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Transcript of Open10 - Quality of Medical Care for Patients With Mental Illness - Do Patients Get A Raw Deal?
Alex MitchellOliver Lord
AcknowledgementsDarren MaloneCaroline Carney-DoebblingNasser AbdelmawlaBrett ThombsRoy Ziegelstein
Open meeting Jan 2010Open meeting Jan 2010
Quality Of Medical Care for Patients With Mental Illness -
Do Our Patients Get A Raw Deal?
ContentsContents
1. Mental Health & Physical Health Comorbidity & Mortality
2. Preventive Health Care InequalityScreening & prevention
3. Medical Health Care InequalityProcedures & prescribing
4. Implications for mortalityLinking poor quality of care with mortality
5. Who is Monitoring?Guidelines & responsibility
6. Can inequalities be Improved?Interventions
1. Physical Health Comorbidity / Mortality1. Physical Health Comorbidity / Mortality
Comorbid Physical Diagnoses in Elderly Depressed Patients
0
10
20
30
40
50
60
70
80
One Tw o Three+ None
Proctor EK, et al (2003) American Journal of Geriatric Psychiatry;11:329-38.
Physical Comorbidity in Schizophrenia and Depression
0
5
10
15
20
25
30
35
40H
yper
tens
ion
Chr
onic
bro
nchi
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Ast
hma
Dia
bete
s
Ulc
er
Rhe
umat
oid
arth
ritis
Hea
rt c
ondi
tion
Ost
eoar
thrit
is
Any
can
cer
Stro
ke
Emph
ysem
a
Live
r pro
blem
s
Wea
k/fa
iling
kid
neys
Con
gest
ive
hear
tfa
ilure
Myo
card
ial i
nfar
ctio
n
Ang
ina
Cor
onar
y he
art
dise
ase
SchizophreniaDepressionNHANES
Sokal 2004J Nerv Ment Dis 192:
421– 427
NHANES - US Department of Health National Health and Nutrition Examination Survey , 1988 –1994
Maine Study Results:Comparison of Health Disorders Between SMI & Non-SMI GroupsMaine Study Results:Comparison of Health Disorders Between SMI & Non-SMI Groups
59.4
33.930 28.6 28.4
22.8 21.716.5
11.5 11.16.3 5.9
0
10
20
30
40
50
60
70
80
Skeletal- Connective
Gastro-Intestinal
Obesity/Dyslipid
COPDInfectious Disease
Hypertension
Dental Disorders
DiabetesCancer
Heart Disease
Pneumonia/Influenza
Liver Disease
Perc
ent M
embe
rs
SMI (N=9224)Non-SMI (N=7352)
Colton CW, Manderscheid RW. Colton CW, Manderscheid RW. PrevPrev Chronic Dis [serial online] 2006 Apr [date cited]. Available frChronic Dis [serial online] 2006 Apr [date cited]. Available from: om: URL:http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htmURL:http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm
Lawrence & Coghlan N S W Public Health Bull 2002; 13(7): 155–158 n=240,000
Mortality and Depression - IHD
Psychosomatic Med (2004) Barth et al
Schizophrenia – all cause mortality
Pooled estimate=2.50
(95% CI=2.18-2.83)
>
>>>
Saha (2007) AGP
Five-year Mortality ratesFive-year Mortality rates
28%
19%
22%
12%
9%8%
0
5
10
15
20
25
30
CHD Diabetes Stroke
People with schizophrenia
People without schizophrenia
Hippisley-Cox J et al (2006) A comparison of survival rates for people with mental health problems and the remaining population with specific conditions.Disability Rights Commission. Equal treatment: closing the gap, July 2006
Slide credit: Dr Alan Farmer, Worcestershire Mental Health Partnership NHS Trust
Mortality & Mental illness: CaveatMortality & Mental illness: Caveat
Has the mortality gap been reducing?
Has modern medication improved the situation?
Mortality TrendsMortality Trends
Mortality TrendsMortality Trends
Effect of MedicationEffect of Medication
Varies according to
Schizophrenia
Dementia
Depression
Smoller et al (2010) Ann Int MedSmoller et al (2010) Ann Int Med
SSRI associated with increased all-cause mortalityHR 1.32 95% CI, 1.10-1.59
SSRI associated with increased stroke HR 1.45, 95% CI, 1.08-1.97
TCA associated with increased risk of all-cause mortality HR,1.67 [95% CI, 1.33-2.09
Mental Illness => High Medical Morbidity & MortalityMental Illness => High Medical Morbidity & Mortality
Therefore do we?
i Improve preventive screening
ii Enhance quality of routine medical care
iii Ensure adequate physical health medication
iv Help with treatment adherence (NICE)
v Monitor physical health issues
2. Preventive Health Care Inequality2. Preventive Health Care Inequality
Screening activitiesScreening activities
Mammography => use as an example (over)
Pap. Smear
Vaccinations
Lifestyle counselling
Blood pressure
Bowel cancer screening
Breast examination
PSA
Osteoporosis
Hepatitis & HIV
MammographyMammography
USPSTF recommendationsScreening mammography with or without clinical breast exam (CBE) every
1-2 years starting at age 40Insufficient evidence for or against CBE alone
UK NSC (England)Age 50-70 every 3 years
Mammography and DepressionMammography and Depression
Over 40 yearsDruss (2008)US n= OR of not having mammogram
OR 1.22 (95% CI 1.18-1.26).This difference was even greater if the depression was untreated
adj.OR 1.32 ( 1.22- 1.42).Those being treated in secondary care were more likely to have not had
a mammogram than those treated in primary care adjusted OR 1.22(95% CI 1.03-1.44).
Pirraglia (2004) US n=3302Those who screened positive for depression were less likely to have a
mammogram in the subsequent year adj. OR 0.84 (95% CI 0.73-0.97).Stecker et trend to increased use in Depression vs Hypertensive controlsGreen and Pope, US 2000, n=589
showed increased rates of mammographyOver 65 year olds
2 US studies showing no difference n=3864Over 50 year olds
Canadian study showed no difference, n =1,868European study showed no difference, n = 15,380
Mammography and any mental disorderMammography and any mental disorder
Werenke (2006) UK n= 533,340no difference for mental health service usersbut those on enhanced care were less likely to attend (OR 0.4 95% CI 0.29-
0.55). more than 2 admissions to a mental health hospital were less likely to attend
for mammography (OR 0.65, 95% CI, 0.49-0.85).
Carney and Jones (2006) US n= 191356, 5 year study period:
high risk OR 0.38 (95% CI 0.33-0.43), moderate risk 0.62 (95% CI 0.59-0.66).
last 2 years: low risk 0.95(95% CI 0.92-.99), moderate risk OR 0.71 (95% CI 0.66-0.75), high risk OR 0.63 (95% CI 0.53-0.75).
Lasser (2003) US n=526 no difference for mammography in last 2 years
Steiner (1998) US n=64 no difference
Iezzoni (2001) US n=11399 a trend to reduced use of mammography (SMI) in the last 2 yrs OR 0.6 (95% CI 0.4 – 1.1)
Mammography and SchizophreniaMammography and Schizophrenia
Chochinov (2009) Canada n=110,240In comparison to the general population (without schizophrenia)
(n=108,792), women with schizophrenia (n=1448) OR 0.64 of mammography in the selected two year period.
Carney and Jones (2006) n=191,356No difference over five yearsless likely in the last two years
OR 0.31 (95% CI 0.12-0.83). Werenke (2006) UK n= 533,340
Those with a diagnosis of psychosis were the least likely to attend for mammography
OR 0.33 (95% CI 0.18-0.61)Lindamer (2003) US n=116
(Convenience sample) in last 2 years68% of women with psychotic disorder98% of respondents to advertisement
Druss (2002) USless likely to have had a mammogram in last 2 years (for women aged 50-69
years) adjusted OR 0.78(95% CI 0.67-0.91).
3. Medical Health Care Inequality3. Medical Health Care Inequality
Medical monitoring eg HBA1c
Medical procedures eg CABG
Medical prescribing eg Insulin
Quality of Care MI vs No MIQuality of Care MI vs No MI
27 examined receipt of medical care in those with and without mental illness
19/27 showed deficits in care
10 examined medical care in those with and without substance use disorder (or dual-diagnosis
10/10 showed deficits in care
Studies examining Cardiovascular care
Druss B et al 2000. JAMA 283; 506-511 *
Druss BD et al. 2001. Arch Gen psych. 58; 565-572 *
Young J et al 2000.JAMA 28, 3198-9 *
Lawrence D et al 2003.Br J Psych 182;31-36.
Petersen LA et al 2003Health Serv Res 38; 41-63.
Jones L et al. 2005. PsychosomMed 67; 568-76.
Relevant Primary Data Studies
Wang P et al. 2005. Hypertension. 46; 273-279* Studies reporting substance
abuse and/or mental illness
Studies examiningHIV Care
Studies examiningGeneral Medical Care
Palepu A et al. 2006. J Sub Abuse Treat. In Press *
Redelmeier D et al. 1998 N Eng J Med. 338; 1516-1520
Cradock-O’Leary,et al 2002. Psychia Serv 53;874-8 *
Dickerson F et al 2003Psychiatric Serv 41; 560-570.
Desai M et al. 2002 J Gen Intern Med.17; 556-560 *
Studies examining Diabetes Care
Jones L et al. 2004. Medical care.42;1167-1175
Desai M et al. 2002Am J Psych. 159;1584-90 *
Frayne S et al. 2006.Arch Intmed. 165;2631-2638
Krein et al 2006 Psychia Serv57:1016–1021
Dixon L 2004. Psychiatric services. 55;892-900 ª
Studies examining Cancer Care
Goodwin JS et al. 2004JAGS 52; 106-111.
Desai MM, et a; 2002.JNMD 190(1), 51-53 *
Sullivan et al. 2006 PsychiatrServ 57:1126–1131
Bogart et al 2006 AIDS Patient Care & STDs 20(3) 175-182
4 studies9 studies2 studies1 study 10 studies
Lin EH et al. 2004 Diabetes Care 27(9):2154-60.
Weiss AP. et al 2006Psychiatr Serv 57(8):1145-1152
Kreyenbuhl J et al 2006JNMD 194:404–410 ª
Goldberg RW et al. 2007Psychiatr Serv 58:536–543 ª
a Studies reporting on the same data set
Hippisley-Cox et al. 2007 Heart 93:1256–1262
26 studies
Quality of Medical Treatment i ProceduresQuality of Medical Treatment i Procedures
Any Mental illnessHR = 0.86 (0.80-0.92)
Meta-Analysis of Procedure Rate (PCI) after Myocardial Infarction
SchizophreniaHR = 0.53 (0.44 – 0.64)
Meta-Analysis of Procedure Rate (PCI) after Myocardial Infarction
Quality of Medical Treatment i MedicationQuality of Medical Treatment i Medication
Inequality of Prescribed Meds ii Medication by Diagnosis
OR =0.92 OR =0.68 OR =0.72
SMI Schz Affective
Inequality of Prescribed Meds ii Medication by Drug
OR =0.79 OR =0.99ns
OR =0.83 OR =0.84ns
Quality of Medical Treatment ii Medication by Drug
OR =0.94ns
OR =0.96
4. Implication for Mortality4. Implication for Mortality
5. Who Is Monitoring Physical Issues?5. Who Is Monitoring Physical Issues?
Medical Colleagues
Mental health
Primary care
Disparities in care: impact of mental illness on diabetes managementDisparities in care: impact of mental illness on diabetes management
313,586 Veteran Health Authority patients with diabetes76,799 (25%) had mental health conditions (1999)
Frayne et al. Arch Intern Med. 2005;165:2631-2638
Depression
Anxiety
Psychosis
Mania
Substance use disorder
Personality disorder
0.8 1.0 1.2 1.4 1.6
No HbA test done
0.8 1.0 1.2 1.4 1.6
No LDL test done
0.8 1.0 1.2 1.4 1.6
No Eye examination
done
0.8 1.0 1.2 1.4 1.6
No Monitoring
0.8 1.0 1.2 1.4 1.6
Poor glycemiccontrol
0.8 1.0 1.2 1.4 1.6
Poor lipemiccontrol
Odds ratio for:
Buckley PF et al Schizophrenia Research 79 (2005) 281– 288
Monitoring patients DURING treatment with an atypical Monitoring patients DURING treatment with an atypical
Frequency of baseline assessment PRIOR to initiating treatment with an atypical
Buckley PF et al Schizophrenia Research 79 (2005) 281– 288
Summary of Monitoring ProtocolSummary of Monitoring Protocol
XXXFasting lipid profile
XXXFasting plasma glucose
XXXBlood press.
XXWaist circum.
XXXXXWeight (BMI)
XXPersonal/fam. Hist.
5 yrAnnQuart12 wk8 wk4 wkBase line
American Diabetes Association and the American Psychiatric Association (ADA/ APA/AACE/NAASO, 2004).
Annual physical health checks(NSF for mental health/NICE guidance)
Annual physical health checks(NSF for mental health/NICE guidance)
Blood pressure & weight/BMI
Lifestyle advice (smoking/diet/exercise/alcohol/drugs)
Urine/blood test to exclude diabetes
Cholesterol check
Medication side effect monitoring(Include thyroid function & creatinine if on lithium)
Encourage screening in appropriate groups (cervical smears/mammography/hepatitis/HIV/high prolactin)
Offer flu vaccination and contraceptive advice
N=6000 pre-guidelineN=18,000 post guideline
Screening for metabolic side effects in AO clientsScreening for metabolic side effects in AO clientsReview of 1966 case records from 53 teams, Barnes et al (2007)
Dyslipidaemia6%
Diabetes 6%
Hypertension 6%
Documented diagnosis
11%All of the above
37%22%Plasma lipids
62%28%Blood glucose
17%Measure of obesity
48%26%Blood pressure
Documented treatment
% with recorded measurement over last 12 months
Slide credit: Dr Alan Farmer, Worcestershire Mental Health Partnership NHS Trust
Physical Screening of Psychiatric PatientsPhysical Screening of Psychiatric Patients
57.6% of inpatients receive a comprehensive physical examination(Hodgson R, Adeyemo O. Physical examination performed by psychiatrists. International Journal of Psychiatry in Clinical Practice 2004;8:57-60.)
No dental health target achieved in 428 people with Schizophrenia McCreadie RG, et al The dental health of people with schizophrenia. Acta Psychiatrica Scandinavica 2004;110:306-10)
On screening at admission: 34% of older people had unrecognized medical disorders (Woo BKR, et al. Unrecognized medical disorders in older psychiatric inpatients in a senior behavioral health unit in a university hospital. Journal of Geriatric Psychiatry and Neurology 2003;16:121-5)
On screening at admission: 29% had physical disorder (80% previously known 20% new diagnoses). These were contributory to diagnosis in 5.5% (Koran LM, et al Medical disorders among patients admitted to a public-sector psychiatric inpatient unit. Psychiatric Services 2002;53:1623-5.
6. Can inequalities be Improved?6. Can inequalities be Improved?
NICE Schizophrenia guidelinesNICE Schizophrenia guidelines
“The higher physical morbidity and mortality of service users with schizophrenia should be considered in all assessments.
“Whilst this would normally be expected to be the role of primary care services, secondary care services should nevertheless monitor these matters where they believe a service user may have little regular contact with primary care.”
NICE 2002
Longitudinal f/u and monitoring Pr Pr Pr Pr Pr/Ps Pr/B/Ps Pr/Ps Pr/B/Ps B2/Ps Ps/B2
Extended B/P/S interventions B1 B1 B B B B B2 B2 B2 B2
2nd level or higher meds Pr Ps Ps Ps Ps Ps Ps Ps Ps Ps
Brief B/P/S interventions Pr/B1 Pr/B1 Pr/B1 Pr/B1 B1/Pr B/Pr B/Ps B/Ps B/Ps B/Ps
Initial Medications Pr Pr Pr Pr/Ps Pr/Ps Ps/Pr Ps Ps/Pr Ps Ps
Diagnosis/Comprehensive Pr Pr Pr Pr/B1 B1/Pr B1//Pr B/Ps B/Ps B/Ps PsP/S assessment
Counseling/Psychoeducation Pr Pr Pr Pr/B1 B1//Pr B1/Pr B/Ps B B B
Recognition/Limited P/S assessment Pr Pr Pr Pr Pr Pr Pr Pr Pr Pr
Primary Care For GMC Pr Pr Pr Pr Pr Pr Pr* Pr* Pr* Pr*
Primary Care Provider* = in specialty settingB1 - Behavioral health
Specialist in PCP settingB2 - Behavorial Health
specialist in specialty setting
Psychiatrist
Note - did not include child (e.g. ADHD)geriatric (eg. dementia)
Depressive D
isorders
Substance Use Problem
s
Panic Disorder
Somatization
Other -A
nxiety Disorders e.g.
Social, Specific Phobias
Substance Abuse
Bipolar D
isorder
Substance Dependence
Severe Personality Disorder
Schizophrenia
Conditions/Populations
B
Ps
Pr
Inte
rven
tions
No Physical Health Without Mental HealthNo Physical Health Without Mental Health
Awareness of the link between physical and mental health
Liaison Mental Health Services
Engaging Patients and Carers
Re-organisation, Quality & Commissioning
Training and Education
ConclusionsConclusions
Co-morbidity and mortality is high
Excess medical deaths > non-accidental deaths in MI
Medication influences morbidity & mortality
Quality of medical care is below usual standard
Physical health monitoring is poor
Guidelines accumulating but implementation lacking