[ppt] RCpsych - Failing medical care of psychiatric patients (vMar11)
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This is a 30min talk given at the RCPsych liaison conference 2011 on the topic of the failing (suboptimal) medical care provided to psychiatric patients by physicians and psychiatrists. Available in free full text PPT for a limited period.
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[ppt] RCpsych - Failing medical care of psychiatric patients (vMar11)
- 1. Alex J Mitchell see www.psycho-oncology.info Acknowledgements Oliver Lord Darren Malone Caroline Carney-Doebbling Nasser Abdelmawla Brett Thombs Roy Ziegelstein Jim Coyne Marc DeHert Davy Vancampfort Liaison faculty - Mar2011 Failing Medical Care of Psychiatric Patients Latest evidence on suboptimal medical care from physicians and psychiatrists
- 3. Quality of medical care In medical settings Quality of preventive care (mass screening) Quality of Psychiatric medical care Medication Prescribing in medical settings Procedures rate & Mortality
- 5. Merikangas (2007) NCS-R (n=5962) : disability days
- 6. Days totally out of role per year Alonso (2010) WHO MH Survey n=62,971
- 7. How much physical co-morbidity is there in mental ill health?
- 8. Sokal 2004 J Nerv Ment Dis 192: 421– 427 NHANES - US Department of Health National Health and Nutrition Examination Survey , 1988 –1994
- 9. Gili et al (2011) 10,257 Primary care in Spain
- 10. Metabolic syndrome meta-analysis in schizophrenia (Mitchell, DeHert et al unpublished)
- 11. MetS in First episode Patients Saddichha S et al. Schizophr Res 2008;101:266-72.
- 12. Lawrence & Coghlan N S W Public Health Bull 2002; 13(7): 155–158 n=240,000
- 13. Five-year Mortality rates 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
- 14. 2. Preventive Health Care Inequality Should vulnerable patients receive similar or enhanced care?
- 18. 3. Medical Health Care Inequality Medical monitoring eg HBA1c Medical procedures eg CABG Medical prescribing eg Aspirin post MI
- 19. Frayne et al. Arch Intern Med . 2005 Diab care 313,586 Veteran Health Authority patients with diabetes 76,799 (25%) had mental health conditions (1999) 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 glycemic control 0.8 1.0 1.2 1.4 1.6 Poor lipemic control Odds ratio for:
- 21. 3b. Inequalities in Procedures CABG – Coronary artery bypass graft CC - Cardiac catheterization PTCA – Percutaneous transluminal coronary angioplasty PCI - Percutaneous coronary intervention
- 22. Lawrence et al
- 23. Any Mental illness HR = 0.86 (0.80-0.92) Meta-Analysis of Procedure Rate (PCI) after Myocardial Infarction
- 24. Schizophrenia HR = 0.53 (0.44 – 0.64) Meta-Analysis of Procedure Rate (PCI) after Myocardial Infarction
- 25. 3c. Medication Prescribing Inequalities Aspirin ACE Inhibitors Statin / non-statin B-Blockers HAART HRT Chemotherapy
- 26. OR =0.94 (0.90-0.96) OR =0.69 (0.57-0.83) OR =0.72 (0.51-1.00) SMI Schz Affective Inequality of Prescribed Meds ii Medication by Diagnosis
- 27. OR =0.77 (0.69-0.86) Inequality of Prescribed Meds ii Medication by ALL
- 28. OR =0.79 OR =0.99 ns OR =0.83 OR =0.84 ns Inequality of Prescribed Meds ii Medication by drug class
- 29. OR =0.94 ns OR =0.96
- 30. 4. Inequality in Physical Care in Psychiatry
- 32. Bobes et al (2010) n=1193, 229 psychiatrists
- 34. Rothbard et al Psychiatric Services 2009; 60(4); (n=588)
- 35. Rothbard et al Proportion of Missed Medical Conditions……
- 36. Solution?......is the solution in (more) guidelines?
- 37. Summary of Monitoring Protocol American Diabetes Association and the American Psychiatric Association (ADA/ APA/AACE/NAASO, 2004). Base line 4 wk 8 wk 12 wk Quart Ann 5 yr 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
- 39. Monitoring Guidelines Simplified Adapted from Cohn TA, Sernyak M. Metabolic monitoring for patients treated with antipsychotic medications. Can J Psychiatry 2006;51:492–501. US-Mount Sinai Australia US-ADA–APA Belgium UK Canada Guidelines Apply to Which Groups? Schizophr, FGA/SGA All patients, FGA/SGA All patients, SGA Schizophr, SGA Schizophr, FGA/SGA Schizophr Biochemical Screening Fasting plasma glucose (FPG) Yes Yes Yes Yes Yes Yes Random glucose (RG) Yes Yes HbA1c optional No Yes OGTT Yes Yes Lipids Yes Yes Yes Yes Yes Physical Examination Weight Yes Yes Yes Yes Yes Waist circumference Yes Yes Yes Yes Yes Height Yes Yes Yes Yes Yes Hip Yes Yes Blood pressure Yes Yes Yes Yes Clinical Interview Family history Yes Yes Yes Yes Yes Past Medical history Yes Yes Yes Yes Yes Ethnicity Yes Yes Yes Tobacco Yes Yes Diet/activity Yes Yes Yes Diabetes signs/symptoms Yes Yes Yes Yes Yes
- 40. HR= 0.42 (0.34-0.50) Initiating antipsychotics
- 41. N=6000 pre-guideline N=18,000 post guideline
- 43. 5. Extras - Implication for Mortality
Editor's Notes
- Days out of role because of health problems are a major source of lost human capital. We examined the relative importance of commonly occurring physical and mental disorders in accounting for days out of role in 24 countries that participated in the World Health Organization (WHO) World Mental Health (WMH) surveys. Face-to-face interviews were carried out with 62 971 respondents (72.0% pooled response rate). Presence of ten chronic physical disorders and nine mental disorders was assessed for each respondent along with information about the number of days in the past month each respondent reported being totally unable to work or carry out their other normal daily activities because of problems with either physical or mental health. Multiple regression analysis was used to estimate associations of specific conditions and comorbidities with days out of role, controlling by basic socio-demographics (age, gender, employment status and country). Overall, 12.8% of respondents had some day totally out of role, with a median of 51.1 a year. The strongest individual-level effects (days out of role per year) were associated with neurological disorders (17.4), bipolar disorder (17.3) and post-traumatic stress disorder (15.2). The strongest population-level effect was associated with pain conditions, which accounted for 21.5% of all days out of role (population attributable risk proportion). The 19 conditions accounted for 62.2% of all days out of role. Common health conditions, including mental disorders, make up a large proportion of the number of days out of role across a wide range of countries and should be addressed to substantially increase overall productivity. Molecular Psychiatry advance online publication, 12 October 2010; doi:10.1038/mp.2010.101
- Abstract: We studied the medical comorbidity among individuals with serious mental illness who were receiving community-based psychiatric treatment. A total of 200 psychiatric outpatients divided between those with schizophrenia and affective disorder diagnoses were recruited from samples receiving outpatient care at two psychiatric centers. Interviews used questions from national health surveys. Logistic regression analyses compared responses from each sample with those of matched subsets of individuals from the general population. Both patient groups had greater odds of having many medical conditions. The odds of respiratory illnesses remained elevated in the patient groups even after controlling for smoking, as did the odds of diabetes in the affective disorder group after controlling for weight. Persons with serious mental illness who are in outpatient care are more likely to have comorbid medical conditions than persons in the general population. The odds of diabetes, lung diseases, and liver problems are particularly elevated. These findings underscore the need for intensified preventive health interventions and medical services for this population. Key Words: Comorbidity, medical, schizophrenia. ( J Nerv Ment Dis 2004;192: 421– 427) We hoped to overcome these deficiencies by using a thorough survey and a comparison group from the National Health Interview Survey (NHIS; US Department of Health and Human Services, 1998) and the National Health and Nutrition Examination Survey (NHANES; US Department of Health and Human Services, 1988 –1994). The purpose of the current study was to compare the prevalence of a variety of medical comorbidities among persons with schizophrenia and affective disorder (AD) with each other and with the prevalence in a matched control group from the general population. We hypothesized that the mentally ill groups would have higher comorbidity rates than the general population. We then used post hoc analyses to assess the extent to which the modifiable risk factors of smoking and body mass index (BMI) change the odds of having hypertension, diabetes, and respiratory disease in the psychiatric groups, anticipating that such modifiable factors would account for part of the increased comorbidity rates we expected to observe.
- 65% of depressions treated in primary care Gili M, Garcia-Toro M, Vives M, Armengol S, Garcia-Campayo J, Soriano JB, Roca M. Medical comorbidity in recurrent versus .rstepisode depressive patients. Objective: This study compares the comorbidity of a.ective disorders and medical diseases in primary care patients with either a .rst or recurrent depressive episode. Method: A cross-sectional epidemiological study in primary care centres in Spain was designed. A total of 10 257 primary care patients su.ering a DSM-IV major depressive episode (MDD) were analysed. Depression was assessed using the Montgomery–Asberg Depression Rating Scale (MADRS), and World Health Organization (WHO) medical diagnoses were provided by the patients general practitioner according to medical records revised on the basis of radiology or laboratory test data. Results: A total of 88.6% of recurrent patients and 71.1% of .rstepisode depressive patients reported a medical condition (aOR = 2.61, CI = 2.31–2.93). All medical conditions were more prevalent in the recurrent group than in .rst-episode group, and with the exception of myocardial infarction, psoriasis and migraine, all other crude ORs showed statistically signi.cant di.erences between .rst- and recurrent episodes patients after adjusting for gender, age, education, socioeconomic status and body mass index (BMI). Conclusion: Recurrent depression is associated with a decrement in health that is signi.cantly greater than in .rst-episode depression. Special attention needs to be paid to the physical health in the middleand long-term management of patients with a.ective disorders.
- Lawrence and Coghlan N S W Public Health Bull 2002; 13(7): 155–158
- Data on uptake of all of these Bold ones are those recommended in England
- ACS - Acute coronary syndrome (ACS) CABG – Coronary artery bypass graft CC - Cardiac catheterization PTCA – Percutaneous transluminal coronary angioplasty PCI - Percutaneous coronary intervention
- ACS - Acute coronary syndrome (ACS) CABG – Coronary artery bypass graft CC - Cardiac catheterization PTCA – Percutaneous transluminal coronary angioplasty PCI - Percutaneous coronary intervention
- Rfichard hodgson
- Bobes J, Alegría AA, Saiz-Gonzalez MD, Barber I, Pérez JL, Saiz-Ruiz J. Change in psychiatrists' attitudes towards the physical health care of patients with schizophrenia coinciding with the dissemination of the consensus on physical health in patients with schizophrenia. Eur Psychiatry. 2010 Purpose. – To evaluate the impact of the ‘‘Spanish Consensus on Physical Health in Patients with Schizophrenia’’ on psychiatrists’ evaluations of the physical health of patients with schizophrenia. Method. – Epidemiological, non-interventional, national, multicentre study, with two retrospective, cross-sectional data collection stages in which 229 psychiatrists evaluated 1193 clinical records of patients with schizophrenia (ICD-10) seen in January and September of 2007. Results. – Mean age of the patients was 39.7 11.6 years, 65.5% were men, diagnosed for schizophrenia 14.0 10.3 years ago. Forty percent of the patients suffer from a concomitant disease, the most prevalent being hypercholesterolemia (46.3%), hypertriglyceridaemia (33.5%) and arterial hypertension (26.0%). The difference in the number of patients who had all the physical measurements taken between the two cross-sectional evaluations was 13.8% (CI: 11.8%, 15.7%). The differences for each parameter were: weight 13.7% (CI: 11.7%, 15.6%), BMI 13.58% (CI: 11.6%, 15.5%), waist circumference 14.0% (CI: 12.0%, 15.39%), lipid pro.le 2.9% (CI: 1.9%, 3.9%) and glycaemia 2.6% (CI: 1.7%, 3.5%). Conclusions. – These results imply that the dissemination of the ‘‘Consensus on Physical Health in Schizophrenia Patients’’, and possibly other actions, has made psychiatrists more aware of an integral approach to patients with schizophrenia, promoting increasedmonitoring of the physical health of these patients. 2010 Elsevier Masson SAS. All rights reserved.
- Rothbard et al PSYCHIATRIC SERVICES April 2009 Vol. 60 No. 4
- Rothbard et al PSYCHIATRIC SERVICES April 2009 Vol. 60 No. 4
- Useful consensus-based recommendations for screening and monitoring metabolic risks, specifically among schizophrenia patients, have been developed jointly by the American Diabetes Association and the American Psychiatric Association (ADA/ APA/AACE/NAASO, 2004; World Federation for Mental Health, 2005).
- Background: This study investigated whether differences in quality of medical care might explain a portion of the excess mortality associated with mental disorders in the year after myocardial infarction. Methods: This study examined a national cohort of 88241 Medicare patients 65 years and older who were hospitalized for clinically confirmed acute myocardial infarction. Proportional hazard models compared the association between mental disorders and mortality before and after adjusting 5 established quality indicators: reperfusion, aspirin, b-blockers, angiotensin-converting enzyme inhibitors, and smoking cessation counseling. All models adjusted for eligibility for each procedure, demographic characteristics, cardiac risk factors and history, admission characteristics, left ventricular function, hospital characteristics, and regional factors. Results: After adjusting for the potential confounding factors, presence of any mental disorder was associated with a 19% increase in 1-year risk of mortality (hazard ratios [HR], 1.19; 95% confidence interval [CI], 1.04-1.36). After adding the 5 quality measures to the model, the association was no longer significant (HR, 1.10; 95% CI, 0.96-1.26). Similarly, while schizophrenia (HR, 1.34; 95% CI, 1.01-1.67) and major affective disorders (HR, 1.11; 95% CI, 1.02-1.20) were each initially associated with increased mortality, after adding the quality variables, neither schizophrenia (HR, 1.23; 95% CI, 0.86-1.60) nor major affective disorder (HR, 1.05; 95% CI, 0.87-1.23) remained a significant predictor. Conclusions: Deficits in quality of medical care seemed to explain a substantial portion of the excess mortality experienced by patients with mental disorders after myo-cardial infarction. The study suggests the potential importance of improving these patients’ medical care as a step toward reducing their excess mortality. Arch Gen Psychiatry. 2001;58:565-572