Quality Of Medical Care for Patients With
 Mental Illness -

 Do Our Patients Get A Raw Deal?


Alex Mitchell
Oliver Lord
...
Contents
 1. Mental Health & Physical Health
    Comorbidity & Mortality

 2. Preventive Health Care Inequality
    Screen...
1. Physical Health Comorbidity / Mortality
Comorbid Physical Diagnoses in Elderly Depressed
                                Patients
80

70

60

50

40

30

20

10

...
40

                                                  P hysical C omorbidity in S chiz ophrenia and D epression
35


30
  ...
Maine Study Results:
Comparison of Health Disorders Between SMI & Non-SMI Groups
            of Health Disorders Between

...
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

                                      >
                                      >
     ...
Five-year Mortality rates

    30                   People with schizophrenia                     28%

                   ...
Mortality & Mental illness: Caveat


 Has the mortality gap been reducing?

 Has modern medication improved the situation?
Mortality Trends
Mortality Trends
Effect of Medication
 Varies according to

        Schizophrenia

        Dementia

        Depression
Smoller et al (2010) Ann Int Med

SSRI associated with increased all-cause mortality
  HR 1.32 95% CI, 1.10-1.59


SSRI as...
Mental Illness => High Medical Morbidity & Mortality

 Therefore do we?

   i Improve preventive screening

   ii Enhance ...
2. Preventive Health Care Inequality
Screening activities
    Mammography => use as an example (over)

    Pap. Smear

    Vaccinations

    Lifestyle counsell...
Mammography
USPSTF recommendations
   Screening mammography with or without clinical breast exam (CBE) every
      1-2 yea...
Mammography and Depression
Over 40 years
   Druss (2008)US n= OR of not having mammogram
            OR 1.22 (95% CI 1.18-...
Mammography and any mental disorder
Werenke (2006) UK n= 533,340
    no difference for mental health service users
    but...
Mammography and Schizophrenia
Chochinov (2009) Canada n=110,240
     In comparison to the general population (without schi...
3. Medical Health Care Inequality

     Medical monitoring eg HBA1c

     Medical procedures eg CABG

     Medical prescri...
Quality of Care MI vs No MI

27 examined receipt of medical care in
  those with and without mental illness

   19/27 show...
Relevant Primary Data Studies


                                                                                          ...
Quality of Medical Treatment i Procedures
Meta-Analysis of Procedure Rate (PCI) after Myocardial Infarction




 Any Mental illness
HR = 0.86 (0.80-0.92)
Meta-Analysis of Procedure Rate (PCI) after Myocardial Infarction




   Schizophrenia
HR = 0.53 (0.44 – 0.64)
Quality of Medical Treatment i Medication
Inequality of Prescribed Meds ii Medication by Diagnosis

     OR =0.92          OR =0.68            OR =0.72




       S...
Inequality of Prescribed Meds ii Medication by Drug

                                                 OR =0.99
OR =0.79
  ...
Quality of Medical Treatment ii Medication by Drug

OR =0.94                                        OR =0.96
ns
4. Implication for Mortality
5. Who Is Monitoring Physical Issues?

     Medical Colleagues

     Mental health

     Primary care
Disparities in care: impact of mental illness on diabetes
management

  Depression

      Anxiety


   Psychosis


       ...
Monitoring patients DURING treatment with an atypical




                  Buckley PF et al Schizophrenia Research 79 (20...
Frequency of baseline assessment PRIOR to
initiating treatment with an atypical




               Buckley PF et al Schizo...
Summary of Monitoring Protocol

                                    Base
                                              4 w...
Annual physical health checks
(NSF for mental health/NICE guidance)
   Blood pressure & weight/BMI

   Lifestyle advice (s...
N=6000 pre-guideline
N=18,000 post guideline
Screening for metabolic side effects in AO clients
Review of 1966 case records from 53 teams, Barnes et al (2007)


      ...
Physical Screening of Psychiatric Patients
 57.6% of inpatients receive a comprehensive physical examination
     (Hodgson...
6. Can inequalities be Improved?
NICE Schizophrenia guidelines

“The higher physical morbidity and mortality of service
 users with schizophrenia should be...
Longitudinal f/u and monitoring            Pr                     Pr                       Pr               Pr            ...
No Physical Health Without Mental Health

 Awareness of the link between physical and
    mental health

 Liaison Mental H...
Conclusions
Co-morbidity and mortality is high

Excess medical deaths > non-accidental deaths in MI

Medication influences...
Open10 - Quality of Medical Care for Patients With Mental Illness - Do Patients Get A Raw Deal?
Open10 - Quality of Medical Care for Patients With Mental Illness - Do Patients Get A Raw Deal?
Open10 - Quality of Medical Care for Patients With Mental Illness - Do Patients Get A Raw Deal?
Open10 - Quality of Medical Care for Patients With Mental Illness - Do Patients Get A Raw Deal?
Open10 - Quality of Medical Care for Patients With Mental Illness - Do Patients Get A Raw Deal?
Open10 - Quality of Medical Care for Patients With Mental Illness - Do Patients Get A Raw Deal?
Open10 - Quality of Medical Care for Patients With Mental Illness - Do Patients Get A Raw Deal?
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Open10 - Quality of Medical Care for Patients With Mental Illness - Do Patients Get A Raw Deal?

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This is a lecture from the friday Open Meeting series, Leicester Partnership Trust, Leicester. Delivered jan15, 2010.

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Open10 - Quality of Medical Care for Patients With Mental Illness - Do Patients Get A Raw Deal?

  1. 1. Quality Of Medical Care for Patients With Mental Illness - Do Our Patients Get A Raw Deal? Alex Mitchell Oliver Lord Acknowledgements Darren Malone Caroline Carney-Doebbling Nasser Abdelmawla Brett Thombs Roy Ziegelstein Open meeting Jan 2010 Open meeting Jan 2010
  2. 2. Contents 1. Mental Health & Physical Health Comorbidity & Mortality 2. Preventive Health Care Inequality Screening & prevention 3. Medical Health Care Inequality Procedures & prescribing 4. Implications for mortality Linking poor quality of care with mortality 5. Who is Monitoring? Guidelines & responsibility 6. Can inequalities be Improved? Interventions
  3. 3. 1. Physical Health Comorbidity / Mortality
  4. 4. Comorbid Physical Diagnoses in Elderly Depressed Patients 80 70 60 50 40 30 20 10 0 One Tw o Three+ None Proctor EK, et al (2003) American Journal of Geriatric Psychiatry;11:329- 38.
  5. 5. 40 P hysical C omorbidity in S chiz ophrenia and D epression 35 30 Schizophrenia Depression 25 NHANES 20 15 10 Sokal 2004 J Nerv Ment Dis 192: 421– 427 5 0 Angina Ulcer Heart condition Any cancer Asthma Diabetes Chronic bronchitis Stroke Emphysema Myocardial infarction Hypertension Rheumatoid arthritis Osteoarthritis Coronary heart Weak/failing kidneys Congestive heart Liver problems disease failure NHANES - US Department of Health National Health and Nutrition Examination Survey , 1988 –1994
  6. 6. Maine Study Results: Comparison of Health Disorders Between SMI & Non-SMI Groups of Health Disorders Between 80 SMI (N=9224) 70 59.4 Non-SMI (N=7352) 60 P e rc e n t M e m b e rs 50 40 33.9 30 28.6 28.4 30 22.8 21.7 20 16.5 11.5 11.1 10 6.3 5.9 0 Sk Ga Ob CO In Hy De D C He Pn L iv el e st r es P D f ect pe nt a iab e an c ar t eu e tal o-I it y iou rt e lD tes er D is mo r Di -C nte /D y s D nsi o iso ea n se on ne sti sl i pid ise n rd e se ia/ In f ase cti nal ase rs l ue nz ve a Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date cited]. Available from: from: URL:http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm
  7. 7. Lawrence & Coghlan N S W Public Health Bull 2002; 13(7): 155–158 n=240,000
  8. 8. Mortality and Depression - IHD Psychosomatic Med (2004) Barth et al
  9. 9. Schizophrenia – all cause mortality > > > > Saha (2007) AGP Pooled estimate=2.50 (95% CI=2.18-2.83)
  10. 10. Five-year Mortality rates 30 People with schizophrenia 28% People without schizophrenia 25 22% 20 19% 15 12% 10 9% 8% 5 0 CHD Diabetes Stroke 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
  11. 11. Mortality & Mental illness: Caveat Has the mortality gap been reducing? Has modern medication improved the situation?
  12. 12. Mortality Trends
  13. 13. Mortality Trends
  14. 14. Effect of Medication Varies according to Schizophrenia Dementia Depression
  15. 15. Smoller et al (2010) Ann Int Med SSRI associated with increased all-cause mortality HR 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
  16. 16. Mental 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
  17. 17. 2. Preventive Health Care Inequality
  18. 18. Screening activities Mammography => use as an example (over) Pap. Smear Vaccinations Lifestyle counselling Blood pressure Bowel cancer screening Breast examination PSA Osteoporosis Hepatitis & HIV
  19. 19. Mammography USPSTF recommendations Screening mammography with or without clinical breast exam (CBE) every 1-2 years starting at age 40 Insufficient evidence for or against CBE alone UK NSC (England) Age 50-70 every 3 years
  20. 20. Mammography and Depression Over 40 years Druss (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=3302 Those 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 controls Green and Pope, US 2000, n=589 showed increased rates of mammography Over 65 year olds 2 US studies showing no difference n=3864 Over 50 year olds Canadian study showed no difference, n =1,868 European study showed no difference, n = 15,380
  21. 21. Mammography and any mental disorder Werenke (2006) UK n= 533,340 no difference for mental health service users but 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)
  22. 22. Mammography and Schizophrenia Chochinov (2009) Canada n=110,240 In 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=191,356 No difference over five years less 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 years 68% of women with psychotic disorder 98% of respondents to advertisement Druss (2002) US less 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).
  23. 23. 3. Medical Health Care Inequality Medical monitoring eg HBA1c Medical procedures eg CABG Medical prescribing eg Insulin
  24. 24. Quality 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
  25. 25. Relevant Primary Data Studies 26 studies 1 study 2 studies 10 studies 9 studies 4 studies Studies examining Cancer Studies examining Studies examining Studies examining Studies examining Care HIV Care Diabetes Care Cardiovascular care General Medical Care Goodwin JS et al. 2004 Palepu A et al. 2006. J Sub Abuse Desai M et al. 2002 Druss B et al 2000. Redelmeier D et al. 1998 N Eng J JAGS 52; 106-111. Treat. In Press * Am J Psych. 159;1584-90 * JAMA 283; 506-511 * Med. 338; 1516-1520 Bogart et al 2006 AIDS Patient Lin EH et al. 2004 Diabetes Care Young J et al 2000. Desai M et al. 2002 J Gen Intern Care & STDs 20(3) 175-182 27(9):2154-60. JAMA 28, 3198-9 * Med.17; 556-560 * Dixon L 2004. Psychiatric Druss BD et al. 2001. Arch Gen Cradock-O’Leary,et al 2002. services. 55;892-900 ª psych. 58; 565-572 * Psychia Serv 53;874-8 * Jones L et al. 2004. Medical Desai MM, et a; 2002. Dickerson F et al 2003 care.42;1167-1175 JNMD 190(1), 51-53 * Psychiatric Serv 41; 560-570. Frayne S et al. 2006.Arch Int Lawrence D et al 2003. med. 165;2631-2638 Br J Psych 182;31-36. Krein et al 2006 Psychia Serv Petersen LA et al 2003 57:1016–1021 Health Serv Res 38; 41-63. Sullivan et al. 2006 Psychiatr Jones L et al. 2005. Psychosom Serv 57:1126–1131 Med 67; 568-76. Weiss AP. et al 2006 Wang P et al. 2005. * Studies reporting substance Psychiatr Serv 57(8):1145-1152 Hypertension. 46; 273-279 abuse and/or mental illness Kreyenbuhl J et al 2006 Hippisley-Cox et al. 2007 Heart JNMD 194:404–410 ª 93:1256–1262 a Studies reporting on the same data set Goldberg RW et al. 2007 Psychiatr Serv 58:536–543 ª
  26. 26. Quality of Medical Treatment i Procedures
  27. 27. Meta-Analysis of Procedure Rate (PCI) after Myocardial Infarction Any Mental illness HR = 0.86 (0.80-0.92)
  28. 28. Meta-Analysis of Procedure Rate (PCI) after Myocardial Infarction Schizophrenia HR = 0.53 (0.44 – 0.64)
  29. 29. Quality of Medical Treatment i Medication
  30. 30. Inequality of Prescribed Meds ii Medication by Diagnosis OR =0.92 OR =0.68 OR =0.72 SMI Schz Affective
  31. 31. Inequality of Prescribed Meds ii Medication by Drug OR =0.99 OR =0.79 ns OR =0.83 OR =0.84 ns
  32. 32. Quality of Medical Treatment ii Medication by Drug OR =0.94 OR =0.96 ns
  33. 33. 4. Implication for Mortality
  34. 34. 5. Who Is Monitoring Physical Issues? Medical Colleagues Mental health Primary care
  35. 35. Disparities in care: impact of mental illness on diabetes management Depression Anxiety Psychosis Mania Substance use disorder Personality disorder 0.8 1.0 1.2 1.4 1.6 0.8 1.0 1.2 1.4 1.6 0.8 1.0 1.2 1.4 1.6 0.8 1.0 1.2 1.4 1.6 0.8 1.0 1.2 1.4 1.6 0.8 1.0 1.2 1.4 1.6 No HbA test No LDL test No Eye No Poor Poor Odds ratio for: done done examination Monitoring glycemic lipemic done control control 313,586 Veteran Health Authority patients with diabetes 76,799 (25%) had mental health conditions (1999) Frayne et al. Arch Intern Med. 2005;165:2631-2638
  36. 36. Monitoring patients DURING treatment with an atypical Buckley PF et al Schizophrenia Research 79 (2005) 281– 288
  37. 37. Frequency of baseline assessment PRIOR to initiating treatment with an atypical Buckley PF et al Schizophrenia Research 79 (2005) 281– 288
  38. 38. Summary of Monitoring Protocol Base 4 wk 8 wk 12 wk Quart Ann 5 yr line Personal/fam. Hist. X X Weight (BMI) X X X X X Waist circum. X X Blood press. X X X Fasting plasma glucose X X X Fasting lipid profile X X X American Diabetes Association and the American Psychiatric Association (ADA/ APA/AACE/NAASO, 2004).
  39. 39. 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
  40. 40. N=6000 pre-guideline N=18,000 post guideline
  41. 41. Screening for metabolic side effects in AO clients Review of 1966 case records from 53 teams, Barnes et al (2007) % with recorded Documented Documented measurement over diagnosis treatment last 12 months Blood pressure 26% Hypertension 6% 48% Measure of 17% obesity Blood glucose 28% Diabetes 6% 62% Plasma lipids 22% Dyslipidaemia 37% 6% All of the above 11% Slide credit: Dr Alan Farmer, Worcestershire Mental Health Partnership NHS Trust
  42. 42. Physical 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.
  43. 43. 6. Can inequalities be Improved?
  44. 44. NICE 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
  45. 45. 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 Interventions Diagnosis/Comprehensive Pr Pr Pr Pr/B1 B1/Pr B1//Pr B/Ps B/Ps B/Ps Ps P/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* Substance Use Problems Depressive Disorders Panic Disorder Severe Personality Disorder Somatization Social, Specific Phobias Other - Anxiety Disorders e.g. Substance Abuse Bipolar Disorder Substance Dependence Schizophrenia Pr Primary Care Provider * = in specialty setting B1 - Behavioral health B Specialist in PCP setting B2 - Behavorial Health specialist in specialty Ps setting Psychiatrist Note - did not include child (e.g. ADHD) Conditions/Populations geriatric (eg. dementia)
  46. 46. No 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
  47. 47. Conclusions 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

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