Annotated Abstracts of Journal Articles
2014, 2nd Quarter
Annotations by Lydia Chwastiak, MD, MPH, FAPM and Oliver Freudenreich, MD, FAPM
Also of interest:
Consensus guidelines for the screening, diagnosis, and management of major risk factors for CVD have changed dramatically in the past several years. As a result, practitioners are now able to rely on non-fasting laboratory assessments for lipid profiles (non-HDL values) and blood glucose (hemoglobin A1c) to screen and diagnose dyslipidemia and diabetes. The use of non-fasting values to detect and manage common risk factors should lead to higher rates of screening by community mental health center prescribers, a critical first step to decreasing the mortality gap experienced by patients with serious mental illness.
Chwastiak LA, Davydow DS, McKibbin CL, et al
Psychosomatics 2014 Mar-Apr; 55(2):134-43
ANNOTATION (Chwastiak & Freudenreich)
The Finding: Among Medicare beneficiaries, rehospitalisation within 30 days of discharge occurs in almost 20% of patients, costing the healthcare system an estimated $17.4 billion. A key part of the comprehensive strategy of the Centers for Medicare and Medicaid Services to reduce costs is a focus on reducing 30-day rehospitalizations for heart failure, acute myocardial infarction, and pneumonia. In this study of all admissions in Washington State to community hospitals for diabetes between 2010-2011, a diagnosis of serious mental illness was independently associated with increased risk of early medical rehospitalization.
Strength and Weaknesses: This observational cohort study was comprised of a very large (82,060 adults in Washington State), population-based sample of patients who had a medical-surgical hospitalization between 2010 and 2011 with any discharge diagnosis indicating diabetes mellitus. The study sample is likely to be representative of patients in Washington State with diabetes, as data was obtained from all community hospitals in the state.
The study limitations relate to the use of administrative data. First, there may have been misclassification of patients with SMI disorders resulting in their inclusion in the reference group.
Moreover, the administrative dataset used for these analyses did not include information about health behaviors (such as smoking, sedentary lifestyle and poor diet), or laboratory or pharmacy data—so the impact of these important factors could not be evaluated.
Relevance: These findings may indicate poor quality of medical care for patients with diabetes who also have comorbid SMI—or may be further evidence that patients with SMI interact with the
healthcare system differently, and have unique barriers to adherence with medical care and follow-up. Improving the coordination or integration of outpatient medical and psychiatric care for these complex patients may decrease risk of early rehospitalizations.
Background: Medical-surgical rehospitalizations within a month after discharge among patients with diabetes result in tremendous costs to the US health care system.
Objective: The study’s aim was to examine whether co-morbid serious mental illness diagnoses (bipolar disorder, schizophrenia, or other psychotic disorders) among patients with diabetes are independently associated with medical-surgical rehospitalization within a month of discharge after an initial hospitalization.
Methods: This cohort study of all community hospitals in Washington state evaluated data from 82,060 adults discharged in the state of Washington with any International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis indicating diabetes mellitus between 2010 and 2011. Data on medical-surgical hospitalizations were obtained from the Washington State Comprehensive Hospital Abstract Reporting System. Co-morbid serious mental illness diagnoses were identified based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes indicating bipolar disorder, schizophrenia, or other psychotic disorders. Logistic regression analyses identified factors independently associated with rehospitalization within a month of discharge. Cox proportional hazard analyses estimated time to rehospitalization for the entire study period.
Results: After adjusting for demographics, medical co-morbidity, and characteristics of the index hospitalization, co-morbid serious mental illness diagnosis was independently associated with increased odds of rehospitalization within 1 month among patients with diabetes who had a medical-surgical hospitalization (odds ratio: 1.24, 95% confidence interval: 1.07, 1.44). This increased risk of rehospitalization persisted throughout the study period (up to 24 months).
Conclusions: Co-morbid serious mental illness in patients with diabetes is independently associated with greater risk of early medical-surgical rehospitalization. Future research is needed to define and specify targets for interventions at points of care transition for this vulnerable patient population.
ANNOTATION (Chwastiak & Freudenreich)
The Finding: The burden of lung cancer is increased in elderly patients with schizophrenia. In this study using a large population-based registry of patients with cancer, individuals with schizophrenia presented
with earlier stages of lung cancer but were less likely to undergo standard diagnostic evaluation or to receive stage-appropriate treatment. Survival was decreased among patients with schizophrenia, perhaps due to these differences in use of stage-appropriate treatment.
Strength and Weaknesses: The major strength of the paper is the use of a large population-based dataset of patients with cancer: the Surveillance, Epidemiology, and End Results (SEER) database
was linked to Medicare claims to assemble the study cohort. The SEER registry is sponsored by the National Cancer Institute and integrates data from 17 regional cancer registries throughout the United States. The SEER-Medicare database encompasses approximately 94% of individuals 65 years or older in the SEER registry.
Some limitations include that the study was limited to elderly patients, and the findings may not be generalizable to younger populations. Second, investigators were unable to evaluate the smoking history of study patients because of the lack of data on tobacco use in the SEER-Medicare database.
The study design also provided no information about the underlying reasons for suboptimal evaluation and treatment of patients with schizophrenia because these data are not available in the SEER-Medicare database.
Relevance: This study provides evidence of considerable inequalities in the lung cancer care received by elderly patients with schizophrenia, a finding that translates into worse survival
of these vulnerable individuals. This healthcare disparity is of particular concern given the persistently high rates of tobacco dependence among individuals with schizophrenia—and under-treatment by community mental health providers.
Objective: Cancer mortality is higher in individuals with schizophrenia, a finding that may be due, in part, to inequalities in care. We evaluated gaps in lung cancer diagnosis, treatment, and survival among elderly individuals with schizophrenia.
Methods: The Surveillance, Epidemiology, and End Results database linked to Medicare records was used to identify patients 66 years or older with primary non-small cell lung cancer. Lung cancer stage, diagnostic evaluation, and rates of stage-appropriate treatment were compared among patients with and without schizophrenia using unadjusted and multiple regression analyses. Survival was compared among groups using Kaplan-Meier methods.
Results: Of the 96,702 patients with non-small cell lung cancer in the Surveillance, Epidemiology, and End Results database, 1303 (1.3%) had schizophrenia. In comparison with the general population, patients with schizophrenia were less likely to present with late-stage disease after controlling for age, sex, marital status, race/ethnicity, income, histology, and comorbidities (odds ratio = 0.82, 95% confidence interval = 0.73-0.93) and were less likely to undergo appropriate evaluation (p < .050 for all comparisons). Adjusting for similar factors, patients with schizophrenia were also less likely to receive stage-appropriate treatment (odds ratio = 0.50, 95% confidence interval = 0.43-0.58). Survival was decreased among patients with schizophrenia (mean survival = 22.3 versus 26.3 months, p = .002); however, no differences were observed after controlling for treatment received (p = .40).
Conclusions: Elderly patients with schizophrenia present with earlier stages of lung cancer but are less likely to undergo diagnostic evaluation or to receive stage-appropriate treatment, resulting in poorer outcomes. Efforts to increase treatment rates for elderly patients with schizophrenia may lead to improved survival in this group.