Quality of medical care for persons with serious mental illness: A comprehensive review

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Abstract

Objectives

Prior studies suggest variation in the quality of medical care for somatic conditions such as cardiovascular disease and diabetes provided to persons with SMI, but to date no comprehensive review of the literature has been conducted. The goals of this review were to summarize the prior research on quality of medical care for the United States population with SMI; identify potential sources of variation in quality of care; and identify priorities for future research.

Methods

Peer-reviewed studies were identified by searching four major research databases and subsequent reference searches of retrieved articles. All studies assessing quality of care for cardiovascular disease, diabetes, dyslipidemia, and HIV/AIDs among persons with schizophrenia and bipolar disorder published between January 2000 and December 2013 were included. Quality indicators and information about the study population and setting were abstracted by two trained reviewers.

Results

Quality of medical care in the population with SMI varied by study population, time period, and setting. Rates of guideline-concordant care tended to be higher among veterans and lower among Medicaid beneficiaries. In many study samples with SMI, rates of guideline adherence were considerably lower than estimated rates for the overall US population.

Conclusions

Future research should identify and address modifiable provider, insurer, and delivery system factors that contribute to poor quality of medical care among persons with SMI and examine whether adherence to clinical guidelines leads to improved health and disability outcomes in this vulnerable group.

Introduction

Persons with serious mental illnesses (SMIs) such as schizophrenia and bipolar disorder have a mortality rate two to three times higher than the overall United States (US) population (Brown, 1997, Saha et al., 2007). Almost all of this premature mortality is due to somatic causes, particularly cardiovascular disease (Daumit et al., 2010, Osborn et al., 2007, Osby et al., 2000). Prevalence of every cardiovascular risk factor and risk behavior – including diabetes mellitus (Osborn et al., 2008), dyslipidemia (Osborn et al., 2008), hypertension (Osborn et al., 2008), tobacco smoking (Compton et al., 2006), obesity (Osborn et al., 2008), physical inactivity (Daumit et al., 2005) and poor diet (Henderson et al., 2006) – is elevated in the population with SMI. Obesogenic effects of commonly prescribed antipsychotic medications often cause weight gain and alter glucose metabolism, compounding the burden of cardiovascular illness in this group (Casey et al., 2004, McGinty and Daumit, 2011). Persons with SMI are at heightened risk for other somatic conditions as well. In particular, high rates of risky sexual behaviors (Dickerson et al., 2004) and intravenous drug use (Carey et al., 2004) contribute to increased prevalence of HIV in this group (Rosenberg et al., 2001). The high burden of somatic conditions in this population leads to costly disability: persons with SMI are the largest and fastest growing subgroup of social security disability beneficiaries in the US (Drake et al., 2013, Substance Abuse and Mental Health Administration (SAMHSA), 2010).

Poor health and disability outcomes in the population with SMI are affected by multiple factors, including severity and complexity of co-morbid conditions (Jones et al., 2004), individual health behaviors (Compton et al., 2006, Daumit et al., 2005, Henderson et al., 2006), socioeconomic status (Mueser and McGurk, 2004), neighborhood and living conditions that may facilitate or impede adoption of healthy behaviors or access to services (Chun-Chung, 2003), and – the focus of this review – quality of medical care. Prior studies have shown mixed results regarding quality of care for somatic conditions in the population with SMI. For example, studies of post-myocardial infarction quality of care have shown significant variation in rates of guideline-concordant care across Medicaid beneficiaries (McGinty et al., 2012), Medicare beneficiaries (Druss et al., 2000), and veterans with SMI (Desai et al., 2002, Petersen et al., 2003). A large body of quality of care research suggests that variation in quality is attributable to a range of interacting patient, provider, insurer, and health-system factors.

Delivery of high quality medical care for somatic conditions in the population with SMI should be a priority given this population's high rates of somatic co-morbidity and premature mortality due to cardiovascular disease. To date, no comprehensive review of the literature has documented and characterized the variation in quality of care for somatic conditions in the population with SMI. This information could inform development of quality improvement initiatives and provide direction for future research designed to identify and address modifiable provider, insurer, and delivery system factors that lead to poor quality of care for somatic conditions in this vulnerable population. To fill this gap in the literature, we reviewed studies on quality of medical care for cardiovascular disease, diabetes, dyslipidemia, and HIV/AIDs in the population with SMI published in the peer-reviewed literature between January 2000 and December 2013. Our objectives were to provide a comprehensive review of the prior research on quality of medical care for the population with SMI; identify potential sources in variation of quality of care by study population and setting; and identify priorities for future research on this topic.

Section snippets

Methods

We conducted a comprehensive review of studies measuring quality of care for somatic conditions in the population with SMI published in the peer-reviewed literature between January 2000 and December 2013. Robust epidemiologic literature shows heightened rates of cardiovascular disease, the cardiovascular risk factors diabetes mellitus and dyslipidemia, and HIV/AIDS among persons with SMI. Our review therefore focused on studies measuring quality of care for these conditions. Relevant studies

Results

Our search yielded a total of 778 unique studies. 757 studies were excluded for failure to meet inclusion criteria, yielding an initial sample of 21 studies. Two additional studies were identified by searching the reference lists of studies included in the initial sample, for a final sample of 23 articles (see Appendix C for inclusion flow diagram).

Discussion

In studies published from 2000–2013, quality of care for somatic conditions in the population with SMI varied by study population, setting and time period. Consistent with the results of a prior review of disparities in care provided to those with versus without SMI (Mitchell et al., 2009), we found that some study populations with SMI were less likely to receive high-quality medical care than their counterparts without SMI. Comparisons with the non-SMI population alone should not be used to

Role of funding source

This study was funded by the National Institute of Mental Health (NIMH).

On September 10–11, 2012, NIMH convened the meeting Improving Health and Longevity of People with Severe Mental Illness, bringing together diverse stakeholders to identify the most critically needed research to reduce premature mortality in people with SMI. Meeting participants included leading researchers on medical comorbidities in people with SMI and on prevention of and treatment for diabetes, heart disease, tobacco

Conflict of interest statement

The authors have no conflicts of interest to report.

Contributors

All study authors designed the review, contributed to and approved the final manuscript. Drs. McGinty and Baller conducted the data abstraction. Dr. McGinty drafted the manuscript.

Acknowledgments

This study was commissioned and supported by the National Institute of Mental Health (NIMH).

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