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Original Investigation
October 26, 2020

Assessment of Emergency Department and Inpatient Use and Costs in Adult and Pediatric Functional Neurological Disorders

Author Affiliations
  • 1Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
  • 2Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston
  • 3Division of Clinical Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
  • 4James J. and Joan A. Gardner Center for Parkinson’s Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, Ohio
JAMA Neurol. 2021;78(1):88-101. doi:10.1001/jamaneurol.2020.3753
Key Points

Question  What are emergency department and inpatient health care use and costs in patients with functional neurological disorders?

Findings  In this economic evaluation using large US health care databases of more than 40 000 emergency department visits and 20 000 functional neurological disorder admissions annually from 2008 to 2017, the health care use and annual charges for emergency department and inpatient care were estimated to be more than $1.2 billion per year and rising, comparable to other investigation-intensive and pharmacologically demanding neurological disorders.

Meaning  Functional neurological disorders are associated with a high level of health care use, with treatment costs comparable to those of care-intensive neurological disorders.


Importance  There is limited information about health care use and costs in patients with functional neurological disorders (FNDs).

Objective  To assess US emergency department (ED) and inpatient use and charges for FNDs.

Design, Setting, and Participants  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). International Classification of Diseases, Ninth Revision, Clinical Modification code 300.11 (conversion disorder) or 306.0 (musculoskeletal malfunction arising from mental factors) and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification 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.

Main Outcomes and Measures  Admission traits (eg, demographic characteristics of patients, length of stay, and discharge disposition) and hospital charges.

Results  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, P < .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.

Conclusions and Relevance  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.

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    1 Comment for this article
    Functional Neurological Disorders-Awareness, Cost, Quality and Management
    Khichar Shubhakaran, MD (Med), D.M.(Neurology) | Senior Professor and Head of Department of Neurology, M D M Hospital, Dr. S.N Medical College, Jodhpur, (Rajasthan)-India
    The functional neurological dysfunctions may be chronic but usually present in an emergency setting which increases panic and more frequently results in inpatient admissions, so smooth handling, ideal workup and appropriate guidelines for management and follow up may help in this direction.
    Since there is limited information about awareness, health care use, and costs in patients with functional neurological disorders (FNDs), it should be taken into mainstream.
    There is also dire need for attention to inpatient physical therapy, occupational therapy, speech and language pathology, and psychiatric consultation as most of these patients may also have an attention seeking behavior. /> Because of overlap with refractory neurological disorders like headache, seizure, focal deficit etc..., they should be subcategorized in such cases. Guidelines also need to be framed for such subcategories with respect to appropriate line of management as is with other disorders so as improve management and avoid unwanted costs.