A clinical pathway improves use of outside services.
Avoidant restrictive food intake disorder (ARFID) was first defined by the DSM-5 in 2013. One area that is often overlooked is inpatient management of children and teens with ARFID who are admitted for medical stabilization. Now a team from Boston Children’s Hospital and Harvard Medical School has developed a multidisciplinary standardized inpatient clinical pathway (ICP) to help guide use of psychiatric, psychologic and social work consulting for these children and teens (J Eat Disord. 2024. 12:66).
Dr. Elana M. Bern and colleagues developed the ICP after examining various approaches to care by the admitting services at a stand-alone hospital. Dr. Bern and her colleagues included data from 110 children and teens with ARFID in their four-year study, and examined admissions from the gastrointestinal, pediatrics, and psychology departments. The study began two years before the ICP was in place, and followed 57 teens and children; 53 teens and children were admitted in the post-ICP period.
In the first part of the study, the authors retrospectively extracted electronic medical record (EMR) data for patients with ARFID admitted to the hospital for medical stabilization from January 1, 2015 to December 31, 2017 (before the pathway was developed). The team examined sociodemographic variables, including gender, age, race/ethnicity, insurance payor, approximation of the distance traveled from home to the hospital), co-morbid medical and psychiatric diagnoses based on billed ICD-10diagnosis codes, anthropometrics (weight and height, for example) upon admission, length of stay, all-cause medical readmissions within 30 days (excluding psychiatric causes), and information about the admitting and discharging inpatient team.
Additional chart review was performed to record use of enteral tube feeding (nasogastric tube, nasojejunal tube, or gastrostomy tube) and results of endoscopy, requests for consultation by psychiatry/psychology consultation services (PCS), nutrition or social work, and use of the existing restrictive eating disorder (RED) protocol, which had been developed primarily for patients with anorexia nervosa.
Developing the ICP
The authors then created a standardized ICP using Quality Improvement (QI) methods. The next step was examining changes in care among inpatients with ARFID in the two-year period after the new pathway had been in place. The authors studied use of the RED protocol, subspecialty consultations, use of enteral tube feeding, and diagnostic endoscopic evaluation, as well as clinical outcomes (change in BMI z-scores during hospitalization), length of hospital stay, and 30-day readmissions. Their post-ICP study was delayed due to the COVID-19 pandemic in March 2020.
Results
Patients admitted from the adolescent medicine service were older and were more likely to have private insurance than those admitted from the gastrointestinal or general pediatric services. There were no significant differences in weight, comorbid medical or psychiatric disorders by admitting services in the pre-ICP cohort. More than half of patients were underweight, and comorbid depression (18%) and anxiety were common (26% of patients had generalized anxiety and 70% had other anxiety disorders).
Adolescent patients were more likely to have been treated with the RED protocol and less likely to have social work consultations than were patients admitted from the general pediatrics division or the gastrointestinal department. No differences were found in length of stay, readmission rates, or changes in BMI. The authors did find variations in care from the admitting services for patients with ARFID prior to the development of the standardized ICP. For example, prior to the new protocol, the adolescent medicine service commonly used a feeding protocol designed for patients with AN.
When the ICP was in place, use of consultation services increased—this was especially true for social work, nutrition, and psychiatry. In contrast, use of the RED protocol was nearly eliminated. Readmission rates remained low and, according to the authors, over time there had been a greater understanding of restrictive eating disorders and ARFID among children and adolescents.
Limitations
There were some limitations to the study, including the relatively small cohort of patients examined. This probably resulted in low statistical power to detect a difference by the individual admitting services. In addition, the authors noted that the study had examined early changes after the pathway was established, although this involved a relatively small number of patients.
Additional research on the longer-term influence of the ICP will help researchers better understand the longitudinal impact on health outcomes, cost-effectiveness, provider adherence to the ICP components, and improve their knowledge of both the health care providers and those receiving care.
