Urgent call to action: mobilising physicians and the medical workforce to address treatment of medical instability from eating disorders

Abstract

Eating disorders remain understudied, underfunded and under addressed despite their substantial impact on public health and the economy. These disorders cost Australia an estimated $66 billion annually,¹ far surpassing the costs of obesity ($12 billion)² and even stroke ($32 billion).³ Yet research into eating disorders remains disproportionately low (Fig. 1).

The rising prevalence of eating disorders has been well documented in the medical literature⁴ and lay press alike. Yet at most Australian hospitals, the sequence of care for the medically unstable inpatient admitted with an eating disorder has not led to a commensurate rise in improved outcomes.⁵

To begin addressing this apparent paradox, we propose three broad goals to make inroads leading to better inpatient care and outcomes.

Proactive medical leadership begins at the bedside. Inpatient mortality for eating disorders might not equal that of stroke or sepsis, but the standardised mortality ratio for anorexia nervosa is 5.86 for females aged 15–24 years⁶ and as high as 21.7 even years after treatment.^{7, 8} Often these patients spend time in hospital primarily for nutritional therapy. We do not delay the administration of antibiotics to people with sepsis; a similar urgency about nutritional resuscitation, including placement of a nasogastric tube for those who need it and accelerating the initiation of tube feeding, could reduce unwanted time in hospital. Accelerating the rate of refeeding may result in better weight gains.⁹ A mature and effective multidisciplinary team (MDT) can work together with a medically unstable inpatient to build goals that are sensitive to culture and mental health and, where possible, involve family.¹⁰

Medical leadership extends beyond the bedside by connecting and engaging a MDT of nursing, psychiatry and dietetics to improve inpatient care. Proactive medical leadership also includes multidisciplinary involvement in the research enterprise from the moment of admission and life-sustaining hospital bedside care. Multidisciplinary care is a national standard, but it remains unclear how many hospitals admitting medically unstable patients with eating disorders conduct formal MDT meetings or how many admissions per year would make regular meetings justified. An effective MDT meeting¹¹ fosters a collaborative spirit and enables a sense of shared care and responsibility. It is also an opportunity for cross-disciplinary learning and can reduce stigmatising attitudes towards patients.¹² The Australia & New Zealand Academy for Eating Disorders (ANZAED) Clinical Practice Standards for eating disorder treatment recommend team members should have clear roles and communication pathways to support best patient outcomes.¹³ Proactive medical leadership during an effective MDT meeting could buoy the compassion fatigue felt by nursing staff caring for this challenging patient cohort.¹⁴

Importantly, proactive medical leadership should lead the design of better hospital systems to treat, track and learn what approaches have the greatest real-world effectiveness. Effective hospital systems redesign requires MDT solutions and generates robust, actionable data.¹⁵ Hospital systems can be leveraged with an urgency similar to that applied in discussions of patient flow, but to collect data for quality feedback to teams providing care. For example, recording the time to nasogastric feeds or MDT consultation, with feedback to the clinical teams, could result in faster nutritional recovery, shorter lengths of stay and better long-term weight maintenance. Without a systematic approach to data collection around these activities, it will be difficult to tease out best practices. Identifying which elements of the current approaches to care have the best long-term outcomes has been identified as one of the top 10 research areas for the field.¹⁶

Finally, proactive medical leadership extends to the national level. This could begin by forming special interest groups (SIGs) within professional societies to contribute to the development of national standards that can benchmark inpatient quality. Each Australian state has different guidelines and perhaps different admission and discharge criteria; some could be associated with better outcomes, but this will never be known without a nationwide network of participating hospitals. SIGs for these eating disorder patients will help build enthusiasm for national data collection to understand where variations in inpatient care matter most.

The multisystem consequences of eating disorders and the management of acute physiological instability also align with generalist expertise. Starvation destabilises virtually every organ system. Some of the symptoms underpinning the eating disorder might be secondary to caloric restriction and coincident with the reduction in resting energy expenditure known to accompany starvation.¹⁷ Biases towards seeing eating disorder patients as healthier than they are¹⁸ can impede the therapeutic alliance¹⁹ and blind treatment teams to the incipient or actual severity of life-threatening metabolic derangements.

Only by conducting careful, systematic studies of responses to adequate nutritional resuscitation will clinicians improve their understanding of physiological changes in eating disorders. Many practical questions remain unanswered: Does confinement to the hospital room improve weight gain? Are there medical therapies that can be repurposed to aid weight gain safely in someone recovering from starvation?²⁰ Where do the physiology and psychiatric manifestations of eating disorders overlap? Where do they diverge?

While Australian authors contribute a remarkable 6%–10% of the world's lead or corresponding author literature on eating disorders over the past 5 years, general physician authors are few. By illustration: Of the publications listed on pubmed.gov using the search terms ‘eating disorder’ for peer-reviewed publications in the last 5 years, a manual, reverse chronological review of 180 consecutive titles and their lead and corresponding author departmental affiliations suggests that <1% of this body of literature originates from departments of general or internal medicine.

To advance the field, general physicians must develop greater expertise in this field of medicine and integrate with the same enthusiasm and interest as colleagues in the psychiatric field who have researched these patients since the 19th century. Breakthroughs are possible. A better understanding of underlying pathophysiology will expand the margins of what is known and encourage more interested compassionate care and research into the physiological underpinnings of both physical and psychological manifestations of restrictive eating disorders.

In Australia, the National Eating Disorders Strategy 2023–2033 is a 10-year roadmap for improving eating disorder care in Australia.¹⁰ Supported by the National Eating Disorders Collaboration (NEDC), it encourages ‘research, data collection and evaluation’ in a quest to improve quality and consistency of treatment. Clinical quality registries (CQRs) are one solution previously suggested to support this.²¹ The National Strategy of the Australian Commission on Safety and Quality in Health Care (ACSQHC) suggests a CQR is most effective when used in areas with significant burden of disease and cost to the Australian health system; this is a situation where the population with the disease can be captured completely (in this case, the medically unstable patient with an eating disorder), and/or with significant variation in care and outcomes.

We can gain insight from the value added by CQRs for specific patient cohorts in other areas of health in Australia.²² Other CQRs have improved care, improved efficiency and helped these craft groups develop greater expertise.

Eating disorder care has already been informed by registry data from the Australia and New Zealand Clinical Quality Registry for the Treatment of Eating Disorders (TrEAT Registry).²³ This registry has enabled more effective assessment of treatments,²⁴ but it does not include medically unstable inpatients. Regular CQR feedback loops have the potential to improve inpatient outcomes as well.

Accordingly, we have launched an inpatient registry (ACTRN12623001259640) in South Australia for adult and paediatric patients. It is structured in accordance with the National Framework of the ACSQHC, ensuring adherence to best-practice principles in registry governance and management. Feasibility is supported by overlapping the data entry with the best-practice principles of a MDT discussion of patients with an eating disorder. The minimum data set (MDS) is aligned with the aspirational national MDS developed by the Australian Government Department of Health.²¹ Our MDS is regularly reviewed by an operations committee with oversight governance aligned with the ACSQHC standards. Deidentified data are then collated, and feedback is provided to individual hospitals through a data analytics page. Periodic validation is performed using hospital coding data (ICD-10 coding for eating disorders, F500-F509). Our registry is an attempt to think about the NEDC National Strategy but act locally to improve quality and consistency of treatment and encourage research. Other Australian states could develop similarly contemporary and forward-thinking registries to empower each hospital and state to leverage data for continuous improvement and link digitally on a national scale. Doing so would build a national framework organically, the staged rollout previously suggested²¹ and begin with a baseline assessment of treatment across the country. A collaborative national CQR can gather data about outcomes of interest and benchmarks for care, beginning with criteria for admission and discharge. It could be led by the newly established Internal Medicine Society of Australia and New Zealand-Research Network, collaborating directly with the NEDC.

Linkage of inpatient data with outpatient data like those collected by the TrEAT Registry could then highlight the inpatient care with the strongest associations with long-term recovery to build what the NEDC calls ‘recovery-oriented care’.

In conclusion, there are foundations already laid on which we must build with investment by hospital-based physicians. Working locally and nationally, we need proactive medical leadership, more high-quality research and better data to make needed leaps in improved care, even if these are built on incremental advances. A registry can highlight successes in a way that builds expertise and collaboration around multidisciplinary care and nationally with benchmarks for quality, building a stronger evidence base that can lead the world.