To the emergency room and back again: Circular healthcare pathways for acute functional neurological disorders, 2022, Williams et al

Highlights

• We prospectively identified acute FND referrals in a UK city hospital.
• Dynamic, moving maps of patient pathways show loops around recurrent ED attendance.
• Rates of appropriate FND care are low, including documented diagnosis.
• Better practice FND care is associated with reduced risk of ED reattendance.

Abstract
Background and objectives
Studies of Functional Neurological Disorders (FND) are usually outpatient-based. To inform service development, we aimed to describe patient pathways through healthcare events, and factors affecting risk of emergency department (ED) reattendance, for people presenting acutely with FND.

Methods
Acute neurology/stroke teams at a UK city hospital were contacted regularly over 8 months to log FND referrals. Electronic documentation was then reviewed for hospital healthcare events over the preceding 8 years. Patient pathways through healthcare events over time were mapped, and mixed effects logistic regression was performed for risk of ED reattendance within 1 year.

Results
In 8 months, 212 patients presented acutely with an initial referral suggesting FND. 20% had subsequent alternative diagnoses, but 162 patients were classified from documentation review as possible (17%), probable (28%) or definite (55%) FND. In the preceding 8 years, these 162 patients had 563 ED attendances and 1693 inpatient nights with functional symptoms, but only 26% were referred for psychological therapy, only 66% had a documented diagnosis, and care pathways looped around ED. Three better practice pathway steps were each associated with lower risk of subsequent ED reattendance: documented FND diagnosis (OR = 0.32, p = 0.004), referral to clinical psychology (OR = 0.35, p = 0.04) and outpatient neurology follow-up (OR = 0.25, p < 0.001).

Conclusion
People that present acutely to a UK city hospital with FND tend to follow looping pathways through hospital healthcare events, centred around ED, with low rates of documented diagnosis and referral for psychological therapy. When better practice occurs, it is associated with lower risk of ED reattendance.

Open access, https://www.jns-journal.com/article/S0022-510X(22)00113-7/fulltext

 

Why is reduced ED attendance the end goal, rather than objective signs of functional improvement?

Reduced ED attendance can also be achieved via bad service - patients don't think it will be helpful and hence don't return.

 

It's pretty wild that when you think of it, they are making the exact same mistake twice. They are looking at sick people whose health issues are discriminated and where all available support is withheld on purpose, and cannot reason why this is happening, cannot possibly imagine that neglecting sick people will obviously not magically make them disappear from healthcare services. Sick people are "looping" through healthcare services the same way homeless people are "looping" through the pitiful services that can do no more than barely keep them alive. Even though it's fully known that housing and feeding homeless people is better for them and cheaper overall. The punishment loop must keep on looping.

But then they look at what they are doing about it, and somehow cannot reason their own role in creating and perpetuating this loop. The loop doesn't exist without the discrimination and completely misrepresenting and denying the reality of those patients, and yet the physicians responsible for creating and maintaining the loop look at the loop and can only find ways to blame the patients for the loop they created themselves, dripping with condescension as to why they can't break out of the loop they created.

Talk about failing self-awareness. And yeah Snow Leopard says, this is entirely about healthcare services usage. Which means they're not even interested in why those neglected patients keep begging for help since their intent is to... perpetuate the loop of failure they created in the first place.

This fully reminds of people who justify the perpetuation of the war on drugs... by pointing out all the violence the... war on drugs has created. Violence which, without prohibition, would simply not exist. So it must loop on, because the loop was started, and it's important to maintain loops, otherwise it would mean creating them was wrong.

Although there's something both hilarious and sad about "centered on ED", which is only there because... the people doing the study are ED doctors. Which is exactly as foolish as the self-important Victorian era psychiatrists who could not possibly imagine that people who lived outside of cities, where they themselves lived and worked, could have those "maladies of urban excess" or whatever, simply because cities is where they happened to live and work. Literally making the entire concept about themselves, simply because it's the perspective being written.

Something something history being written by the "victors", aka whoever has the power to write down what happened, true or false. Turns out it isn't limited to history.