Assessment of Emergency Department and Inpatient Use and Costs in Adult and Pediatric Functional Neurological Disorders
Authors: Christopher D. Stephen, Vicki Fung, Codrin I. Lungu, Alberto J. Espay
Journal: JAMA Neurology (2020)

<h3>Importance</h3> There is limited information about health care use and costs in patients with functional neurological disorders (FNDs). <h3>Objective</h3> To assess US emergency department (ED) and inpatient use and charges for FNDs. <h3>Design, Setting, and Participants</h3> This economic evaluation used Healthcare Cost and Utilization Project data to assess all-payer (1) adult (age, ≥18 years) hospitalizations (2008-2017), (2) pediatric (age, 5-17 years) hospitalizations (2003, 2006, 2009, 2012, and 2016), and (3) adult and pediatric ED evaluations (2008-2017).<i>International Classification of Diseases, Ninth Revision, Clinical Modification</i>code 300.11 (conversion disorder) or 306.0 (musculoskeletal malfunction arising from mental factors) and<i>International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification</i>codes for conversion disorder/functional neurological symptom disorder (F44.4 to F44.7) were used to conservatively define FNDs and to compare them with other neurological disorders that are associated with high levels of health care use. Analysis was performed between January 2019 and July 2020. <h3>Main Outcomes and Measures</h3> Admission traits (eg, demographic characteristics of patients, length of stay, and discharge disposition) and hospital charges. <h3>Results</h3> Compared with other neurological disorders in 2017, emergency FND evaluations of 36 359 adults (25 807 women [71.0%] and 3800 children (2733 girls [71.9%]) more frequently resulted in inpatient admissions (22 895 adult admissions [69.2% female] and 1264 pediatric admissions [73.4% ]). These FND admissions had a shorter mean (SEM) hospital length of stay (5.21 [0.15] days vs 6.03 [0.03] days,<i>P</i> &lt; .001) but higher workup rates than admissions for comparable neurological diagnoses. Admissions for FNDs had low rates of inpatient physical therapy, occupational therapy, speech and language pathology, and psychiatric consultation. The total annual costs (a proxy for total costs in 2017 US dollars) were $1066 million (95% CI, $971-$1160 million) for adult FND inpatient charges in 2017 compared with $1241 million (95% CI, $1132-$1351 million) for anterior horn cell disease; $75 million (95% CI, $57-$92 million) for pediatric FND inpatient charges in 2012 compared with $86 million (95% CI, $63-$108 million) for demyelinating diseases; and $163 million (95% CI, $144-$182 million) for adult and pediatric ED visits in 2017 compared with $135 million (95% CI $111-$159 million) for refractory epilepsy. Total charges per admission for ED care of FNDs were higher than the other comparison groups in adults. Total costs and costs per admission for FNDs increased from 2008 to 2017 at a higher rate than that of other neurological disorders. <h3>Conclusions and Relevance</h3> This economic evaluation found that the more than $1.2 billion and increasing annual costs for ED and inpatient care of FNDs were similar to other investigation-intensive and pharmacologically demanding neurological disorders. Unnecessary investigations and iatrogenic harm inflate costs at the expense of necessary but neglected psychiatric and rehabilitative treatments.