Journal Article Annotations
2017, 4th Quarter
Annotations by Lydia Chwastiak MD, MPH, FAPM, and Oliver Freudenreich, MD, FAPM
Type of study: Quasi-experimental, case control
The finding: This observational study aimed to evaluate the impact of a behavioral health home (BHH) on patients with psychosis, with respect to ER and inpatient utilization, and metabolic monitoring and outcomes. These outcomes were examined among 424 BHH patients in a single, urban safety net system in the year before and the year after the implementation of the BHH—and these changes were compared to those of 1521 patients who were not enrolled in a BHH. BHH patients had fewer psychiatric—but not medical—hosptializations, and fewer ER visits. BHH patients were more likely to receive A1c monitoring, but not lipid monitoring and there were no differences in clinical outcomes.
Strength and weaknesses: This report describes outcomes from a large-scale implementation of a behavioral health home. It specifies program elements in more details than previous reports from BHH initiatives.
Weaknesses: This study involved only a single healthcare organization (although a large one), which limits the generalizability of the findings. The quasi-experimental design with pre-post implementation comparison is not as rigorous as a clinical trial. Moreover, the intervention was implemented incrementally over 12 months. Mental health outcomes were not assessed, as these outcomes were not available in the EMR. Dataset was not able to distinguish medical from psychiatric ER visits.
Relevance: This study contributes to the (somewhat limited) existing literature on behavioral health homes by demonstrating significant reduction in ER visits and psychiatric hospitalizations and increased A1c monitoring among those patients enrolled in BHH.
Type of study: Meta-analysis
The finding: This meta-analysis included 69 studies, and over 35,000 people with severe mental illness—and found that individuals with serious mental illness were significantly more sedentary than age- and gender-matched healthy controls (p=0.003). Their mean amount of moderate or vigorous physical activity was significantly lower than that of healthy controls (p=0.002 for moderate activity, p<0.001 for vigorous activity). People with severe mental illness were significantly less likely than matched healthy controls to meet physical activity guidelines (odds ratio = 1.5; 95% CI: 1.1-2.0, p<0.001, I2=95.8).
Strength and weaknesses: The main strength of the study is the rigorous Meta-analytic methods, and the inclusion of data on over 35,000 individuals from research studies around the world.
Weaknesses: The main limitations reflect limitations in the studies that were included in the meta-analysis. First, the vast majority of the included studies relied on data from self-report questionnaires (rather than objective measures of physical activity). Second, the data were cross-sectional and there is a paucity of longitudinal physical activity research. Third, there was limited data on medications which precluded a specific analysis. Finally, there was high heterogeneity across the studies.
Relevance: Cardiovascular disease is the leading cause of premature mortality among people with serious mental illness, and sedentary behavior and lack of physical activity are modifiable risk factors. This meta-analysis provides a comprehensive review of the magnitude of this important risk factor.