conditions.
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Read More »In addition, the DPC database does not include clinical or physiological information such as that regarding hypotension or arrhythmia. Although we substituted the use of medications for this information, we could not adjust for these factors using actual blood pressure values or types of arrhythmia. Moreover, we could not identify the history or duration of AN or the time of onset. Therefore, we could not identify medical or psychiatric treatment before hospitalization. We examined the data for a long period (7 years); however, because AN is a disease that is sometimes treated over the life span [28], this could have been insufficient. Further, because of the database design, our assessment of hospital readmission was limited to individuals admitted to the same hospital. Therefore, we could identify only individuals using the same index if they had been readmitted to the same hospital. If patients were admitted to different hospitals, they were regarded as different patients with different index values. Therefore, we could have duplicated data for some patients, and the actual number of patients could have been lower. The database design was also a study limitation, as when patients received home–based care or were admitted to psychiatric hospitals, their data were not included in the DPC database, and their mortality rate was unknown. As psychiatric hospitals are relatively scarce (approximately one-seventh of traditional hospitals in Japan [29], this factor could have exerted a weak impact on overall mortality.
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