Comparison of time to rehospitalization among schizophrenic patients discharged on typical antipsychotics, clozapine or risperidone

Risk factors associated with readmissions of patients with severe mental disorders under treatment with antipsychotics

BACKGROUND

The aim of this study was to assess the risk of readmission in patients with severe mental disorders, compare it between patients using different types of antipsychotics and determine risk factors for psychiatric readmission.

METHODS

Medical records of a non-concurrent cohort of 625 patients with severe mental disorders (such as psychoses and severe mood disorders) who were first discharged from January to December 2012 (entry into the cohort), with longitudinal follow-up until December 2017 constitute the sample. Descriptive statistical analysis of characteristics of study sample was performed. The risk factors for readmission were assessed using Cox regression.

RESULTS

Males represented 51.5% of the cohort, and 75.6% of the patients had no partner. Most patients (89.9%) lived with relatives, and 64.7% did not complete elementary school. Only 17.1% used more than one antipsychotic, 34.2% did not adhere to the treatment, and 13.9% discontinued the medication due to unavailability in public pharmacies. There was a need to change the antipsychotic due to the lack of therapeutic response (11.2% of the patients) and adverse reactions to the antipsychotic (5.3% of the patients). Cox regression showed that the risk of readmission was increased by 25.0% (RR, 1.25; 95% CI, 1.03-1.52) when used typical antipsychotics, compared to those who used atypical ones, and by 92.0% (RR, 1.92; 95% CI, 1.63-2.27) when patients did not adhere to maintenance treatment compared to those who adhered.

CONCLUSIONS

Use of atypical antipsychotics and adherence to treatment were associated with a lower risk of psychiatric readmissions.

The effects of adding long-acting injectable antipsychotic drugs to clozapine on relapse and hospitalization in patients with treatment-resistant schizophrenia: a mirror-image retrospective study

The literature assessing the addition of long-acting injectable antipsychotics (LAIs) to clozapine is limited. The aim of this retrospective study was to determine the safety and effectiveness of adding LAIs to clozapine in patients with treatment-resistant schizophrenia (TRS). Patients aged 18-65 years with TRS, who were treated with first-generation (FGA-LAIs) and second-generation (SGA-LAIs) for at least 1 year after clozapine use, were included retrospectively by registration system scanning. Effectiveness measures included relapses and hospitalizations and days of hospitalization. Safety outcomes included levels of neutrophils, fasting blood sugar, total cholesterol, triglycerides, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and prolactin. The data of 29 patients who met the study criteria were evaluated. The numbers and days of hospitalizations and the numbers of relapses significantly decreased after LAI addition. Comparisons of the neutrophil counts and the total cholesterol, triglyceride, HDL, LDL, prolactin, and fasting blood glucose levels as safety indicators of the clozapine and LAI combination revealed no statistically significant change in these values before and after LAI addition. Adding LAIs to clozapine is apparently well tolerated in patients with TRS and may have a positive effect on the course of the disease.

Chronic physical illnesses in patients with schizophrenia spectrum disorders are independently associated with higher rates of psychiatric rehospitalization; a cross-sectional study in Croatia

Background:

Increased physical morbidity in patients with schizophrenia spectrum disorders (SSDs) is well documented. However, much less is known about the association between somatic comorbidities and psychosis treatment outcomes.

Subjects and methods:

This cross-sectional study, nested within the larger frame of a prospective cohort study, was done in 2016 at Psychiatric Hospital Sveti Ivan, Zagreb, Croatia. Data were collected on a consecutive sample of 301 patients diagnosed with schizophrenia spectrum disorders who achieved a stable therapeutic dosage. Key outcome was the number of psychiatric rehospitalizations since diagnosis of the primary psychiatric illness. Predictors were number of physical and psychiatric comorbidities. By robust regression, we controlled different clinical, sociodemographic, and lifestyle confounding factors.

Results:

The number of chronic somatic comorbidities was statistically significantly associated with a larger number of psychiatric rehospitalizations, even after the adjustment for number of psychiatric comorbidities and large number of other clinical, sociodemographic, and lifestyle variables.

Conclusions:

Chronic somatic comorbidities are associated with higher rates of psychiatric rehospitalization independently of psychiatric comorbidities and other clinical, sociodemographic, and lifestyle factors. Therefore, to treat psychosis effectively, it may be necessary to treat chronic somatic comorbidities promptly and adequately. Chronic somatic comorbidities should be considered equally important as the SSD, and should be brought to the forefront of psychiatric treatment and research with the SSD as one entity. The integrative approach should be the imperative in clinical practice.

Association With Hospitalization and All-Cause Discontinuation Among Patients With Schizophrenia on Clozapine vs Other Oral Second-Generation Antipsychotics: A Systematic Review and Meta-analysis of Cohort Studies

IMPORTANCE

Recent meta-analyses of randomized clinical trials (RCTs) comparing clozapine with nonclozapine second-generation antipsychotics (NC-SGAs) in schizophrenia have challenged clozapine's superiority in treatment-resistant patients. However, patients in RCTs are not necessarily generalizable to those in clinical practice.

OBJECTIVE

To conduct a systematic review and meta-analysis to compare various outcomes of clozapine vs oral NC-SGAs in cohort studies.

DATA SOURCES

Systematic literature search in PubMed, PsycINFO, and CINAHL without language restriction from database inception until December 17, 2018.

STUDY SELECTION

Nonrandomized cohort studies reporting effectiveness and/or safety outcomes comparing clozapine with NC-SGAs in schizophrenia or schizoaffective disorder.

DATA EXTRACTION AND SYNTHESIS

Independent investigators assessed studies and extracted data. Using a random-effects model, the study calculated risk ratio (RR) unadjusted for covariates and follow-up duration, number needed to treat/number needed to harm (NNT/NNH) for dichotomous data, and standardized mean difference (SMD) or mean difference (MD) for continuous data.

MAIN OUTCOMES AND MEASURES

Coprimary outcomes were hospitalization and all-cause discontinuation. Secondary outcomes included all effectiveness and safety outcomes reported in at least 3 analyzable studies.

RESULTS

Of 8446 hits, 68 articles from 63 individual cohort studies (n = 109 341) (60.3% male; mean [SD] age of 38.8 [6.5] years, illness duration of 11.0 [5.1] years, and study duration of 19.1 [23.3] months) were meta-analyzed. Compared with NC-SGAs, despite greater illness severity (17 studies [n = 38 766]; Hedges g, 0.222; 95% CI, 0.013-0.430; P = .04), clozapine was significantly associated with lower hospitalization risk (19 studies [n = 49 453]; RR, 0.817; 95% CI, 0.725-0.920; P = .001; NNT, 18; 95% CI, 12-40) and all-cause discontinuation (16 studies [n = 56 368]; RR, 0.732; 95% CI, 0.639-0.838; P < .001; NNT, 8; 95% CI, 6-12). Associations were statistically significant for comparisons with quetiapine fumarate and aripiprazole regarding hospitalization and all NC-SGAs, except aripiprazole, for all-cause discontinuation. Clozapine was also significantly associated with better outcomes regarding overall symptoms (SMD, -0.302; 95% CI, -0.572 to -0.032; P = .03) and Clinical Global Impressions scale severity (SMD, -1.182; 95% CI, -2.243 to -0.122; P = .03). Clozapine was significantly associated with increases in body weight (MD, 1.70; 95% CI, 0.31-3.08 kg; P = .02), body mass index (MD, 0.96; 95% CI, 0.24-1.68; P = .009), and type 2 diabetes (RR, 1.777; 95% CI, 1.229-2.570; P = .002; NNH, 27; 95% CI, 13-90).

CONCLUSIONS AND RELEVANCE

In cohort studies, despite more severely ill patients being treated with clozapine, use of clozapine was associated with better key efficacy outcomes and higher cardiometabolic-related risk outcomes vs NC-SGAs.

Five-year rehospitalization experience of a state-wide cohort of persons with schizophrenia

PURPOSE

This study has the objective of assessing the psychiatric rehospitalization experience of a large cohort of persons with schizophrenia and modeling the effects of personal and systemic conditions on rehospitalization risk.

METHODS

The study employs a secondary analysis of US data from Massachusetts' casemix database of all patients discharged from acute general hospital units. It focuses on 11,291 patients during 1994-2000 who were discharged from acute adult psychiatric units. Predictors used include basic demographics, length of stay, continuity of care with doctors and facilities, diagnoses, discharge referral, type of insurance, and distance to and selected socioeconomic characteristics of the patient's home zip code. Data are analyzed with descriptive statistics and modeled with the Cox proportional hazard model. The model was assessed through split-half reliability testing, the generalized R², and Harrell's Concordance Index.

RESULTS

Overall, 13.4% of patients were rehospitalized within 1 month; 38.9% within 1 year; and 64.1% within 5 years. Predictors that are most strongly associated with lower rehospitalization rates include continuity of care, discharge to a chronic hospital, and density of home zipcode, whereas discharge to another acute psychiatric unit had the greatest effect on increasing risk of rehospitalization. Overall the Cox model has generalized R² of 0.343 and a Concordance Index of 0.734.

CONCLUSIONS

The results highlight the need to enhance the continuity of the relationships with providers, whether these are with the assigned psychiatrists or other therapists and case managers, as well as workplace issues involving staff turnover and hospital assignment and admitting policies.

Risk of readmission in patients with schizophrenia and schizoaffective disorder newly prescribed clozapine

BACKGROUND

Insight into the effect of clozapine is limited by a lack of controlling for confounding variables in current research. Our objective was to investigate the association between clozapine prescribed at discharge, following an inpatient episode, and risk of readmission into secondary mental health services in patients with schizophrenia and schizoaffective disorder, controlling extensively for confounding variables.

METHODS

Clinical records from 3651 patients were analysed in a retrospective observational cohort study. Cox proportional-hazards regression models were used to assess the risk of hospital readmission. A series of sensitivity analyses were also conducted. Propensity score methods were used to address confounding-by-indication.

RESULTS

Patients on clozapine ( n=202) had a reduced risk of readmission compared with patients on other antipsychotics (adjusted hazard ratio=0.79; 95% confidence interval: 0.64-0.99; p=0.043). Clozapine also had a protective effect on risk of readmission when compared with olanzapine (adjusted hazard ratio 0.76; 95% confidence interval: 0.60-0.96; p=0.021). The effect size remained consistent after adjusting for an array of possible confounders, as well as using propensity scores to address confounding-by-indication. A statistically significant result was also noted in all but two sensitivity analyses.

CONCLUSION

Our findings suggest that clozapine is associated with a reduced risk of readmission into secondary mental health services.

Claims data-driven modeling of hospital time-to-readmission risk with latent heterogeneity

Hospital readmission risk modeling is of great interest to both hospital administrators and health care policy makers, for reducing preventable readmission and advancing care service quality. To accommodate the needs of both stakeholders, a readmission risk model is preferable if it (i) exhibits superior prediction performance; (ii) identifies risk factors to help target the most at-risk individuals; and (iii) constructs composite metrics to evaluate multiple hospitals, hospital networks, and geographic regions. Existing work mainly addressed the first two features and it is challenging to address the third one because available medical data are fragmented across hospitals. To simultaneously address all three features, this paper proposes readmission risk models with incorporation of latent heterogeneity, and takes advantage of administrative claims data, which is less fragmented and involves larger patient cohorts. Different levels of latent heterogeneity are considered to quantify the effects of unobserved factors, provide composite measures for performance evaluation at various aggregate levels, and compensate less informative claims data. To demonstrate the prediction performances of the proposed models, a real case study is considered on a state-wide heart failure patient cohort. A systematic comparison study is then carried out to evaluate the performances of 49 risk models and their variants.

The impact of clozapine on hospital use: a systematic review and meta-analysis

OBJECTIVE

The objective of this study was to perform a systematic review and meta-analysis of studies reporting the impact of clozapine on hospital use in people with a psychotic illness.

METHOD

PubMed, EMBASE, PsycINFO and the Cochrane Schizophrenia Group Trials Register were systematically searched from inception to 12 October 2016. We included all trials and observational studies, except case reports.

RESULTS

Thirty-seven studies were included. Clozapine significantly reduced the proportion of people hospitalised compared to control medicines (RR = 0.74; 95% CI: 0.69-0.80, P < 0.001, 22 studies, n = 44 718). There were significantly fewer bed days after clozapine treatment compared to before clozapine treatment in both controlled (MD = -34.41 days; 95% CI: -68.22 to -0.60 days, P = 0.046, n = 162) and uncontrolled studies (MD = -52.86 days; 95% CI: -79.86 days to -25.86 days, P < 0.001, n = 2917). Clozapine and control medicines had a similar time to rehospitalisation (-19.90 days; 95% CI: -62.42 to 22.63 days, P = 0.36).

CONCLUSION

Clozapine treatment reduced the number of people hospitalised and the number of bed days after treatment compared with before treatment. Clozapine has the potential to reduce acute hospital use among people with treatment refractory schizophrenia.

Systematic review of long-acting injectables versus oral atypical antipsychotics on hospitalization in schizophrenia

OBJECTIVE

To assess the impact of long-acting injectables (LAIs) versus oral antipsychotics (OAs) on hospitalizations among patients with schizophrenia by conducting a systematic literature review of studies with different study designs and performing a meta-analysis.

METHODS

Using the PubMed database and major psychiatric conference proceedings, a systematic literature review for January 2000 to July 2013 was performed to identify English-language studies evaluating schizophrenia patients treated with atypical antipsychotics. Studies reporting hospitalization rates as a percentage of patients hospitalized or as the number of hospitalizations per person per year were selected. The primary meta-analysis assessed the percentage decrease in hospitalization rates before and after treatment initiation for matched time periods. The secondary meta-analysis assessed the absolute rate of hospitalization during follow-up. Pooled treatment-effect estimates were calculated using random-effects models. To account for differences in patient and study-level characteristics between studies, meta-regression analyses were used. Subset analyses further explored the heterogeneity across study designs.

RESULTS

Fifty-eight studies evaluating 25 arms (LAIs: 13 arms, 4516 patients; OAs: 12 arms, 23,516 patients) in the primary meta-analysis and 78 arms (LAIs: 12 arms, 4481 patients; OAs: 66 arms, 96,230 patients) in the secondary meta-analysis were identified. Reduction in hospitalization rates for LAIs was 20.7 percentage points higher than that of OAs (random-effects estimates: LAIs = 56.2% vs. OAs = 35.5%, P = 0.023). Controlling for patient and study characteristics, the adjusted percentage reduction in hospitalization rates for LAIs was 26.4 percentage points higher than for OAs (95% CI: 3.3-49.5, P = 0.027). As for the secondary meta-analysis, no significant difference between LAIs and OAs was observed (random-effects estimate: -8.6, 95% CI: -18.1-1.0, P = 0.077). Subset analyses across type of study yielded consistent results. Limitations of this analysis include the long observation period, which may not reflect current treatment patterns, the use of all-cause hospitalization, which may not be solely related to schizophrenia, and the fact that most studies in the LAI cohort evaluated risperidone.

CONCLUSION

The primary results of this meta-analysis, including studies with both interventional and non-interventional designs and using meta-regressions, suggest that LAIs are associated with higher reductions in hospitalization rates for schizophrenia patients compared to OAs.

Electroconvulsive therapy and clozapine in adolescents with schizophrenia spectrum disorders: is it a safe and effective combination?

OBJECTIVE

To evaluate the safety and effectiveness of the combination of electroconvulsive therapy (ECT) and clozapine compared to ECT with other antipsychotics or benzodiazepines in a sample of adolescents diagnosed with schizophrenia spectrum disorders.

METHODS

Data regarding 28 adolescent subjects aged 13 to 18 with diagnoses of schizophrenia spectrum disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision and treated with ECT were retrospectively collected. Twelve subjects were also treated with clozapine and 16 with other antipsychotics or benzodiazepines during ECT course and follow-up. Electroconvulsive therapy parameters and adverse effects were assessed using a systematic protocol. Positive and Negative Syndrome Scale and Clinical Global Impression scores before ECT and after acute ECT, and rate of rehospitalization during 1-year follow-up were used to assess effectiveness. Response was defined as a 20% decrease in Positive and Negative Syndrome Scale scores.

RESULTS

No differences were observed in the mean charge needed to induce seizure and electroencephalographic duration, but there was a slight difference in the current used. The nonclozapine group showed greater restlessness and agitation, although no differences were found in other adverse effects. The percentage of responders was similar: 66.7% in the clozapine group and 68.8% in the nonclozapine group. However, the rate of rehospitalization was lower in the patients treated with clozapine during 1-year follow-up (7.1%) compared to that of the nonclozapine group (58.3%) (P = 0.009).

CONCLUSIONS

The main findings of this study were that combining ECT with clozapine, compared to ECT with other antipsychotics or benzodiazepines, was safe and that both treatments were equally effective. Charges needed to induce seizure were similar in both groups. Patients treated with clozapine during 1-year follow-up had a lower rate of rehospitalization.

The costs of schizophrenia and predictors of hospitalisation from the statutory health insurance perspective

BACKGROUND

The aim of the study was to determine the costs of treating schizophrenia from the perspective of the statutory health insurance, as well as the identification of predictors of hospitalisation of formerly stable schizophrenia patients.

METHODS

Claims data for the years 2004-2006 were analysed. Patients who did not have to be treated in a hospital as a result of an ICD diagnosis F20 both in the year 2005 as well as also in 2006 were defined as stable patients. In contrast, those patients who had to be treated in a hospital in 2006 because of a diagnosis of schizophrenia were defined as unstable. In addition to the overall healthcare costs, the costs specific to schizophrenia were also analysed. Also, based on binary logistic regression analysis, predictors for hospital treatment were determined.

RESULTS

8497 stable and 1449 unstable patients were identified. The schizophrenia specific costs for stable patients were € 1605 and the overall costs were € 4029 in 2006, respectively. Unstable patients had indication-specific costs amounting to € 12864 and overall health care costs of € 16824. For unstable patients, the costs of hospital treatment were identified as being a substantial cost area. Predictors for a higher probability of hospital treatment were: female patients, at least one rehabilitation measure, at least one stay in hospital in 2004, and being co-morbid with substance abuse. In contrast, older patients, who were treated with concomitant medications, and if they received a continuous drug therapy in all quarters of a year had a lower probability of hospitalisation. In addition, an increased number of visits to a doctor reduced the probability of hospitalisation. The variable 'depot medication' were close to significance and the variable 'inability to work lasting more than six weeks' had, in contrast, no significant influence.

CONCLUSIONS

The schizophrenia specific and overall health care costs of unstable patients were clearly higher than was the case with stable patients and mainly determined by inpatient hospital treatment. A range of potential predicting factors which can be extracted from routine claims data have a positive or negative influence on the probability of treatment in hospital.

Time to rehospitalization in patients with schizophrenia discharged on first generation antipsychotics, non-clozapine second generation antipsychotics, or clozapine

Rehospitalization is an important outcome of drug effectiveness in schizophrenia. In this study, the hypothesis that clozapine and some second generation antipsychotics (SGA) were superior to first generation antipsychotics (FGA) in preventing rehospitalization of patients with schizophrenia discharged from a university hospital in Brazil was tested. A retrospective observational study was conducted designed to evaluate time to rehospitalization of patients with schizophrenia discharged on a regimen of oral FGA, depot FGA, risperidone, olanzapine and amisulpride, other SGA, or clozapine, during a three-year follow-up period. Risk factors associated with rehospitalization were examined. Of the 464 patients with schizophrenia discharged from hospital, 242 met criteria for study entry. Higher rehospitalization rates were observed in patients treated with depot FGA (30%), risperidone (30%) and other SGA groups (28.5%), respectively. Clozapine was significantly associated with lower rehospitalization risk compared with risperidone. The risk of rehospitalization in patients on olanzapine and amisulpride, and oral FGA, was similar to that of patients in use of clozapine. These results however, are limited by the heterogeneity of illness severity across the groups.

Two-year rehospitalization rates of patients with newly diagnosed or chronic schizophrenia on atypical or typical antipsychotic drugs: retrospective cohort study

AIM

To determine if atypical antipsychotic agents reduce the rehospitalization rates of patients with newly diagnosed or chronic schizophrenia in comparison with typical antipsychotic drugs.

METHODS

From January 1, 2003, to December 31, 2004, we retrospectively compared two-year rehospitalization rates of 135 patients with newly diagnosed schizophrenia and 398 patients with chronic schizophrenia (62% and 65% men, respectively), who were initially discharged from Vrapce Psychiatric Hospital, Zagreb, with the prescription of atypical (olanzapine, risperidone or clozapine) or typical (haloperidol or fluphenazine) antipsychotic treatment between January 1, 2002 and December 31, 2002. Time-to-readmission was determined with Kaplan-Meier formula for survival analysis.

RESULTS

In the two-year follow-up, 52 (39%) newly diagnosed patients and 197 (47%) patients with chronic schizophrenia were rehospitalized. No significant differences in time-to-rehospitalization were observed with respect to the type of medications in patients with newly diagnosed schizophrenia (P=0.378) or patients with chronic schizophrenia (P=0.531).

CONCLUSIONS

Rehospitalization rates of patients who were prescribed atypical antipsychotic drugs were similar to those of patients who were prescribed typical antipsychotic drugs for both the group with the first psychotic episode and group with chronic schizophrenia.

Rehospitalization rates of patients with schizophrenia discharged on haloperidol, risperidone or clozapine

OBJECTIVE:The purpose of this study was to evaluate the rehospitalization rates of patients discharged from the Institute of Psychiatry of the Hospital das Clínicas of the Universidade de São Paulo Medical School while being treated with haloperidol, risperidone or clozapine. METHOD: This is a naturalistic study designed to monitor rehospitalization rates for patients discharged on haloperidol (n = 43), risperidone (n = 22) or clozapine (n = 31). Time to readmission over the course of three years was measured by the product-limit (Kaplan-Meier) method. Risk factors associated with rehospitalizations were examined. RESULTS: At 36 months, remained in the community 74% of the haloperidol-treated patients, 59% of the risperidone-treated patients and 84% of the clozapine-treated patients. The haloperidol group showed a higher proportion of women, a late age of onset and shorter length of illness than the other groups, whereas the opposite was observed in the clozapine group. CONCLUSIONS: This study suggests that the rehospitalization rates of patients taking clozapine are lower than the rate for patients treated with haloperidol and risperidone. However confounding variables such as gender distribution and age of onset represent limitations that should be taken into account for the interpretation of the results.