[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.TRANSCRIPT
Alex J Mitchell see www.psycho-oncology.info
AcknowledgementsOliver LordDarren MaloneCaroline Carney-DoebblingNasser AbdelmawlaBrett ThombsRoy ZiegelsteinJim CoyneMarc DeHertDavy Vancampfort Liaison faculty - Mar2011
Failing Medical Care of Psychiatric Patients Latest evidence on suboptimal medical care from physicians and psychiatrists
Contents1. Mental Health & Physical Health
Mortality | Impairment | Co-morbidity
2. Preventive Health Care InequalityScreening | prevention
3. Medical Health Care InequalityProcedures | prescribing
4. Physical and Metabolic Monitoring?Guidelines & responsibility
5. Implications for Mortality
Quality of medical careIn medical settings
Quality of preventive care(mass screening)
Quality of Psychiatric medical care
Medication Prescribing in medical settings
Procedures rate & Mortality
1. Physical Health Comorbidity / Mortality
Merikangas (2007) NCS-R (n=5962) : disability days
34.4
42.9 42.7
33.8
39.3
41.239.8
30.6
36.6
9
14.315.2
3.9
7.3
17.3
7.7
1.92.5
5.1
2.6 2.2 1.8 1.7 1.4 10.3 0.1
0
5
10
15
20
25
30
35
40
45
50
Depression Panic disorder PTSD Specific phobia Social phobia Bipolar disorder GAD Alcohol abuse Drug abuse
Yearly DOR
Unique
PAR%
Days totally out of role per yearAlonso (2010) WHO MH Survey n=62,971
How much physical co-morbidity is there in mental ill health?
Physical Comorbidity in Schizophrenia and Depression
0
5
10
15
20
25
30
35
40H
yper
tens
ion
Chr
onic
bro
nchi
tis
Ast
hma
Dia
bete
s
Ulc
er
Rhe
umat
oid
arth
ritis
Hea
rt c
ondi
tion
Ost
eoar
thrit
is
Any
can
cer
Stro
ke
Emph
ysem
a
Live
r pro
blem
s
Wea
k/fa
iling
kid
neys
Con
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ive
hear
tfa
ilure
Myo
card
ial i
nfar
ctio
n
Ang
ina
Cor
onar
y he
art
dise
ase
SchizophreniaDepressionNHANES
Sokal 2004 J Nerv Ment Dis 192:
421– 427
NHANES - US Department of Health National Health and Nutrition Examination Survey , 1988 –1994
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Card
iova
scul
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iseas
eFu
nctio
nal s
omat
ic sy
ndro
mes
Osteoa
rticu
lar di
sord
ers
Neu
rolo
gical
dise
ases
Derm
atol
ogica
l dise
ases
Endo
crin
e dis
orde
rsRe
spira
tory
dise
ases
Dige
stive
dise
ases
: Ulce
r
Urin
ary
tract
dise
ase:
Ren
al lit
hias
is
Any m
edic
al di
sord
er
First Episode MDD (n=6090)
Recurrent Episode MDD (n=4167)
Gili et al (2011) 10,257 Primary care in Spain
Proportion meta-analysis plot [random effects]
0.0 0.2 0.4 0.6 0.8 1.0
combined 0.3227 (0.2882, 0.3581)
Saddicha et al (2007) [Females] 0.0333 (0.0008, 0.1722)
Padmavati et al (2010) 0.0392 (0.0048, 0.1346)
De Hert et al (2008) 0.0556 (0.0207, 0.1170)
Saddichha et al (2008) [ATPIII-A] 0.0909 (0.0424, 0.1656)
Baptista et al (2010) [Females] 0.1039 (0.0459, 0.1945)
De Hert et al (2010) [Sertindole] 0.1327 (0.0726, 0.2162)
Rezaei et al (2009) [Males] 0.1435 (0.1003, 0.1965)
Saddichha et al (2008) [IDF] 0.1818 (0.1115, 0.2720)
Kurt et al (2007) 0.1892 (0.1462, 0.2385)
Bernardo et al (2009) 0.1926 (0.1577, 0.2316)
Saari et al (2005) 0.1935 (0.0745, 0.3747)
Bai et al (2009) [Risperidone] 0.1942 (0.1463, 0.2498)
L’Italien (2007) [Aripiprazole] 0.1985 (0.1524, 0.2515)
De Hert et al (2010) [Risperidone] 0.2095 (0.1362, 0.2999)
Boke et al (2008) [Males] 0.2241 (0.1645, 0.2934)
Meyer et al (2009) [Black/Hispanic] [Olanzapine] 0.2273 (0.1331, 0.3470)
Bai et al (2009) [Olanzapine] 0.2447 (0.1619, 0.3442)
Kaya et al (2009) [Females] 0.2500 (0.1212, 0.4220)
Rejas et al (2007) [Females][ATPIII-A] 0.2559 (0.2200, 0.2943)
Rejas et al (2007) [Males][ATP III-A] 0.2561 (0.2273, 0.2866)
L’Italien (2007) [Placebo] 0.2581 (0.1912, 0.3344)
Baptista et al (2010) [Males] 0.2614 (0.1981, 0.3328)
Yazici et al (2010) [Males] 0.2766 (0.2047, 0.3582)
L’Italien (2007) [Aripiprazole Active] 0.2789 (0.2344, 0.3270)
Bai et al (2009) [Clozapine] 0.2857 (0.2284, 0.3486)
van Winkel et al (2008) [Schizophrenia] 0.2883 (0.2490, 0.3300)
Meyer et al (2009) [White][Aripiprazole] 0.2895 (0.1911, 0.4049)
Meyer et al (2009) [Black/Hispanic][Aripiprazole] 0.3239 (0.2176, 0.4455)
Hagg et al (2006) [Males] 0.3277 (0.2591, 0.4021)
Meyer et al (2009) [White][Olanzapine] 0.3297 (0.2347, 0.4361)
Kaya et al (2009) [Males] 0.3333 (0.2076, 0.4792)
McEvoy et al (2005) [Males] 0.3602 (0.3184, 0.4037)
Suvisaari et al (2007) [Schizophrenia] 0.3684 (0.2181, 0.5401)
Srisurapanont et al (2007) 0.3684 (0.2181, 0.5401)
Vuksan-Cusa et al (2010) 0.3710 (0.2516, 0.5031)
Hagg et al (2006) [Females] 0.3804 (0.2812, 0.4876)
Shi et al (2009) 0.3887 (0.3727, 0.4050)
Yazici et al (2010) [Females] 0.3933 (0.3210, 0.4691)
L’Italien (2007) [Olanzapine] 0.4155 (0.3650, 0.4674)
Brunero et al (2009) [Females][IDF] 0.4286 (0.2446, 0.6282)
Ramos-Rios et al (2010) 0.4561 (0.3799, 0.5339)
Maslow et al (2010) 0.4585 (0.3889, 0.5294)
Rezaei et al (2009) [Females] 0.4698 (0.3876, 0.5532)
Correll et al (2008) [Males][ATP III-A] 0.4815 (0.3434, 0.6216)
Correll et al (2008) [Males] 0.4815 (0.3434, 0.6216)
McEvoy et al (2005) [Females] 0.5140 (0.4383, 0.5892)
Correll et al (2010) (fasting cohort) 0.5166 (0.4829, 0.5503)
Steylen et al (2009) [Males] 0.5217 (0.3695, 0.6711)
Correll et al (2008) [Females][ATPIII-A] 0.5614 (0.4236, 0.6926)
Correll et al (2008) [Females] 0.5614 (0.4236, 0.6926)
Brunero et al (2009) [ATP] 0.5753 (0.4541, 0.6903)
Boke et al (2008) [Females] 0.6140 (0.4757, 0.7400)
Kato et al (2004) 0.6250 (0.4735, 0.7605)
Brunero et al (2009) [Males][IDF] 0.7333 (0.5806, 0.8540)
Steylen et al (2009) [Females] 0.8750 (0.6165, 0.9845)
proportion (95% confidence interval)
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
0 5 10 15 20 25
Schizophrenia & Related Psychoses
Schizophrenia Alone
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Clozapine(N=14)
Olanzapine(N=16)
Risperidone(N=18)
Aripiprazole(N=4)
Sertindole (n=4) Unmedicated(N=9)
Metabolic syndrome meta-analysis in schizophrenia (Mitchell, DeHert et al unpublished)
MetS in First episode Patients
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
Mets by ATP IIIA Mets by IDF BP (>130/85) HDL (M<40mg/dl, F<50
mg/dl)
TGL (>150mg/dl)
Glucose (>100mg/dl)
ATP IIIA Waist(M>102, F>88)
Saddichha S et al. Schizophr Res 2008;101:266-72.
Lawrence & Coghlan N S W Public Health Bull 2002; 13(7): 155–158 n=240,000
Five-year Mortality rates28%
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
2. Preventive Health Care Inequality
Should vulnerable patients receive similar or enhanced care?
Annual physical health checks(NSF for mental health/NICE guidance)
Blood pressure & weight/BMI
Lifestyle advice (smoking/diet/exercise/alcohol/drugs)
Urine/glucose 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
Mass Screening activitiesMammography
Pap. Smear
Lifestyle counselling
Blood pressure
Bowel cancer screening
Prostate PSA
Osteoporosis
Hepatitis & HIV tests
USPST recommendationsScreening mammography every 1-2 years starting at age 40
UK NSC (England)Age 50-70 every 3 years
OR of 0.7P<0.0001
Summary meta-analysis plot [random effects]
0.001 0.01 0.1 0.2 0.5 1 2 5
combined 0.709 (0.642, 0.784)
Lindamer et al (2003) 0.040 (0.002, 0.250)
Schwartz et al (2003) 0.310 (0.100, 0.960)
Werneke et al. (2006) [psychosis] 0.330 (0.180, 0.610)
Carney & Jones (2006) [high severity] 0.340 (0.280, 0.420)
Lasser et al (2003) 0.350 (0.240, 0.510)
Carney & Jones (2006) 0.380 (0.330, 0.430)
Werneke et al. (2006) [any] 0.400 (0.290, 0.550)
Carney & Jones (2006) [medium severity] 0.470 (0.330, 0.670)
Ludman et al (2010) 0.490 (0.310, 0.760)
Druss et al (2002) 0.520 (0.340, 0.790)
Carney & Jones (2006) [high severity] 0.560 (0.260, 1.210)
Carney & Jones (2006) [low severity] 0.590 (0.450, 0.780)
Iezzoni et al (2001) 0.600 (0.400, 1.100)
Leiferman et al (2006) 0.610 (0.350, 1.060)
Carney & Jones (2006) 0.620 (0.590, 0.660)
Carney & Jones (2006) [medium severity] 0.630 (0.570, 0.690)
Chochinov et al (2009) 0.640 (0.580, 0.710)
masterton et al (2010) 0.670 (0.420, 1.075)
Thorpe et al (2006) 0.680 (0.340, 1.370)
masterton et al (2010) 0.685 (0.448, 1.040)
Druss et al (2002) 0.780 (0.670, 0.910)
Patten et al (2009) 0.800 (0.400, 1.600)
Druss et al (2008) [specialist] 0.820 (0.690, 0.970)
Druss et al (2008) 0.820 (0.790, 0.847)
Pirraglia et al (2004) 0.840 (0.730, 0.970)
Stecker et al (2007) 0.867 (0.662, 1.130)
Werneke et al. (2006) [any] 0.910 (0.800, 1.040)
Carney & Jones (2006) [low severity] 0.930 (0.890, 0.970)
Carney & Jones (2006) 0.980 (0.950, 1.010)
Peytremann- Bridevaux et al (2008) 1.000 (0.800, 1.200)
Pirraglia et al (2004) 1.010 (0.860, 1.180)
Druss et al (2008) [primary care] 1.350 (1.160, 1.610)
Green and Pope (2000) 1.370 (1.040, 1.810)
Schwartz et al (2003) 2.790 (0.730, 1.720)
odds ratio (95% confidence interval)
Receipt of Mammograpy by mental illness(Mitchell, Lord currently unpublished)
3. Medical Health Care Inequality
Medical monitoring eg HBA1c
Medical procedures eg CABG
Medical prescribing eg Aspirin post MI
Frayne et al. Arch Intern Med. 2005 Diab care
313,586 Veteran Health Authority patients with diabetes76,799 (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:
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
3b. Inequalities in Procedures
CABG – Coronary artery bypass graftCC - Cardiac catheterizationPTCA – Percutaneous transluminal coronary angioplastyPCI - Percutaneous coronary intervention
Lawrence et al
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
3c. Medication Prescribing Inequalities
AspirinACE InhibitorsStatin / non-statinB-BlockersHAARTHRTChemotherapy
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
OR =0.77 (0.69-0.86)
Inequality of Prescribed Meds ii Medication by ALL
OR =0.79 OR =0.99ns
OR =0.83 OR =0.84ns
Inequality of Prescribed Meds ii Medication by drug class
OR =0.94ns
OR =0.96
4. Inequality in Physical Care in Psychiatry
Physical Screening of Psychiatric Patients57.6% 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.
0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0
Syphilis test
Ophthalmologist visit
HIV test
HBV-HCV test
Dentist visit / check-up
Respiratory exam including auscultation
Prolactin test
Electrocardiogram
Familiar physical health history
Physical exam
Sexual functioning history
Urine test
Haemogram
Basal creatinine
Blood pressure
Liver function tests
Bobes et al (2010) n=1193, 229 psychiatrists
Screening for metabolic side effects in AO clientsReview of 1966 case records from 53 teams, Barnes et al
(2007)
% with recorded measurement over last 12 months
Documented diagnosis
Documented treatment
Blood pressure
26% Hypertension 6%
48%
Measure of obesity
17%
Blood glucose 28% Diabetes 6% 62%
Plasma lipids 22% Dyslipidaemia 6%
37%
All of the above
11%
Slide credit: Dr Alan Farmer, Worcestershire Mental Health Partnership NHS Trust
0.138
0.108
0.025
0.005
0.080
0.015
0.175 0.179 0.177 0.175
0.256
0.219
0.037
0.071
0.153
0.1700.177
0.204
0.000
0.050
0.100
0.150
0.200
0.250
0.300
High glucoselevels
Hepatitis C High totalcholesterol
levels
High triglyceridelevels
HIV Hepatitis B
Clinician detected
Lab detected
missed
Rothbard et al Psychiatric Services 2009; 60(4); (n=588)
0.213
0.398
0.861
0.970
0.688
0.931
0.000
0.100
0.200
0.300
0.400
0.500
0.600
0.700
0.800
0.900
1.000
High glucoselevels
Hepatitis C High totalcholesterol
levels
High triglyceridelevels
HIV Hepatitis B
Rothbard et al Proportion of Missed Medical Conditions……
Solution?......is the solution in (more) guidelines?
Summary of Monitoring Protocol
Base line 4 wk 8 wk 12
wkQuar
t Ann 5 yr
Personal/fam. Hist. X XWeight (BMI) X X X X XWaist circum. X XBlood press. X X XFasting plasma glucose X X XFasting lipid profile X X X
American Diabetes Association and the American Psychiatric Association (ADA/ APA/AACE/NAASO, 2004).
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,
SGASchizophr,
SGASchizophr, 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
Proportion meta-analysis plot [random effects]
0.0 0.2 0.4 0.6 0.8 1.0
combined 0.42 (0.34, 0.50)
Gul et al (2006) baseline 0.10 (0.04, 0.21)
Batscha et al (2010) 0.11 (0.01, 0.33)
Morrato et al (2009) baseline 0.13 (0.12, 0.13)
Mackin et al (2007) 0.13 (0.07, 0.22)
Holt et al (2009) outpatients 0.14 (0.06, 0.27)
Haupt et al (2009) preguideline: baseline 0.17 (0.16, 0.18)
Holt et al (2009) inpatients 0.18 (0.09, 0.31)
Morrato et al (2008) 0.19 (0.19, 0.19)
Moeller et al (2011) 0.23 (0.21, 0.25)
Morrato et al (2009) 0.23 (0.22, 0.24)
Gonzalez et al (2010) first audit: baseline 0.25 (0.17, 0.33)
Morrato et al (2010) prewarning 0.27 (0.27, 0.27)
Barnes et al (2008) (baseline) 0.28 (0.26, 0.30)
Shi et al (2009) 0.29 (0.28, 0.31)
Nguyen et al (2009) 0.34 (0.25, 0.45)
Taylor et al (2004) 0.41 (0.37, 0.45)
Boilson & Hamilton (2003) 0.50 (0.35, 0.65)
Crabb et al (2009) 0.56 (0.45, 0.66)
Hsu et al (2008) 0.57 (0.55, 0.59)
Batscha et al (2010) 0.58 (0.28, 0.85)
Jennex et al (2008) 0.59 (0.48, 0.68)
Organ et al (2010) 0.60 (0.56, 0.64)
Motsinger et al (2006)_All 0.63 (0.57, 0.69)
Copeland et al (2010) 0.64 (0.64, 0.65)
Kilbourne et al (2007) 0.69 (0.63, 0.74)
Bobes et al (2010) (baseline) 0.71 (0.68, 0.73)
Mangurian et al (2010) 0.71 (0.57, 0.83)
Voruganti et al (2007) 0.78 (0.75, 0.80)
Tarrant et al (2006) 0.82 (0.69, 0.91)
Gumber et al (2010) (baseline) 0.92 (0.84, 0.96)
proportion (95% confidence interval)
HR= 0.42 (0.34-0.50)Initiating antipsychotics
N=6000 pre-guidelineN=18,000 post guideline
ConclusionsCo-morbidity and mortality is high
Excess medical deaths > non-accidental deaths 4:1
Quality of medical care is below usual standard prescribing | procedures after MI
Physical health monitoring is poor
Guidelines accumulating but implementation lacking
5. Extras - Implication for Mortality
Quality of Care Influencing=> Mortality?Druss et al 2000 113,653Druss et al 2001 88,241Jones et al 2005 3,368Kisely et al 2007 13,626Lawrence et al 2003 210,129pLi et al 2007 39,839*Petersen et al 2003 4,340Plomondon et al 2007 14,194nsYoung et al 2000 354,195u