Adverse hospital events for mentally ill patients undergoing coronary artery bypass surgery

Cardiac surgery receipt and outcomes for people using secondary mental healthcare services: Retrospective cohort study using a large mental healthcare database in South London

BACKGROUND

Patients diagnosed with mental health problems are more predisposed to cardiovascular disease, including cardiac surgery. Nevertheless, health outcomes after cardiac surgery for patients with mental health problems as a discrete group are unknown. This study examined the association between secondary care mental health service use and postoperative health outcomes following cardiac surgery.

METHODS

We conducted a retrospective observational research, utilizing data from a large South London mental healthcare supplier linked to national hospitalization data. OPCS-4 codes were applied to classify cardiac surgery. Health results were compared between those individuals with a mental health disorder diagnosis from secondary care and other local residents, including the length of hospital stay (LOS), inpatient mortality, and 30-day emergency hospital readmission.

RESULTS

Twelve thousand three hundred and eighty-four patients received cardiac surgery, including 1,481 with a mental disorder diagnosis. Patients with mental health diagnosis were at greater risk of emergency admissions for cardiac surgery (odds ratio [OR] 1.60; 1.43, 1.79), longer index LOS (incidence rate ratio 1.28; 1.26, 1.30), and at higher risk of 30-day emergency readmission (OR 1.53; 1.31, 1.78). Those who underwent pacemaker insertion and major open surgery had worse postoperative outcomes during index surgery hospital admission while those who had major endovascular surgery had worse health outcomes subsequent 30-day emergency hospital readmission.

CONCLUSION

People with a mental health disorder diagnosis undertaking cardiac surgery have significantly worse health outcomes. Personalized guidelines and policies to manage preoperative risk factors require consideration and evaluation.

Cardiac surgery for patients with schizophrenia: clinical experience of six patients

PURPOSE

The incidence of schizophrenia in Japan is 0.7%, which is similar to the worldwide incidence. The mortality rate of patients with schizophrenia is reported to be higher than that of the general population, and cardiovascular disease is high among the causes of death. Hence, strategies for cardiovascular surgery for patients with schizophrenia are necessary.

METHODS

We studied six patients with schizophrenia (five males, one female) who underwent cardiac surgery in our hospital between April 2008 and December 2019.

RESULT

The mean age was 63.6 years. The surgical procedures were coronary artery bypass grafting (CABG) (n = 4), CABG concomitant with valve procedures (n = 1), and resection of myxoma (n = 1). There were no major cardiovascular complications and no other fatal complications. The mean observation period was 1510.6 ± 1430.1 (140-4068) days, the mean post-operative hospital stay was 17.8 ± 3.5 (13-22) days, and there was no mortality within 30 days after surgery. During the observation period, one patient died. The survival rate was 83.3% at 1, 3, and 5 years.

CONCLUSION

Cardiac surgery for patients with schizophrenia is possible with careful monitoring of indications and perioperative management.

Healthcare utilization and mortality outcomes in patients with pre-existing psychiatric disorders after intensive care unit discharge: A population-based retrospective cohort study

PURPOSE

Pre-existing psychiatric disorders may lead to negative outcomes following intensive care unit (ICU) discharge. We evaluated the association of pre-existing psychiatric disorders with subsequent healthcare utilization and mortality in patients discharged from ICU.

MATERIALS AND METHODS

We retrospectively studied adult patients admitted to 14 medical-surgical ICUs (January 2014-June 2016) with ICU length stay ≥24 h who survived to hospital discharge. Pre-existing psychiatric disorders were identified using algorithms for diagnostic codes captured ≤5 years before ICU admission. Outcomes were healthcare utilization (emergency department visit, hospital or ICU readmission) and mortality. We used logistic regression models with propensity scores to estimate associations, converted to risk ratios (RR).

RESULTS

We included 10,598 patients. 37.6% (n = 3982) had a psychiatric history. Patients with pre-existing psychiatric disorders were at higher risk of subsequent emergency department visits (RR 1.49, 95%CI 1.29-1.71), hospital readmission (RR 1.49, 95%CI 1.34-1.66), ICU readmission (RR 2.64, 95%CI 1.55-4.49) one-year post-ICU discharge, compared to patients without pre-existing psychiatric disorders. Patients with pre-existing psychiatric disorders had a higher risk of mortality (RR 1.31, 95%CI 1.00-1.71) six-months post-ICU discharge.

CONCLUSION

Critically ill patients with pre-existing psychiatric disorders have an increased risk of healthcare utilization and mortality outcomes following an ICU stay.

Safety of service users with severe mental illness receiving inpatient care on medical and surgical wards: A systematic review

This review aimed to synthesize the evidence on the likelihood of harm and mortality on medical and surgical inpatient wards for people with severe mental illness (SMI). From 937 results identified through database searching, and a further 10 papers identified through citation searching and hand searching, 11 papers met the criteria for inclusion in the final review. This review did not find strong evidence for higher in-hospital mortality in people with SMI. There was evidence that adverse events are higher in people with SMI. A higher likelihood of emergency instead of planned care, and poorer access to treatment were identified as potential contributing factors to these adverse events. In addition, service users with SMI were more likely to have a longer length of stay, associated with a higher cost of care. The severity of the mental illness increased the likelihood of harm or death, and people with schizophrenia were more likely than people with other mental illnesses to experience these adverse outcomes. There is evidence that people with SMI are provided with lower-quality health care, whereas higher-quality, better-planned care is required to overcome the inequalities in access faced by this vulnerable population.

Feasibility of administrative data for studying complications after hip fracture surgery

PURPOSE

There is limited information in administrative databases on the occurrence of serious but treatable complications after hip fracture surgery. This study sought to determine the feasibility of identifying the occurrence of serious but treatable complications after hip fracture surgery from discharge abstracts by applying the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator 4 (PSI-4) case-finding tool.

METHODS

We obtained Canadian Institute for Health Information discharge abstracts for patients 65 years or older, who were surgically treated for non-pathological first hip fracture between 1 January 2004 and 31 December 2012 in Canada, except for Quebec. We applied specifications of AHRQ Patient Safety Indicators 04, Version 5.0 to identify complications from hip fracture discharge abstracts.

RESULTS

Out of 153 613 patients admitted with hip fracture, we identified 12 383 (8.1%) patients with at least one postsurgical complication. From patients with postsurgical complications, we identified 3066 (24.8%) patient admissions to intensive care unit. Overall, 7487 (4.9%) patients developed pneumonia, 1664 (1.1%) developed shock/myocardial infarction, 651 (0.4%) developed sepsis, 1862 (1.1%) developed deep venous thrombosis/pulmonary embolism and 1919 (1.3%) developed gastrointestinal haemorrhage/acute ulcer.

CONCLUSIONS

We report that 8.1% of patients developed at least one inhospital complication after hip fracture surgery in Canada between 2004 and 2012. The AHRQ PSI-4 case-finding tool can be considered to identify these serious complications for evaluation of postsurgical care after hip fracture.

Influence of psychiatric disorders on surgical outcomes and care resource use in Japan

OBJECTIVE

The aim of this study was to quantify the effects of psychiatric disorders on major surgery outcomes and care resource use.

METHODS

This study adopted a retrospective cohort study design. The samples consisted of hospital stays. Subjects were patients who had undergone major surgery. We used multilevel regression analysis to quantify the influence of psychiatric disorders on major surgery outcomes and care resource use.

RESULTS

The total number of hospital stays included in the study was 5569, of which 250 were patients with psychiatric disorders. Compared with those without psychiatric disorders, those with schizophrenia had a significantly higher risk of complications, and those with neurotic disorder tended to have fewer complications. Total cost was significantly higher for those with schizophrenia and mood disorder and significantly lower in those with neurotic disorder. Lengths of stay were significantly longer for those with schizophrenia and mood disorder but not for those with neurotic disorder. Post-surgical mortality was equivalent among those with any psychiatric disorder and among those without a psychiatric disorder.

CONCLUSION

The study revealed that surgical outcomes and care resource use are differentiated by psychiatric disorders.

Disparities in treatment of people with mental disorder in non-psychiatric hospitals: a review of the literature

People with mental disorder experience a heavy burden of physical ill-health. This, alongside structural health-system changes, means more people with mental disorder are being cared for in non-psychiatric hospitals. This article reports on 32 studies that have investigated the care and outcomes of people with comorbid mental and physical health problems in non-psychiatric hospitals. Prevalence of mental disorder ranged between 4%-46%, and rates of psychiatric referral was 2%-10%. The receipt of invasive cardiac procedures was markedly reduced for those with mental disorder. Likelihood of experiencing an adverse event, post-operative complication or increased length of stay was also elevated for those with mental disorder.

Surgical adverse outcomes in patients with schizophrenia: a population-based study

OBJECTIVE

To validate the global features of postoperative adverse outcomes for surgical patients with schizophrenia.

BACKGROUND

Patients with schizophrenia were known to have a higher risk of complications during hospitalization. Quality of care has become the key factor in reducing their potential mortality afterwards.

METHODS

We present a population-based study of 8967 schizophrenic patients receiving major surgery from the Taiwan National Health Insurance Research Database within the years 2004 and 2007 compared with 35,868 surgical patients without mental disorders. Eight major postoperative complications and mortality after complications were evaluated among schizophrenic patients with different severity.

RESULTS

Schizophrenic patients had significantly higher risk for postoperative complications, including acute renal failure, pneumonia, bleeding, septicemia, stroke, and 30-day postoperative mortality (adjusted OR = 2.70; 95% CI: 2.08-3.49), than surgical patients without mental disorders. Among surgical patients with 1 to 2, 3 to 18, 19 to 48, and more than 49 schizophrenia-related outpatient visits within 24-month period preoperatively, the adjusted ORs of 30-day mortality ranged from 1.95 (95% CI: 1.25-3.02) to 3.97 (95% CI: 2.66-5.92) in a frequency-dependent pattern when compared with controls. When compared with surgical patients with schizophrenia-related outpatient services only, OR of 30-day postoperative mortality increased from 2.54 (95% CI: 1.93-3.34) to 3.69 (95% CI: 2.25-6.03) in surgical patients with preoperative hospitalization or emergency visit because of schizophrenia.

CONCLUSIONS

Surgical patients with schizophrenia showed significantly higher postoperative adverse outcome rates with risk of 30-day mortality nearly threefold when compared with patients without mental disorders. Our findings suggest the urgency revising the protocol of postoperative care for this specific population.

Differences in the prescribing of medication for physical disorders in individuals with v. without mental illness: meta-analysis

BACKGROUND

There is some concern that patients with mental illness may be in receipt of inferior medical care, including prescribed medication for medical conditions.

AIMS

We aimed to quantify possible differences in the prescription of medication for medical conditions in those with v. without mental illness.

METHOD

Systematic review and random effects meta-analysis with a minimum of three independent studies to warrant pooling by drug class.

RESULTS

We found 61 comparative analyses (from 23 publications) relating to the prescription of 12 classes of medication for cardiovascular health, diabetes, cancer, arthritis, osteoporosis and HIV in a total sample of 1 931 509 people. In those with severe mental illness the adjusted odds ratio (OR) for an equitable prescription was 0.74 (95% CI 0.63-0.86), with lower than expected prescriptions for angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACE/ARBs), beta-blockers and statins. People with affective disorder had an odds ratio of 0.75 (95% CI 0.55-1.02) but this was not significant. Individuals with a history of other (miscellaneous) mental illness had an odds ratio of 0.95 (95% CI 0.92-0.98) of comparable medication with lower receipt of ACE/ARBs but not highly active antiretroviral therapy (HAART) medication. Results were significant in both adjusted and unadjusted analyses.

CONCLUSIONS

Individuals with severe mental illness (including schizophrenia) appear to be prescribed significantly lower quantities of several common medications for medical disorders, largely for cardiovascular indications, although further work is required to clarify to what extent this is because of prescriber intent.

Mentally ill Medicare patients less likely than others to receive certain types of surgery

Mentally ill people may face barriers to receiving elective surgical procedures as a result of societal stigma and the cognitive, behavioral, and interpersonal deficits associated with mental illness. Using data from a cohort of elderly Medicare beneficiaries in 2007, we examined whether the mentally ill have less access than people without mental illness to several common procedures that are typically not for emergencies and are performed at the discretion of the provider and the patient. Results suggest that Medicare patients with mental illness are 30-70 percent less likely than others to receive these "referral-sensitive" surgical procedures. Those who did undergo an elective procedure generally experienced poorer outcomes both in the hospital and after discharge. Efforts to improve access to and outcomes of nonpsychiatric care for mentally ill patients are warranted.

Poor clinical outcomes among pneumonia patients with schizophrenia

Despite the recent attention to patient safety and quality of care, no prior studies have addressed outcomes of hospitalization for pneumonia among patients with schizophrenia. This study investigated the extent to which clinical outcomes of pneumonia were different among patients with schizophrenia. This study used data from the Taiwan National Health Insurance Research Database. Of the total of 81,599 patients admitted with a principal diagnosis of pneumonia from 2002 to 2004, 949 had previously been admitted with a principal or secondary diagnosis of schizophrenia within the 2 years of their index pneumonia admission. We randomly selected 2847 pneumonia patients matched with the study group in terms of gender, age, year of admission, length of stay, and Charlson Comorbidity Index score as the comparison cohort. Conditional logistic regression models were used for analysis. Findings indicated a higher prevalence of adverse outcomes among patients with schizophrenia. Patients with schizophrenia were independently associated with a 1.81 times greater risk of intensive care unit admission (95% confidence interval [CI] = 1.37-2.40), a 1.37 times greater risk of acute respiratory failure (95% CI = 1.08-1.88), and a 1.34-fold greater risk of mechanical ventilation (95% CI = 1.04-1.92) after adjusting for characteristics of patients, physicians, hospitals, and potential clustering effects. Adjusted odds ratios were further evident among those treated in private hospitals and in regional/district hospitals. Significant barriers to prompt and appropriate medical care for pneumonia persist for patients with schizophrenia. Careful monitoring of physical health and proper integration between psychiatrists and physicians should be stressed to reduce poor clinical outcomes in this vulnerable population.

Do deficits in cardiac care influence high mortality rates in schizophrenia? A systematic review and pooled analysis

We have previously documented inequalities in the quality of medical care provided to those with mental ill health but the implications for mortality are unclear. We aimed to test whether disparities in medical treatment of cardiovascular conditions, specifically receipt of medical procedures and receipt of prescribed medication, are linked with elevated rates of mortality in people with schizophrenia and severe mental illness. We undertook a systematic review of studies that examined medical procedures and a pooled analysis of prescribed medication in those with and without comorbid mental illness, focusing on those which recruited individuals with schizophrenia and measured mortality as an outcome. From 17 studies of treatment adequacy in cardiovascular conditions, eight examined cardiac procedures and nine examined adequacy of prescribed cardiac medication. Six of eight studies examining the adequacy of cardiac procedures found lower than average provision of medical care and two studies found no difference. Meta-analytic pooling of nine medication studies showed lower than average rates of prescribing evident for the following individual classes of medication; angiotensin converting enzyme inhibitors (n = 6, aOR = 0.779, 95% CI = 0.638-0.950, p = 0.0137), beta-blockers (n = 9, aOR = 0.844, 95% CI = 0.690-1.03, p = 0.1036) and statins (n = 5, aOR = 0.604, 95% CI = 0.408-0.89, p = 0.0117). No inequality was evident for aspirin (n = 7, aOR = 0.986, 95% CI = 0.7955-1.02, p = 0.382). Interestingly higher than expected prescribing was found for older non-statin cholesterol-lowering agents (n = 4, aOR = 1.55, 95% CI = 1.04-2.32, p = 0.0312). A search for outcomes in this sample revealed ten studies linking poor quality of care and possible effects on mortality in specialist settings. In half of the studies there was significantly higher mortality in those with mental ill health compared with controls but there was inadequate data to confirm a causative link. Nevertheless, indirect evidence supports the observation that deficits in quality of care are contributing to higher than expected mortality in those with severe mental illness (SMI) and schizophrenia. The quality of medical treatment provided to those with cardiac conditions and comorbid schizophrenia is often suboptimal and may be linked with avoidable excess mortality. Every effort should be made to deliver high-quality medical care to people with severe mental illness.