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

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40H

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Rhe

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Hea

rt c

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Ost

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Any

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Stro

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Emph

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Live

r pro

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s

Wea

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kid

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Con

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hear

tfa

ilure

Myo

card

ial i

nfar

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Ang

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Cor

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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