Mortality and guideline-concordant care for older patients with schizophrenia: a retrospective longitudinal study

BMC Medicine

Laurel A Copeland⁵  Emran Rouf¹  John E Zeber⁵  David S Greenawalt²  Jazmin M Gonzalez³  Eileen M Stock⁵  Jack Y Tsan⁴ 

[1] Department of Internal Medicine, Scott & White Healthcare, 2401 S. 31st St., Temple, TX 76508, USA;VISN 17 Center of Excellence for Research on Returning War Veterans, Department of Veterans Affairs, 4800 Memorial Drive (151C), Waco, TX 76711, USA;Autism Comprehensive Educational Services, El Paso, TX 79912, USA;VA Texas Valley Coastal Bend Health Care System, Department of Veterans Affairs, 2106 Treasure Hills Blvd., Harlingen, TX 78550, USA;Center for Applied Health Research, Scott & White Healthcare System, 2102 Birdcreek Drive Temple, TX 76502, USA

关键词: preventive care;    primary care;    mortality;    quality of health care;    veterans;    schizophrenia;   

Others  :  857280
DOI  :  10.1186/1741-7015-10-147

 received in 2012-07-24, accepted in 2012-11-26,  发布年份 2012

【 摘 要 】

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.

【 授权许可】

   
2012 Tsan et al; licensee BioMed Central Ltd.

【 图 表 】

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