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Ter Braake JG, Fleetwood KJ, Vos RC, Blackbourn L, McGurnaghan SJ, Wild SH, Jackson CA. Cardiovascular risk management among individuals with type 2 diabetes and severe mental illness: a cohort study. Diabetologia 2024; 67:1029-1039. [PMID: 38409440 PMCID: PMC11058755 DOI: 10.1007/s00125-024-06111-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/09/2024] [Indexed: 02/28/2024]
Abstract
AIMS/HYPOTHESIS The aim of this study was to compare cardiovascular risk management among people with type 2 diabetes according to severe mental illness (SMI) status. METHODS We used linked electronic data to perform a retrospective cohort study of adults diagnosed with type 2 diabetes in Scotland between 2004 and 2020, ascertaining their history of SMI from hospital admission records. We compared total cholesterol, systolic BP and HbA1c target level achievement 1 year after diabetes diagnosis, and receipt of a statin prescription at diagnosis and 1 year thereafter, by SMI status using logistic regression, adjusting for sociodemographic factors and clinical history. RESULTS We included 291,644 individuals with type 2 diabetes, of whom 1.0% had schizophrenia, 0.5% had bipolar disorder and 3.3% had major depression. People with SMI were less likely to achieve cholesterol targets, although this difference did not reach statistical significance for all disorders. However, people with SMI were more likely to achieve systolic BP targets compared to those without SMI, with effect estimates being largest for schizophrenia (men: adjusted OR 1.72; 95% CI 1.49, 1.98; women: OR 1.64; 95% CI 1.38, 1.96). HbA1c target achievement differed by SMI disorder and sex. Among people without previous CVD, statin prescribing was similar or better in those with vs those without SMI at diabetes diagnosis and 1 year later. In people with prior CVD, SMI was associated with lower odds of statin prescribing at diabetes diagnosis (schizophrenia: OR 0.54; 95% CI 0.43, 0.68, bipolar disorder: OR 0.75; 95% CI 0.56, 1.01, major depression: OR 0.92; 95% CI 0.83, 1.01), with this difference generally persisting 1 year later. CONCLUSIONS/INTERPRETATION We found disparities in cholesterol target achievement and statin prescribing by SMI status. This reinforces the importance of clinical review of statin prescribing for secondary prevention of CVD, particularly among people with SMI.
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Affiliation(s)
- Jonne G Ter Braake
- Department of Public Health and Primary Care, Leiden University Medical Centre, The Hague, the Netherlands
| | | | - Rimke C Vos
- Department of Public Health and Primary Care, Leiden University Medical Centre, The Hague, the Netherlands
| | - Luke Blackbourn
- MRC Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | | | - Sarah H Wild
- Usher Institute, University of Edinburgh, Edinburgh, UK
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Barasche-Berdah D, Ein-Mor E, Calderon-Margalit R, Rose AJ, Krieger M, Brammli-Greenberg S, Ben-Yehuda A, Manor O, Cohen AD, Bar-Ratson E, Bareket R, Matz E, Paltiel O. Nationwide Evaluation of Quality of Care Indicators for Individuals with Severe Mental Illness and Diabetes Mellitus, Following Israel's Mental Health Reform. Community Ment Health J 2024; 60:354-365. [PMID: 37697183 DOI: 10.1007/s10597-023-01178-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 07/31/2023] [Indexed: 09/13/2023]
Abstract
Diabetes Mellitus (DM) is more common among individuals with severe mental illness (SMI). We aimed to assess quality-of-care-indicators in individuals with SMI following the 2015 Israel's Mental-Health-reform. We analyzed yearly changes in 2015-2019 of quality-of-care-measures and intermediate-DM-outcomes, with adjustment for gender, age-group, and socioeconomic status (SES) and compared individuals with SMI to the general adult population. Adults with SMI had higher prevalences of DM (odds ratio (OR) = 1.64; 95% confidence intervals (CI): 1.61-1.67) and obesity (OR = 2.11; 95% CI: 2.08-2.13), compared to the general population. DM prevalence, DM control, and obesity rates increased over the years in this population. In 2019, HbA1c testing was marginally lower (OR = 0.88; 95% CI: 0.83-0.94) and uncontrolled DM (HbA1c > 9%) slightly more common among patients with SMI (OR = 1.22; 95% CI: 1.14-1.30), control worsened by decreasing SES. After adjustment, uncontrolled DM (adj. OR = 1.02; 95% CI: 0.96-1.09) was not associated with SMI. Cardio-metabolic morbidity among patients with SMI may be related to high prevalences of obesity and DM rather than poor DM control. Effective screening for metabolic diseases in this population and social reforms are required.
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Affiliation(s)
- Deborah Barasche-Berdah
- Braun School of Public Health and Community Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, POB 12272, 92210, Jerusalem, Israel.
| | - Eliana Ein-Mor
- National Program for Quality Indicators in Community Healthcare in Israel, Jerusalem, Israel
| | - Ronit Calderon-Margalit
- Braun School of Public Health and Community Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, POB 12272, 92210, Jerusalem, Israel
- National Program for Quality Indicators in Community Healthcare in Israel, Jerusalem, Israel
| | - Adam J Rose
- Braun School of Public Health and Community Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, POB 12272, 92210, Jerusalem, Israel
- National Program for Quality Indicators in Community Healthcare in Israel, Jerusalem, Israel
| | - Michal Krieger
- National Program for Quality Indicators in Community Healthcare in Israel, Jerusalem, Israel
| | - Shuli Brammli-Greenberg
- Braun School of Public Health and Community Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, POB 12272, 92210, Jerusalem, Israel
- National Program for Quality Indicators in Community Healthcare in Israel, Jerusalem, Israel
| | - Arye Ben-Yehuda
- National Program for Quality Indicators in Community Healthcare in Israel, Jerusalem, Israel
| | - Orly Manor
- Braun School of Public Health and Community Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, POB 12272, 92210, Jerusalem, Israel
- National Program for Quality Indicators in Community Healthcare in Israel, Jerusalem, Israel
| | - Arnon D Cohen
- Clalit Health Services, 101 Arlozorov St., POB 16250, 62098, Tel Aviv, Israel
| | | | - Ronen Bareket
- Meuhedet Health Fund, 124 Ibn Gvirol St, 62038, Tel Aviv, Israel
- Department of Family Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Department of Medical Education, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Matz
- Leumit Health Fund, 23 Sprinzak St, 64738, Tel Aviv, Israel
| | - Ora Paltiel
- Braun School of Public Health and Community Medicine, Hadassah Medical Organization, Faculty of Medicine, Hebrew University of Jerusalem, POB 12272, 92210, Jerusalem, Israel
- National Program for Quality Indicators in Community Healthcare in Israel, Jerusalem, Israel
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Carswell C, Coventry PA, Brown JVE, Alderson SL, Double K, Gilbody S, Holt RIG, Jacobs R, Lister JE, Osborn DPJ, Shiers D, Najma S, Taylor J, Kellar I. A theory and evidence-based co-design approach to develop a supported self-management intervention for people with severe mental illness and type 2 diabetes (Preprint). J Med Internet Res 2022; 25:e43597. [PMID: 37171868 DOI: 10.2196/43597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 02/20/2023] [Accepted: 03/14/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND Type 2 diabetes is 2 to 3 times more common among people with severe mental illness (SMI). Self-management is crucial, with additional challenges faced by people with SMI. Therefore, it is essential that any diabetes self-management program for people with SMI addresses the unique needs of people living with both conditions and the inequalities they experience within health care services. OBJECTIVE We combined theory, empirical evidence, and co-design approaches to develop a type 2 diabetes self-management intervention for people with SMI. METHODS The development process encompassed 4 steps: step 1 involved prioritizing the mechanisms of action (MoAs) and behavior change techniques (BCTs) for the intervention. Using findings from primary qualitative research and systematic reviews, we selected candidate MoAs to target in the intervention and candidate BCTs to use. Expert stakeholders then ranked these MoAs and BCTs using a 2-phase survey. The average scores were used to generate a prioritized list of MoAs and BCTs. During step 2, we presented the survey results to an expert consensus workshop to seek expert agreement with the definitive list of MoAs and BCTs for the intervention and identify potential modes of delivery. Step 3 involved the development of trigger films using the evidence from steps 1 and 2. We used animations to present the experiences of people with SMI managing diabetes. These films were used in step 4, where we used a stakeholder co-design approach. This involved a series of structured workshops, where the co-design activities were informed by theory and evidence. RESULTS Upon the completion of the 4-step process, we developed the DIAMONDS (diabetes and mental illness, improving outcomes and self-management) intervention. It is a tailored self-management intervention based on the synthesis of the outputs from the co-design process. The intervention incorporates a digital app, a paper-based workbook, and one-to-one coaching designed to meet the needs of people with SMI and coexisting type 2 diabetes. CONCLUSIONS The intervention development work was underpinned by the MoA theoretical framework and incorporated systematic reviews, primary qualitative research, expert stakeholder surveys, and evidence generated during co-design workshops. The intervention will now be tested for feasibility before undergoing a definitive evaluation in a pragmatic randomized controlled trial.
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Carswell C, Brown JVE, Lister J, Ajjan RA, Alderson SL, Balogun-Katung A, Bellass S, Double K, Gilbody S, Hewitt CE, Holt RIG, Jacobs R, Kellar I, Peckham E, Shiers D, Taylor J, Siddiqi N, Coventry P. The lived experience of severe mental illness and long-term conditions: a qualitative exploration of service user, carer, and healthcare professional perspectives on self-managing co-existing mental and physical conditions. BMC Psychiatry 2022; 22:479. [PMID: 35850709 PMCID: PMC9295434 DOI: 10.1186/s12888-022-04117-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/30/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND People with severe mental illness (SMI), such as schizophrenia, have higher rates of physical long-term conditions (LTCs), poorer health outcomes, and shorter life expectancy compared with the general population. Previous research exploring SMI and diabetes highlights that people with SMI experience barriers to self-management, a key component of care in long-term conditions; however, this has not been investigated in the context of other LTCs. The aim of this study was to explore the lived experience of co-existing SMI and LTCs for service users, carers, and healthcare professionals. METHODS A qualitative study with people with SMI and LTCs, their carers, and healthcare professionals, using semi-structured interviews, focused observations, and focus groups across the UK. Forty-one interviews and five focus groups were conducted between December 2018 and April 2019. Transcripts were coded by two authors and analysed thematically. RESULTS Three themes were identified, 1) the precarious nature of living with SMI, 2) the circularity of life with SMI and LTCs, and 3) the constellation of support for self-management. People with co-existing SMI and LTCs often experience substantial difficulties with self-management of their health due to the competing demands of their psychiatric symptoms and treatment, social circumstances, and access to support. Multiple long-term conditions add to the burden of self-management. Social support, alongside person-centred professional care, is a key facilitator for managing health. An integrated approach to both mental and physical healthcare was suggested to meet service user and carer needs. CONCLUSION The demands of living with SMI present a substantial barrier to self-management for multiple co-existing LTCs. It is important that people with SMI can access person-centred, tailored support for their LTCs that takes into consideration individual circumstances and priorities.
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Affiliation(s)
- C. Carswell
- grid.5685.e0000 0004 1936 9668Department of Health Sciences, University of York, York, UK
| | - J. V. E. Brown
- grid.5685.e0000 0004 1936 9668Department of Health Sciences, University of York, York, UK
| | - J. Lister
- grid.5685.e0000 0004 1936 9668Department of Health Sciences, University of York, York, UK
| | - R. A. Ajjan
- grid.9909.90000 0004 1936 8403Clinical and Population Sciences Department, Leeds institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT UK
| | - S. L. Alderson
- grid.9909.90000 0004 1936 8403Leeds Institute of Health, University of Leeds, Leeds, UK
| | - A. Balogun-Katung
- grid.1006.70000 0001 0462 7212Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - S. Bellass
- grid.25627.340000 0001 0790 5329Department of Sport and Exercise Sciences, Manchester Metropolitan University, Manchester, UK
| | - K. Double
- grid.498142.2Bradford District Care NHS Foundation Trust, Bradford, UK
| | - S. Gilbody
- grid.5685.e0000 0004 1936 9668Department of Health Sciences, University of York, York, UK ,grid.413631.20000 0000 9468 0801Hull York Medical School, York, UK
| | - C. E. Hewitt
- grid.5685.e0000 0004 1936 9668Department of Health Sciences, University of York, York, UK ,grid.5685.e0000 0004 1936 9668York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - R. I. G. Holt
- grid.5491.90000 0004 1936 9297Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK ,grid.430506.40000 0004 0465 4079National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - R. Jacobs
- grid.5685.e0000 0004 1936 9668Centre for Health Economics, University of York, York, UK
| | - I. Kellar
- grid.9909.90000 0004 1936 8403School of Psychology, University of Leeds, Leeds, UK
| | - E. Peckham
- grid.5685.e0000 0004 1936 9668Department of Health Sciences, University of York, York, UK
| | - D. Shiers
- Psychosis Research Unit, Greater Manchester Mental Health NHS Trust, Manchester, UK ,grid.5379.80000000121662407Division of Psychology and Mental Health, University of Manchester, Manchester, UK ,grid.9757.c0000 0004 0415 6205School of Medicine, Keele University, Staffordshire, UK
| | - J. Taylor
- grid.5685.e0000 0004 1936 9668Department of Health Sciences, University of York, York, UK
| | - N. Siddiqi
- grid.5685.e0000 0004 1936 9668Department of Health Sciences, University of York, York, UK ,grid.498142.2Bradford District Care NHS Foundation Trust, Bradford, UK ,grid.413631.20000 0000 9468 0801Hull York Medical School, York, UK
| | - P. Coventry
- grid.5685.e0000 0004 1936 9668Department of Health Sciences, University of York, York, UK ,grid.5685.e0000 0004 1936 9668York Environmental Sustainability Institute, University of York, York, UK
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Nieuwenhuijse EA, Struijs JN, Sutch SP, Numans ME, Vos RC. Achieving diabetes treatment targets in people with registered mental illness is similar or improved compared with those without: Analyses of linked observational datasets. Diabet Med 2022; 39:e14835. [PMID: 35342984 PMCID: PMC9325400 DOI: 10.1111/dme.14835] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/25/2022] [Indexed: 11/29/2022]
Abstract
AIMS To determine the association between registered mental illness and type 2 diabetes mellitus treatment targets, while taking into account the effects of health expenditure and social determinants of health. METHODS This observational cross-sectional study was based on routine primary care data, linked to socio-economic and medical claims data. The main outcomes, analysed by multivariate logistic regression, were achieving primary care guideline treatment targets for HbA1c , systolic blood pressure (SBP) and LDL-cholesterol in 2017. We examined the association with diagnosed mental illness registered by the general practitioner (GP) or treated via specialist' mental healthcare between 2016 and 2018, adjusting for, medication use, body mass index, co-morbidity, smoking, and additionally examining effect-modification of healthcare expenditures, migration status, income and demographics. RESULTS Overall (N = 2862), 64.0% of participants achieved their treatment targets for HbA1c , 65.1% for SBP and 53.0% for LDL-cholesterol. Adjusted for migrant background, income and care expenditures, individuals <65 years of age with mental illness achieved their HbA1c treatment target more often than those without (OR (95% CI)): treatment by GP: 1.46 (1.01, 2.11), specialist care: 1.61 (1.11, 2.34), as did men with mental illness for SBP: GP OR 1.61 (1.09, 2.40), specialist care OR 1.59 (1.09, 2.45). LDL-cholesterol target was not associated with mental illness. A migrant background or low income lowered the likelihood of reaching HbA1c targets. CONCLUSIONS People with registered mental illness appear comparable or better able to achieve diabetes treatment targets than those without. Achieving HbA1c targets is influenced by social disadvantage.
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Affiliation(s)
- Emma A. Nieuwenhuijse
- Department of Public Health and Primary CareLUMC‐Campus The HagueLeiden University Medical CentreThe HagueThe Netherlands
| | - Jeroen N. Struijs
- Department of Public Health and Primary CareLUMC‐Campus The HagueLeiden University Medical CentreThe HagueThe Netherlands
- National Institute for Public Health and the EnvironmentBilthovenThe Netherlands
| | - Stephen P. Sutch
- Department of Public Health and Primary CareLUMC‐Campus The HagueLeiden University Medical CentreThe HagueThe Netherlands
- Health Policy and ManagementJohns Hopkins University Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Mattijs. E. Numans
- Department of Public Health and Primary CareLUMC‐Campus The HagueLeiden University Medical CentreThe HagueThe Netherlands
| | - Rimke C. Vos
- Department of Public Health and Primary CareLUMC‐Campus The HagueLeiden University Medical CentreThe HagueThe Netherlands
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Brown JV, Ajjan R, Alderson S, Böhnke JR, Carswell C, Doherty P, Double K, Gilbody S, Hadjiconstantinou M, Hewitt C, Holt RI, Jacobs R, Johnson V, Kellar I, Osborn D, Parrott S, Shiers D, Taylor J, Troughton J, Watson J, Siddiqi N, Coventry PA. The DIAMONDS intervention to support self-management of type 2 diabetes in people with severe mental illness: Study protocol for a single-group feasibility study. SSM - MENTAL HEALTH 2022. [DOI: 10.1016/j.ssmmh.2022.100086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Knudsen L, Hansen DL, Joensen LE, Wibaek R, Benros ME, Jørgensen ME, Andersen GS. Need for improved diabetes support among people with psychiatric disorders and diabetes treated in psychiatric outpatient clinics: results from a Danish cross-sectional study. BMJ Open Diabetes Res Care 2022; 10:10/1/e002366. [PMID: 35078855 PMCID: PMC8796247 DOI: 10.1136/bmjdrc-2021-002366] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 01/04/2022] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION People with psychiatric disorders have increased risk of premature death partly due to diabetes. This study aims to explore the quality of diabetes care, diabetes management, diabetes support and well-being of people with psychiatric disorders and diabetes. RESEARCH DESIGN AND METHODS A total of 107 participants aged ≥18 years with diabetes and psychiatric disorders treated at psychiatric outpatient clinics in Denmark were recruited from August 2018 to June 2019. This descriptive cross-sectional study includes data from medical records on quality of diabetes care (eg, level and annual examination of hemoglobin A1c (HbA1c)) and questionnaires on diabetes management (measured on items from the Summary of Diabetes Self-Care Activities Scale and diabetes distress based on Problem Areas in Diabetes Scale (PAID-5)), diabetes support (no, some or high support from eight potential support persons and experience of care actions measured on items from Patient Assessment of Chronic Illness Care) and well-being (WHO 5-Item Scale and self-rated general health). RESULTS The mean age was 52 years, 56% were men, the mean body mass index was 31.9 kg/m2, the median HbA1c was 53 mmol/mol (7.0%) and the mean blood pressure was 131/83 mm Hg. The proportion with annual measurements of HbA1c was 93%, blood pressure 80%, cholesterol 93%, foot examination 77% and eye examination 75%. Fifty-one per cent had high diabetes distress (PAID-5 score ≥8). Diabetologists and general practitioners (39% and 37%) were the health professionals most frequently reported to provide high diabetes support. CONCLUSIONS This study highlights a need for improved diabetes support in people with psychiatric disorders and diabetes. Although a high proportion received appropriate diabetes care, we found high levels of diabetes distress, moderate levels of optimal self-management behaviors, low well-being and low diabetes support from psychiatric health professionals, while one-third of the population found it relevant to receive diabetes support from psychiatric health professionals.
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Affiliation(s)
- Lenette Knudsen
- Education, Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | | | - Lene Eide Joensen
- Diabetes Management Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Rasmus Wibaek
- Clinical Epidemiology, Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Michael Eriksen Benros
- Biological and Precision Psychiatry, Copenhagen Research Centre for Mental Health, Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marit Eika Jørgensen
- Clinical Epidemiology, Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Center for Health Research in Greenland, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
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Das-Munshi J, Schofield P, Ashworth M, Gaughran F, Hull S, Ismail K, Robson J, Stewart R, Mathur R. Inequalities in glycemic management in people living with type 2 diabetes mellitus and severe mental illnesses: cohort study from the UK over 10 years. BMJ Open Diabetes Res Care 2021; 9:e002118. [PMID: 34497046 PMCID: PMC8438718 DOI: 10.1136/bmjdrc-2021-002118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/29/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Using data from a a primary care pay-for-performance scheme targeting quality indicators, the objective of this study was to assess if people living with type 2 diabetes mellitus (T2DM) and severe mental illnesses (SMI) experienced poorer glycemic management compared with people living with T2DM alone, and if observed differences varied by race/ethnicity, deprivation, gender, or exclusion from the scheme. RESEARCH DESIGN AND METHODS Primary care data from a cohort of 56 770 people with T2DM, including 2272 people with T2DM and SMI, from London (UK), diagnosed between January 17, 2008 and January 16, 2018, were used. Adjusted mean glycated hemoglobin (HbA1c) and HbA1c differences were assessed using multilevel regression models. RESULTS Compared with people with T2DM only, people with T2DM/SMI were more likely to be of an ethnic minority background, excluded from the pay-for-performance scheme and residing in more deprived areas. Across the sample, mean HbA1c was lower in those with T2DM and SMI (mean HbA1c: 58 mmol/mol; 95% CI 57 to 59), compared with people with T2DM only (mean HbA1c: 59 mmol/mol; 95% CI 59 to 60). However, HbA1c levels were greater in Bangladeshi, Indian, Pakistani, and Chinese people compared with the White British reference in the T2DM/SMI group. People with T2DM/SMI who had been excluded from the pay-for-performance scheme, had HbA1c levels which were +7 mmol/mol (95% CI 2 to 11) greater than those with T2DM/SMI not excluded. Irrespective of SMI status, increasing deprivation and male gender were associated with increased HbA1c levels. CONCLUSIONS Despite a pay-for-performance scheme to improve quality standards, inequalities in glycemic management in people with T2DM and SMI persist in those excluded from the scheme and by gender, ethnicity, and area-level deprivation.
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Affiliation(s)
- Jayati Das-Munshi
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
- South London and Maudsley (SLaM) NHS Trust, London, UK
- ESRC Centre for Society and Mental Health, King's College London, London, UK
| | - Peter Schofield
- School of Population Health & Environmental Sciences, King's College London, Faculty of Life Sciences & Medicine (FOLSM), London, UK
| | - Mark Ashworth
- School of Population Health & Environmental Sciences, King's College London, Faculty of Life Sciences & Medicine (FOLSM), London, UK
| | - Fiona Gaughran
- South London and Maudsley (SLaM) NHS Trust, London, UK
- Department of Psychosis Studies, King's College London, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
| | - Sally Hull
- Clinical Effectiveness Group, Institute of Population Health Sciences, Queen Mary, University of London, London, UK
| | - Khalida Ismail
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
- South London and Maudsley (SLaM) NHS Trust, London, UK
| | - John Robson
- Clinical Effectiveness Group, Institute of Population Health Sciences, Queen Mary, University of London, London, UK
| | - Robert Stewart
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
- South London and Maudsley (SLaM) NHS Trust, London, UK
| | - Rohini Mathur
- Clinical Effectiveness Group, Institute of Population Health Sciences, Queen Mary, University of London, London, UK
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Lister J, Han L, Bellass S, Taylor J, Alderson SL, Doran T, Gilbody S, Hewitt C, Holt RIG, Jacobs R, Kitchen CEW, Prady SL, Radford J, Ride JR, Shiers D, Wang HI, Siddiqi N. Identifying determinants of diabetes risk and outcomes for people with severe mental illness: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background
People with severe mental illness experience poorer health outcomes than the general population. Diabetes contributes significantly to this health gap.
Objectives
The objectives were to identify the determinants of diabetes and to explore variation in diabetes outcomes for people with severe mental illness.
Design
Under a social inequalities framework, a concurrent mixed-methods design combined analysis of linked primary care records with qualitative interviews.
Setting
The quantitative study was carried out in general practices in England (2000–16). The qualitative study was a community study (undertaken in the North West and in Yorkshire and the Humber).
Participants
The quantitative study used the longitudinal health records of 32,781 people with severe mental illness (a subset of 3448 people had diabetes) and 9551 ‘controls’ (with diabetes but no severe mental illness), matched on age, sex and practice, from the Clinical Practice Research Datalink (GOLD version). The qualitative study participants comprised 39 adults with diabetes and severe mental illness, nine family members and 30 health-care staff.
Data sources
The Clinical Practice Research Datalink (GOLD) individual patient data were linked to Hospital Episode Statistics, Office for National Statistics mortality data and the Index of Multiple Deprivation.
Results
People with severe mental illness were more likely to have diabetes if they were taking atypical antipsychotics, were living in areas of social deprivation, or were of Asian or black ethnicity. A substantial minority developed diabetes prior to severe mental illness. Compared with people with diabetes alone, people with both severe mental illness and diabetes received more frequent physical checks, maintained tighter glycaemic and blood pressure control, and had fewer recorded physical comorbidities and elective admissions, on average. However, they had more emergency admissions (incidence rate ratio 1.14, 95% confidence interval 0.96 to 1.36) and a significantly higher risk of all-cause mortality than people with diabetes but no severe mental illness (hazard ratio 1.89, 95% confidence interval 1.59 to 2.26). These paradoxical results may be explained by other findings. For example, people with severe mental illness and diabetes were more likely to live in socially deprived areas, which is associated with reduced frequency of health checks, poorer health outcomes and higher mortality risk. In interviews, participants frequently described prioritising their mental illness over their diabetes (e.g. tolerating antipsychotic side effects, despite awareness of harmful impacts on diabetes control) and feeling overwhelmed by competing treatment demands from multiple morbidities. Both service users and practitioners acknowledged misattributing physical symptoms to poor mental health (‘diagnostic overshadowing’).
Limitations
Data may not be nationally representative for all relevant covariates, and the completeness of recording varied across practices.
Conclusions
People with severe mental illness and diabetes experience poorer health outcomes than, and deficiencies in some aspects of health care compared with, people with diabetes alone.
Future work
These findings can inform the development of targeted interventions aimed at addressing inequalities in this population.
Study registration
National Institute for Health Research (NIHR) Central Portfolio Management System (37024); and ClinicalTrials.gov NCT03534921.
Funding
This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jennie Lister
- Department of Health Sciences, University of York, York, UK
| | - Lu Han
- Department of Health Sciences, University of York, York, UK
| | - Sue Bellass
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Jo Taylor
- Department of Health Sciences, University of York, York, UK
| | - Sarah L Alderson
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Tim Doran
- Department of Health Sciences, University of York, York, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
| | | | - Richard IG Holt
- Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Rowena Jacobs
- Centre for Health Economics, University of York, York, UK
| | | | | | - John Radford
- Patient and public involvement representative, Keighley, UK
| | - Jemimah R Ride
- Centre for Health Policy, School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - David Shiers
- Division of Psychology and Mental Health, University of Manchester, Manchester, UK
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
- Primary Care and Health Sciences, Keele University, Keele, UK
| | - Han-I Wang
- Department of Health Sciences, University of York, York, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of York, York, UK
- Bradford District Care NHS Foundation Trust, Bradford, UK
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