LETTERS: NEW OBSERVATIONS
The Impact of Diagnosis on Health Care Utilization in Functional Movement Disorders Kevin Kyle, MD and Allan D. Wu, MD,*
Patients with functional movement disorders (FMD) are common in neurology clinics with prevalence estimates as high as 30%.1 Patients with FMD often undergo an arduous, costly diagnostic odyssey. These patients are often considered as having a poor prognosis despite high health care utilization (HCU), with reports that most
patients with FMD are symptomatically unchanged or worse on follow-up.2 This situation has been described as a crisis.1 It has also been observed that a longer duration of symptoms augurs a worse prognosis. In the realm of FMD this cannot be understated as it is speciﬁcally emphasized that accurate explanation of diagnosis is a key
TABLE 1 Patient characteristics and utilization before/after FMD diagnosis A. All patients with characteristics of patients with FMD
N = 42; F = 31, M = 11
Age, yrs, mean (SD) (range) Mixed phenomenology Tremor Gait Jerking Chorea Oral/facial symptoms Dystonia Other Comorbid psychiatric/psychological Had at least 1 follow-up visit at institution Duration of symptoms, yrs, mean (SD) (range)
51 (21) (14–92) 10 9 4 7 3 2 5 2 37 N = 18; F = 14, M = 4 5.9 (11.9) (0–50)
B. Patients with follow-up ED/inpatient hospitalizations All outpatient visits Outpatient neurology visits Imaging (CT, MRI, PET, US, XR) Laboratory visits (blood draws) Procedure encounters Pt messages/telephone encounters
Before Diagnosis, Mean (SD)
After Diagnosis, Mean (SD)
t Test (P)
1.1 (1.43) 7.9 (8.0) 1.56 (1.64) 4.9 (3.7) 2.1 (2.9) 1.6 (1.9) 10.6 (12.4)
0.6 (1.4) 10 (8.5) 1.89 (1.45) 2.8 (3.6) 1.3 (2.2) 2.8 (6.2) 11.2 (9.7)
0.25 0.48 0.48 0.005 0.29 0.37 0.87
4.8 (3.6) 9.15 (13.9) 1.08 (1.61)
1.8 (2.4) 9 (9.1) 0.15 (0.38)
0.02 0.97 0.046
C. Patients with psychotherapy recommended (N = 13) Imaging (CT, MRI, PET, US, XR) Pt messages/telephone encounters ED/inpatient hospitalizations
F, female; M, male; FMD, functional movement disorder; SD, standard deviation; ED, emergency department; CT, computed tomography; MRI, magnetic resonance imaging; PET, positron emission tomography; US, ultrasound; XR, X-ray; Pt, patient.
Department of Neurology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA *Correspondence to: Allan D. Wu, Department of Neurology, UCLA David Geffen School of Medicine, 710 Westwood Plaza, Los Angeles, CA 90095; E-mail: [email protected]
Keywords: functional movement disorders, health care utilization. Relevant disclosures and conﬂicts of interest are listed at the end of this article. Received 26 June 2020; revised 18 July 2020; accepted 27 July 2020. Published online 00 Month 2020 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/mdc3.13038
MOVEMENT DISORDERS CLINICAL PRACTICE 2020. doi: 10.1002/mdc3.13038 © 2020 International Parkinson and Movement Disorder Society
LETTERS: NEW OBSERVATIONS
part of the therapeutic process.3 Several prior studies examined HCU and the economic impact in psychogenic nonepileptic seizures and reported that establishing the diagnosis reduced HCU.4,5 There is a paucity of data pertaining to the impact of diagnosis on HCU in patients with FMD. By assessing HCU in patients with FMD before and after diagnosis, we aimed to learn more about the whether the reportedly therapeutic process of diagnosis affects HCU in FMD. This was a retrospective analysis of HCU in patients diagnosed with predominant FMD in the University of California Los Angeles movement disorders clinics between January 2014 and December 2018. Cases were identiﬁed by International Classiﬁcation of Diseases Tenth Revision codes and validated by chart review using diagnostic criteria (adapted from Gupta and Lang).6 We included patients explicitly diagnosed with FMD or in whom FMD was the primary differential diagnosis. We compared the number of outpatient, inpatient, emergency, imaging, laboratory, and procedure encounters at our institution as HCU measures for 12 months before versus after diagnosis (dx) date. Of 42 patients with validated FMD dx, 18 patients (14 women, mean age 51.6 [range 16–92]) received follow-up care at our institution and were analyzed. Results are summarized in Table 1. We found a signiﬁcant decrease in imaging studies (mean 4.9 pre-dx, 2.8 post-dx, paired t test P = 0.005), and no signiﬁcant change in outpatient visits (7.9 pre-dx, 10.0 post-dx, P = 0.48), procedures (1.55 pre-dx, 2.83 post-dx, P = 0.37), or patient messages (10.6 pre-dx, 11.2 post-dx, P = 0.87). There were few emergency room and hospital encounters with no signiﬁcant differences (1.06 pre-dx, 0.56 post-dx, P = 0.25). Among 13 of 18 patients (72%) who received documented advice about psychotherapy at time of diagnosis, we found a decrease in emergency room/hospital visits (1.08 pre-dx, 0.15 post-dx, P = 0.046). The mean delay in clinical diagnosis was 5.9 years. These results suggest that an explicit FMD diagnosis or presentation of FMD as a primary differential diagnosis in a tertiary movement disorders clinic may reduce some aspects of HCU such as diagnostic imaging, but not necessarily ambulatory visit frequency. Decreased imaging may reﬂect the lack of need for continued investigation and may be signiﬁcant as a marker of deceleration in diagnostic momentum, validating the importance of clinical diagnosis. Furthermore, recommendations for psychotherapy at a tertiary movement disorders clinic correlated with reduced HCU in terms of hospital and emergency room utilization for those patients without loss to neurologic follow-up. There was a high rate of comorbid psychiatric/psychological illness, and cognitive behavioral therapy may be intrinsically beneﬁcial for FMD, thus the rate of psychotherapy referral should potentially have been higher.7 Future studies could also examine the impact of physiotherapy on FMD HCU. This study is limited by the small sample size at a single academic institution, the exclusion of patients who did not follow-up at our institution, and information available from a single institutional electronic health record. Longer duration of follow-up across the spectrum of care delivery locations is needed to ascertain more
THE IMPACT OF DIAGNOSIS ON HEALTH
comprehensive HCU data. More robust research is needed to determine the impact of neurologist provided FMD diagnosis on HCU and prognosis.
Acknowledgments We acknowledge Federica Agosta and Betty Truong for their assistance in completing this project.
Author Roles (1) Research Project: A. Conception, B. Organization, C. Execution; (2) Statistical Analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript: A. Writing of the First Draft, B. Review and Critique. K.K.: 1A, 1B, 1C, 2A, 2B, 2C, 3A, 3B A.D.W.: 1A, 1B, 1C, 2A, 2B, 2C, 3A, 3B
Disclosures Ethical Compliance Statement: UCLA Institutional Review Board review conﬁrmed that patient consent was not required for this work (19–001610). We conﬁrm that we have read the Journal’s position on issues involved in ethical publication and afﬁrm that this work is consistent with those guidelines. Funding Sources and Conﬂicts of Interest: This research was not funded by any speciﬁc grant from any public, private, or not-for-proﬁt agencies. The authors have no conﬂicts of interest to declare. Financial Disclosures for the Previous 12 Months: Dr. Kevin Kyle has received salary from the Veterans Health Administration. Dr. Allan Wu has received honoraria from the American Academy of Neurology. ■
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MOVEMENT DISORDERS CLINICAL PRACTICE 2020. doi: 10.1002/mdc3.13038