Unforeseen Inpatient Mortality Among Veterans With Schizophrenia

University of Texas at San Antonio, San Antonio, Texas, United States
Medical Care (Impact Factor: 3.23). 02/2006; 44(2):110-6. DOI: 10.1097/01.mlr.0000196973.99080.fb
Source: PubMed


Patients with schizophrenia have co-occurring medical conditions, like other patients, but may lack the capacity to provide good self-care or to work with their providers to ensure appropriate medical treatment. We hypothesized that death among patients with schizophrenia occurs more frequently after minimal care of comorbid conditions.
All patients who died in veterans affairs (VA) hospitals during FY02 were categorized as to type of death: unforeseen (age <80 years, 1-2 inpatient days past year), cancer, organ failure (heart, lungs, kidneys), frailty (dementias, hip fractures, dehydration, etc.), or other deaths. Logistic regression explored factors in unforeseen death.
During the year, 27,798 patients died in VA facilities; 3% had schizophrenia (n = 943). Roughly two-thirds of all deaths were from cancer or organ failure, 11% frailty, 9% other, and 8% met criteria for unforeseen death. Among patients with schizophrenia, however, 20% fell into the unforeseen death category. In an adjusted model, schizophrenia was associated with a 2-fold increased risk of unforeseen death compared with any other category (odds ratio = 2.4, 95% confidence interval 1.6-3.4). Unforeseen death was less likely among patients with substance abuse diagnoses in the year before death and more likely when patients had no outpatient medical care.
VA patients with schizophrenia were more likely to die as inpatients with little previous-year care compared with other inpatient decedents without schizophrenia. Outreach efforts may be necessary to engage patients with schizophrenia in treatment of potentially life-threatening conditions.

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    • "Persons with serious mental illnesses (SMI), e.g., bipolar disorder or schizophrenia, experience a disproportionate burden in morbidity and premature mortality from common medical conditions including cardiovascular diseases and certain cancers [1-3]. These physical health disparities may be exacerbated by long gaps in care from the healthcare system due to psychiatric symptoms or access barriers such as lack of transportation, insurance, or relationship with a primary care provider [4,5]. Many evidence-based practices help to mitigate these risks when this population remains engaged in care [6]. "
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    ABSTRACT: Persons with serious mental illness are disproportionately burdened by premature mortality. This disparity is exacerbated by poor continuity of care with the health system. The Veterans Health Administration (VA) developed Re-Engage, an effective population-based outreach program to identify veterans with SMI lost to care and to reconnect them with VA services. However, such programs often encounter barriers getting implemented into routine care. Adaptive designs are needed when the implementation intervention requires augmentation within sites that do not initially respond to an initial implementation intervention. This protocol describes the methods used in an adaptive implementation design study that aims to compare the effectiveness of a standard implementation strategy (Replicating Effective Programs, or REP) with REP enhanced with External Facilitation (enhanced REP) to promote the uptake of Re-Engage.Methods/design: This study employs a four-phase, two-arm, longitudinal, clustered randomized trial design. VA sites (n = 158) across the United States with a designated Re-Engage provider, at least one Veteran with SMI lost to care, and who received standard REP during a six-month run-in phase. Subsequently, 88 sites with inadequate uptake were stratified at the cluster level by geographic region (n = 4) and VA regional service network (n = 20) and randomized to REP (n = 49) vs. enhanced REP (n = 39) in phase two. The primary outcome was the percentage of veterans on each facility outreach list documented on an electronic web registry. The intervention was at the site and network level and consisted of standard REP versus REP enhanced by external phone facilitation consults. At 12 months, enhanced REP sites returned to standard REP and 36 sites with inadequate participation received enhanced REP for six months in phase three. Secondary implementation outcomes included the percentage of veterans contacted directly by site providers and the percentage re-engaged in VA health services. Adaptive implementation designs consisting of a sequence of decision rules that are tailored based on a site's uptake of an effective program may produce more relevant, rapid, and generalizable results by more quickly validating or rejecting new implementation strategies, thus enhancing the efficiency and sustainability of implementation research and potentially leading to the rollout of more cost-efficient implementation strategies.Trial registration: Current Controlled Trials ISRCTN21059161.
    Full-text · Article · Nov 2013 · Implementation Science
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    • "Premature mortality among individuals with schizophrenia is well documented in the literature [1,2]. The increased mortality rates of these individuals is linked to their increased burden of medical [3,4] and psychiatric [5] comorbidities. Physical disorders in individuals with schizophrenia account for an estimated 60% of premature deaths [6], yet, these individuals are less likely to seek appropriate care and may use medical services intermittently, leading to unresolved medical problems, decreased treatment adherence, and premature mortality [7], which might be preventable with appropriate care. "
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    ABSTRACT: Background Schizophrenia is associated with excess mortality and multimorbidity, which is possibly associated with difficulty in coordinating care for multiple mental and physical comorbidities. We analyzed the receipt by patients with schizophrenia of 11 types of guideline-concordant care and the association of such care with survival. Methods Guideline-concordant care over an 8-year period (financial years 2002 to 2009) was examined in a nationwide sample of 49,173 male veterans with schizophrenia, who were aged 50 years or older. Administrative databases from the electronic medical record system of the Veterans Health Administration (VA) provided comprehensive measures of patient demographics and medical information. Relying on the 2004 American Psychiatric Association guidelines, patterns in 11 types of care were identified and cluster-analyzed. Care types included cardiovascular, metabolic, weight management, nicotine dependence, infectious diseases, vision, and mental health counseling (individual, family, drugs/alcohol, psychiatric medication, and compensated work therapy). Survival analysis estimated association of care patterns with survival, adjusting for clinical and demographic covariates. Results There was an average of four chronic diseases in addition to schizophrenia in the cohort, notably hypertension (43%) and dyslipidemia (29%). Three longitudinal trajectories (clusters) were identified: 'high-consistent' (averaging 5.4 types of care annually), 'moderate-consistent' (averaging 3.8), and 'poor-decreasing' (averaging 1.9). Most veterans were receiving cardiovascular care (67 to 76%), hepatic and renal function assays (79 to 84%), individual counseling (72 to 85%) and psychiatry consults (66 to 82%), with the proportion receiving care varying by cluster group. After adjustment for age, baseline comorbidity, and other covariates, there was a greater survival rate for those with poor-decreasing care compared with high-consistent care, and for high-consistent compared with moderate-consistent care. Conclusions Relatively low levels of guideline-concordant care were seen for older VA patients with schizophrenia, and trajectories of care over time were associated with survival in a non-intuitive pattern. The group with the lowest and decreasing levels of care was also the oldest, but nonetheless had the best age-adjusted and other covariate-adjusted survival rates, possibly because they were requiring less care relative to younger, sicker veterans, and thus their comorbidity burden was markedly lower. Notably, in the group with the sickest individuals (that is those with the highest comorbidity scores, who were very disabled), receiving guideline-concordant care was associated with improved survival in adjusted models compared with those patients receiving only moderate levels of care.
    Full-text · Article · Nov 2012 · BMC Medicine
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    • "For example, one national study of patients diagnosed with mental disorders in the Department of Veterans Affairs (VA) health care system found that 21% had experienced a 12-month gap in contact with the health care system while 42% had a 12- month gap in mental health care [4]. Similarly, another study found that VA patients with schizophrenia who had little VA utilization in the prior year had a twofold increased risk for death relative to patients without schizophrenia [5]. A persistent barrier to improving access and continuity of care among patients with mental disorders has been the lack of a systematic process for identifying and engaging those who have dropped out of care and providing meaningful data to frontline providers on the patients who are most at risk of poor outcomes [6] [7]. "
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    ABSTRACT: Objectives. Persons with mental disorders experience functional impairments and premature mortality. Limited continuity of care may contribute to disparities in this group. We describe the replication of an evidence-based outreach program (Re-Engage) to reconnect Veterans with mental disorders into care who have dropped out of services. Methods. Using the Enhanced Replicating Effective Programs framework, population-based registries were used to identify Veterans lost-to-care, and providers used this information to determine Veteran disposition and need for care. Providers recorded Veteran preferences, health status, and care utilization, and formative process data was collected to document implementation efforts. Results. Among Veterans who dropped out of care (n = 126), the mean age was 49 years, 10% were women, and 29% were African-American. Providers determined that 39% of Veterans identified for re-engagement were deceased, hospitalized, or ineligible for care. Of the remaining 68 Veterans, outreach efforts resulted in contact with 20, with 7 returning to care. Providers averaged 14.2 hours over 4 months conducting re-engagement services and reported that gaining facility leadership support and having service agreements for referrals were essential for program implementation. Conclusions. Population-level, panel management strategies to re-engage Veterans with mental disorders are potentially feasible if practices are identified to facilitate national rollout.
    Full-text · Article · Sep 2012 · Depression research and treatment
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