Health-service use in women with binge eating disorders.

Eating disorders are associated with considerable medical and psychosocial impairment (1). Use of health services represents an important indicator of impairment, as this measurement reflects subjective distress (pain or suffering), dysfunction, or both. The few published studies that have examined health services use among individuals with eating disorders have reported two major findings. First, eating disorders are relatively undertreated. Epidemiological studies consistently show that few participants with eating disorders report having received treatments specifically targeting the eating problem (2–7). Second, despite underutilization of targeted care, health-insurance claims data suggest that total health-services use and costs are elevated among individuals with eating disorders compared to matched controls(8–10). This literature is constrained by methodological limitations. The epidemiological studies cited above were not designed to measure specific features or costs of health services use, and the self-report nature of the data collected in these studies limits the reliability of the findings (11). Studies utilizing electronic medical records (EMR) typically cannot verify the diagnostic information; consequently, the validity of the diagnoses is in question. Patients may be seeking treatment for their eating disorder without making explicit to the care provider that they suffer from an eating disorder. Even if a care provider correctly recognizes the eating disorder, the clinician may not always assign the proper diagnostic code for reasons such as lack of insurance coverage for eating disorder diagnoses or because the provider may consider the eating disorder secondary to another disorder such as depression. Previous research found that diagnosis moderated the amount of health services use in eating disorders, with greatest use reported for women with anorexia nervosa (AN) and lowest use for women with Eating Disorders Not Otherwise Specified (EDNOS) (9;12). Data about health services use in individuals with EDNOS is especially needed because this group represented the largest segment of those both meeting diagnostic criteria in epidemiological studies (13;14) and also receiving treatment as reflected in medical record data (9;15). EDNOS is a “catch-all” diagnostic category including individuals with diverse clinical presentations and most studies examining EDNOS do not provide detailed information about the clinical picture of individuals with this diagnosis (16). The few studies that do report such information suggest that individuals experiencing recurrent binge eating are a sizable subgroup included in EDNOS (17–19). Indeed, binge eating disorder (BED) was introduced in the fourth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV; American Psychiatric Association, 1990) as a specific example of EDNOS. Little is known about health services use in BED, in part because previous studies utilizing EMR data have been based on data sets that did not disaggregate EDNOS into more specific subgroups. The nosology of eating disorders is being reconsidered as part of the development of the fifth edition of the DSM. The diagnostic threshold of a minimum of two binge eating episodes or days per week for a diagnosis of bulimia nervosa (BN) or binge eating disorder (BED), respectively, has been the focus of considerable debate in light of a growing literature that suggests that this threshold is unduly restrictive; some experts have recommended using a frequency threshold of one bulimic episode per week (20;21). Therefore, the present study recruited participants using a binge eating frequency threshold requiring at least one day per week with an objective bulimic episode over a three-month period, with no periods of binge-free time greater than two weeks. Participants who met this threshold but did not meet diagnostic criteria for BN or BED were given a diagnosis of “recurrent binge eating” (RBE). The primary aim of the present study was to expand upon the prior literature by describing costs and health care use associated with binge eating disorders (BED and RBE) with the advantage of stronger methodologies involving both objectively measured health services use and rigorous assessment of patients’ diagnostic status. As a second aim, we sought to determine whether women with RBE differed from women with BED on health-services use or costs.