Longitudinal Patterns of Health System Retention Among Veterans with Schizophrenia or Bipolar Disorder

Center for Mental Healthcare and Outcomes Research, HSR&D, Central Arkansas Veterans Healthcare System, North Little Rock, AR 72114-1706, USA.
Community Mental Health Journal (Impact Factor: 1.03). 05/2008; 44(5):321-30. DOI: 10.1007/s10597-008-9133-z
Source: PubMed


Inconsistent service use for schizophrenia and bipolar disorder is associated with poorer outcomes of care. We analyzed VHA National Psychosis Registry data for 164,150 veterans with these disorders to identify characteristics associated with 5-year patterns of survival and with retention in VHA care. Most cohort members (63%) survived the period with no break in VHA healthcare lasting over 12 months. Inconsistent utilization was associated with younger age, no service-connected disability, and less physical comorbidity, regardless of diagnosis. The influence of gender and ethnicity on attrition varied by diagnosis and gap-duration. Variation in attrition by gender and ethnicity warrants additional attention.

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    • "These groups had different patterns of attrition, with the high attendance group leaving in a steady manner throughout the follow-up period while the low attendance group experienced initial extreme attrition followed by steady, moderate-level loss. Our study found that increased perceived family treatment support was associated with shorter time to attrition, a result that runs contrary to previous research on treatment engagement in psychiatric patients (e.g., Fischer et al. 2008a, b) and suggests the need for collaboration between families and caregivers of patients. The relationship between increased perceived cost of care and earlier attrition mirrors previous work that found increased attrition in patients who expected care to be more expensive or require increased time commitments (Rossi et al. 2002; Young et al. 2000). "
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    ABSTRACT: Disengagement from outpatient care following psychiatric hospitalization is common in high-utilizing psychiatric patients and contributes to intensive care utilization. To investigate variables related to treatment attrition, a range of demographic, diagnostic, cognitive, social, and behavioral variables were collected from 233 veterans receiving inpatient psychiatric services who were then monitored over the following 2 years. During the follow-up period, 88.0 % (n = 202) of patients disengaged from post-inpatient care. Attrition was associated with male gender, younger age, increased expectations of stigma, less short-term participation in group therapy, and poorer medication adherence. Of those who left care, earlier attrition was predicted by fewer prior-year inpatient psychiatric days, fewer lifetime psychiatric hospitalizations, increased perceived treatment support from family, and less short-term attendance at psychiatrist appointments. Survival analyses were used to analyze the rate of attrition of the entire sample as well as the sample split by short-term group therapy attendance. Implications are discussed.
    Community Mental Health Journal 10/2012; 49(6). DOI:10.1007/s10597-012-9544-8 · 1.03 Impact Factor
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    • "[12] Moreover, patients with schizophrenia are less likely to remain engaged in appropriate health care, although when mentally ill patients are "well-engaged" in care, appropriate care is more likely. [13-15] Dixon's research group noted diminished quality of care for patients with both serious mental illness (schizophrenia or major mood disorder) and diabetes, relative to patients with diabetes alone, in their study of quality indicators. [16] This is a troubling finding in view of the high level of risk factors for diabetes among VA patients with serious mental illness. "
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    ABSTRACT: Patients with schizophrenia have difficulty managing their medical healthcare needs, possibly resulting in delayed treatment and poor outcomes. We analyzed whether patients reduced primary care use over time, differentially by diagnosis with schizophrenia, diabetes, or both schizophrenia and diabetes. We also assessed whether such patterns of primary care use were a significant predictor of mortality over a 4-year period. The Veterans Healthcare Administration (VA) is the largest integrated healthcare system in the United States. Administrative extracts of the VA's all-electronic medical records were studied. Patients over age 50 and diagnosed with schizophrenia in 2002 were age-matched 1:4 to diabetes patients. All patients were followed through 2005. Cluster analysis explored trajectories of primary care use. Proportional hazards regression modelled the impact of these primary care utilization trajectories on survival, controlling for demographic and clinical covariates. Patients comprised three diagnostic groups: diabetes only (n = 188,332), schizophrenia only (n = 40,109), and schizophrenia with diabetes (Scz-DM, n = 13,025). Cluster analysis revealed four distinct trajectories of primary care use: consistent over time, increasing over time, high and decreasing, low and decreasing. Patients with schizophrenia only were likely to have low-decreasing use (73% schizophrenia-only vs 54% Scz-DM vs 52% diabetes). Increasing use was least common among schizophrenia patients (4% vs 8% Scz-DM vs 7% diabetes) and was associated with improved survival. Low-decreasing primary care, compared to consistent use, was associated with shorter survival controlling for demographics and case-mix. The observational study was limited by reliance on administrative data. Regular primary care and high levels of primary care were associated with better survival for patients with chronic illness, whether psychiatric or medical. For schizophrenia patients, with or without comorbid diabetes, primary care offers a survival benefit, suggesting that innovations in treatment retention targeting at-risk groups can offer significant promise of improving outcomes.
    BMC Health Services Research 08/2009; 9(1):127. DOI:10.1186/1472-6963-9-127 · 1.71 Impact Factor
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    ABSTRACT: We present an overview of the literature on the patterns of mental health service use and the unmet need for care in individuals with schizophrenia with a focus on studies in the United States. We also present new data on the longitudinal course of treatments from a study of first-admission patients with schizophrenia. In epidemiological surveys, approximately 40% of the respondents with schizophrenia report that they have not received any mental health treatments in the preceding 6-12 months. Clinical epidemiological studies also find that many patients virtually drop out of treatment after their index contact with services and receive little mental health care in subsequent years. Clinical studies of patients in routine treatment settings indicate that the treatment patterns of these patients often fall short of the benchmarks set by evidence-based practice guidelines, while at least half of these patients continue to experience significant symptoms. The divergence from the guidelines is more pronounced with regard to psychosocial than medication treatments and in outpatient than in inpatient settings. The expansion of managed care has led to further reduction in the use of psychosocial treatments and, in some settings, continuity of care. In conclusion, we found a substantial level of unmet need for care among individuals with schizophrenia both at community level and in treatment settings. More than half of the individuals with this often chronic and disabling condition receive either no treatment or suboptimal treatment. Recovery in this patient population cannot be fully achieved without enhancing access to services and improving the quality of available services. The recent expansion of managed care has made this goal more difficult to achieve.
    Schizophrenia Bulletin 08/2009; 35(4):679-95. DOI:10.1093/schbul/sbp045 · 8.45 Impact Factor
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