The effect of a charted history of depression on emergency department triage and outcomes in patients with acute myocardial infarction

Disparities in cardiovascular outcomes among emergency department patients with mental illness

BACKGROUND

Patients with mental illness have been shown to receive lower quality of care and experience worse cardiovascular (CV) outcomes compared to those without mental illness. This present study examined mental health-related disparities in CV outcomes after an Emergency Department (ED) visit for chest pain.

METHODS

This retrospective cohort included adult Medicaid beneficiaries in Washington state discharged from the ED with a primary diagnosis of unspecified chest pain in 2010-2017. Outcomes for patients with any mental illness (any mental health diagnosis or mental-health specific service use within 1 year of an index ED visit) and serious mental illness (at least two claims (on different dates of service) within 1 year of an index ED visit with a diagnosis of schizophrenia, other psychotic disorder, or major mood disorder) were compared to those of patients without mental illness. Our outcomes of interest were the incidence of major adverse cardiac events (MACE) within 30 days and 6 months of discharge of their ED visit, defined as a composite of death, acute myocardial infarction (AMI), CV rehospitalization, or revascularization. Secondary outcomes included cardiovascular diagnostic testing (diagnostic angiography, stress testing, echocardiography, and coronary computed tomography (CT) angiography) rates within 30 days of ED discharge. Only treat-and-release visits were included for outcomes assessment. Hierarchical logistic random effects regression models assessed the association between mental illness and the outcomes of interest, controlling for age, gender, race, ethnicity, Elixhauser comorbidities, and health care use in the past year, as well as fixed year effects.

RESULTS

There were 98,812 treat-and-release ED visits in our dataset. At 30 days, enrollees with any mental illness had no differences in rates of MACE (AOR 0.96; 95% CI, 0.72-1.27) or any of the individual components. At 6 months, enrollees with any mental illness (AOR 1.86; 95% CI, 1.11-3.09) and serious mental illness (AOR 2.60; 95% CI 1.33-5.13) were significantly more likely to be hospitalized for a CV condition compared to those without mental illness. Individuals with any mental illness had higher rates of testing at 30 days (AOR 1.16; 95% CI 1.07-1.27).

CONCLUSION

Patients with mental illness have similar rates of MACE, but higher rates of certain CV outcomes, such as CV hospitalization and diagnostic testing, after an ED visit for chest pain.

Making the implicit explicit: A visual model for lowering the risk of implicit bias of mental/behavioural disorders on safety and quality of care

Persons with mental illness and/or addictions have poorer health outcomes than the general population. Lower quality of healthcare has been identified as an important factor. A main contributor to lower quality of care for people with mental illnesses and/or addictions may be the cognitive implicit bias of mental versus physical care when assessing and categorizing a patient’s clinical presentation. The objective of this article is to highlight how this implicit cognitive bias of mental versus physical care can result in human factor risks to quality of care. We provide three specific case examples of where these quality concerns arise. We also propose the use of a new visual tool to help educate and create awareness of this implicit-bias-based risk and quality care problem.

Call to action regarding the vascular-bipolar link: A report from the Vascular Task Force of the International Society for Bipolar Disorders

OBJECTIVES

The association of bipolar disorder with early and excessive cardiovascular disease was identified over a century ago. Nonetheless, the vascular-bipolar link remains underrecognized, particularly with regard to how this link can contribute to our understanding of pathogenesis and treatment.

METHODS

An international group of experts completed a selective review of the literature, distilling core themes, identifying limitations and gaps in the literature, and highlighting future directions to bridge these gaps.

RESULTS

The association between bipolar disorder and vascular disease is large in magnitude, consistent across studies, and independent of confounding variables where assessed. The vascular-bipolar link is multifactorial and is difficult to study given the latency between the onset of bipolar disorder, often in adolescence or early adulthood, and subsequent vascular disease, which usually occurs decades later. As a result, studies have often focused on risk factors for vascular disease or intermediate phenotypes, such as structural and functional vascular imaging measures. There is interest in identifying the most relevant mediators of this relationship, including lifestyle (eg, smoking, diet, exercise), medications, and systemic biological mediators (eg, inflammation). Nonetheless, there is a paucity of treatment studies that deliberately engage these mediators, and thus far no treatment studies have focused on engaging vascular imaging targets.

CONCLUSIONS

Further research focused on the vascular-bipolar link holds promise for gleaning insights regarding the underlying causes of bipolar disorder, identifying novel treatment approaches, and mitigating disparities in cardiovascular outcomes for people with bipolar disorder.

Evidence-based medicine: A cornerstone for clinical care but not for quality improvement

Quality improvement (QI) as a clinical improvement science has been criticized for failing to deliver broad patient outcome improvement and for being a top-down regulatory and compliance construct. These critics have argued that the focus of QI should be on increasing adherence to clinical practice guidelines (CPGs) and, as a result, should be consolidated into research structures with the science of evidence-based medicine (EBM) at the helm. We argue that EBM often overestimates the role of knowledge as the root cause of quality problems and focuses almost exclusively on the effectiveness of care while often neglecting the domains of safety, efficiency, patient-centredness, and equity. Successfully addressing quality problems requires a much broader, systems-based view of health-care delivery. Although essential to clinical decision-making and practice, EBM cannot act as the cornerstone of health system improvement.

Coverage mandates and market dynamics: employer, insurer and patient responses to parity laws

Parity in coverage for mental health services has been a longstanding policy aim at the state and federal levels and is a regulatory feature of the Affordable Care Act. Despite the importance and legislative effort involved in these policies, evaluations of their effects on patients yield mixed results. I leverage the Employee Retirement Income Security Act and unique claims-level data that includes information on employers’ self-insurance status to shed new light in this area after the implementation of two state parity laws in 2007 and federal parity a few years later. My empirics reveal evidence of strategic avoidance on behalf of insurers in both states prior to the passage of state parity, as well as positive increases in mental health care utilization after parity laws are implemented – but context matters. Policy heterogeneity across states and strategic behaviors by employers and commercial insurers substantively shape the benefits that ultimately flow to patients. Insights from this research have broad relevance to ongoing health policy debates, particularly as states retain great discretion over many health coverage decisions and as federal policy continues to evolve.

Internal Medicine Residents' Attitudes Toward Simulated Depressed Cardiac Patients During an Objective Structured Clinical Examination: A Randomized Study

BACKGROUND

Physician biases toward mental conditions such as depression have been shown to adversely affect medical outcomes.

OBJECTIVE

To explore the relationship between residents' explicit bias toward depressed patients and their clinical skills on a cardiac case during an objective structured clinical exam (OSCE).

DESIGN

Prospective parallel randomized controlled study.

PARTICIPANTS

One hundred eighty-five internal medicine residents from three residency programs in two states.

INTERVENTION

During October-November 2015, residents were randomized to either a depressed or non-depressed standardized patient (SP) presenting with acute chest pain.

MAIN MEASURES

The Medical Condition Regard Scale (MCRS) assessed residents' explicit bias toward patients with depression. Their clinical skills (history-taking, physical examination, patient counseling, patient-physician interaction (PPI), differential diagnosis, and workup plan) and facial expressions were rated during an OSCE.

KEY RESULTS

No significant relationships were found between resident explicit bias and clinical skill measurements. Residents who examined the depressed SP scored lower, on average, on history-taking (t [183] = -2.77, p < 0.01, Cohen's d = 0.41) and higher on PPI (t [183] = 2.24, p < 0.05, Cohen's d = 0.33) than residents examining the non-depressed SP. There were no differences, on average, between stations on physical examination, counseling, correct diagnosis, workup plan, or overall SP satisfaction. Facial recognition software demonstrated that residents with a non-depressed SP had more neutral expressions than depressed-SP residents (t [133] = -2.46, p < 0.05, Cohen's d = 0.46), and residents with a depressed SP had more disgusted expressions than non-depressed-SP residents (t [83.52] = 2.10, p < 0.05, Cohen's d = 0.28).

CONCLUSIONS

Extrinsic bias did not predict OSCE performance in this study. Some differences were noted in the OSCE performance between the two stations. Further study is needed to examine the effects of patient mental health conditions on physician examination procedures, diagnostic behaviors, and patient outcomes.

Effect of charted mental illness on reperfusion therapy in hospitalized patients with an acute myocardial infarction in Florida

Patients with mental illness carry risk factors that predispose them to excess cardiovascular mortality from an acute myocardial infarction (AMI) compared to the general population. The aim of this study was to determine if patients with AMI and charted mental illness (CMI) received less reperfusion therapy following an AMI, compared to AMI patients without CMI in a recent sample population from Florida.A secondary analysis of data was conducted using the Florida Agency for Health Care Administration (FL-AHCA) hospital discharge registry. Adults hospitalized with an AMI from 01/01/2010 to 12/31/2015 were included for the analysis. The dependent variable was administration of reperfusion therapy (thrombolytic, percutaneous coronary intervention [PCI], and coronary artery bypass graft [CABG]), and the independent variable was the presence of CMI (depression, schizophrenia, and bipolar disorder). Multivariate logistic regression models were used to test the association controlling for age, gender, ethnicity, race, health insurance, and comorbidities.The database included 61,614 adults (31.3% women) hospitalized with AMI in Florida. The CMI population comprised of 1036 patients (1.7%) who were on average 5 years younger than non-CMI (60.2 ±12.8 versus 65.2 ±14.1; P < .001). Compared with patients without CMI, patients with CMI had higher proportions of women, governmental health insurance holders, and those with more comorbidities. The adjusted odds ratio indicated that patients with CMI were 30% less likely to receive reperfusion therapy compared with those without CMI (OR = 0.7; 95% CI = 0.6-0.8). Within the AMI population including those with and without CMI, women were 23% less likely to receive therapy than men; blacks were 26% less likely to receive reperfusion therapy than whites; and those holding government health insurances were between 20% and 40% less likely to receive reperfusion therapy than those with private health insurance.Patients with AMI and CMI were statistically significantly less likely to receive reperfusion therapy compared with patients without CMI. These findings highlight the need to implement AMI management care aimed to reduce disparities among medically vulnerable patients (those with CMI, women, blacks, and those with governmental health insurance).

Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions

Mental illness-related stigma, including that which exists in the healthcare system and among healthcare providers, creates serious barriers to access and quality care. It is also a major concern for healthcare practitioners themselves, both as a workplace culture issue and as a barrier for help seeking. This article provides an overview of the main barriers to access and quality care created by stigmatization in healthcare, a consideration of contributing factors, and a summary of Canadian-based research into promising practices and approaches to combatting stigma in healthcare environments.

How Much Do Mental Health and Substance Use/Addiction Affect Use of General Medical Services? Extent of Use, Reason for Use, and Associated Costs

OBJECTIVE

To measure service use and costs associated with health care for patients with mental health (MH) and substance use/addiction (SA) problems.

METHODS

A 5-year cross-sectional study (2007-2012) of administrative health care data was conducted (average annual sample size = 123,235 adults aged >18 years who had a valid Ontario health care number and used at least 1 service during the year; 55% female). We assessed average annual use of primary care, emergency departments and hospitals, and overall health care costs for patients identified as having MH only, SA only, co-occurring MH and SA problems (MH+SA), and no MH and/or SA (MH/SA) problems. Total visits/admissions and total non-MH/SA visits (i.e., excluding MH/SA visits) were regressed separately on MH, SA, and MH+SA cases compared to non-MH/SA cases using the 2011-2012 sample ( N = 123,331), controlling for age and sex.

RESULTS

Compared to non-MH/SA patients, MH/SA patients were significantly ( P < 0.001) more likely to visit primary care physicians (1.82 times as many visits for MH-only patients, 4.24 for SA, and 5.59 for MH+SA), use emergency departments (odds, 1.53 [MH], 3.79 [SA], 5.94 [MH+SA]), and be hospitalized (odds, 1.59 [MH], 4.10 [SA], 7.82 [MH+SA]). MH/SA patients were also significantly more likely than non-MH/SA patients to have non-MH/SA-related visits and accounted for 20% of the sample but over 30% of health care costs.

CONCLUSIONS

MH and SA are core issues for all health care settings. MH/SA patients use more services overall and for non-MH/SA issues, with especially high use and costs for MH+SA patients.

Theoretical and Practical Considerations for Combating Mental Illness Stigma in Health Care

Reducing the stigma and discrimination associated with mental illness is becoming an increasingly important focus for research, policy, programming and intervention work. While it has been well established that the healthcare system is one of the key environments in which persons with mental illnesses experience stigma and discrimination there is little published literature on how to build and deliver successful anti-stigma programs in healthcare settings, towards healthcare providers in general, or towards specific types of practitioners. Our paper intends to address this gap by providing a set of theoretical considerations for guiding the design and implementation of anti-stigma interventions in healthcare.

Accuracy in ED Triage for Symptoms of Acute Myocardial Infarction

More than 6 million people present to emergency departments across the United States annually with symptoms of acute myocardial infarction (AMI). Of the 1 million patients with AMI, 350,000 die during the acute phase. Accurate ED triage can reduce mortality and morbidity, yet accuracy rates are low. In this study we explored the relationship between patient and nurse characteristics and accuracy of triage in patients with symptoms of AMI.

METHODS

This retrospective, descriptive study used patient data from electronic medical records. The sample of 286 patients was primarily white, with a mean age of 61.44 years (standard deviation [SD], ±13.02), and no history of heart disease. The sample of triage nurses was primarily white and female, with a mean age of 45.46 years (SD, ±11.72) and 18 years of nursing experience. Nineteen percent of the nurses reported having earned a bachelor's degree.

RESULTS

Emergency nurse triage accuracy was 54%. Patient race and presence of chest pain were significant predictors of accuracy. Emergency nurse age was a significant predictor of accuracy in triage, but years of experience in nursing was not a significant predictor.

DISCUSSION

Of the 9 variables investigated, only patient race, symptom presentation, and emergency nurse age were significant predictors of triage accuracy. Inconsistency in triage decisions may be due to other conditions not yet explored, such as critical thinking skills and executive functions. This study adds to the body of evidence regarding ED triage of patients with symptoms of AMI. However, further exploration into decisions at triage is warranted to improve accuracy, expedite care, and improve outcomes.

Opening minds in Canada: background and rationale

OBJECTIVE

To summarize the background and rationale of the approach taken by the Mental Health Commission of Canada's Opening Minds (OM) Anti-Stigma Initiative.

METHOD

The approach taken by OM incorporates a grassroots, community development philosophy, has clearly defined target groups, uses contact-based education as the central organizing element across interventions, and has a strong evaluative component, so that best practices can be identified, replicated, and disseminated. Contact-based education occurs when people who have experienced a mental illness share their personal story of recovery and hope.

RESULTS

OM has acted as a catalyst to develop partnerships between community groups who are undertaking anti-stigma work and an interdisciplinary team of academic researchers in 5 universities who are evaluating the results of these programs.

CONCLUSIONS

Building partnerships with existing community programs and promoting systematic evaluation using standardized approaches and instruments have contributed to our understanding of best practices in the field of anti-stigma programming.

Wait times in the emergency department for patients with mental illness

BACKGROUND

It has been suggested that patients with mental illness wait longer for care than other patients in the emergency department. We determined wait times for patients with and without mental health diagnoses during crowded and noncrowded periods in the emergency department.

METHODS

We conducted a population-based retrospective cohort analysis of adults seen in 155 emergency departments in Ontario between April 2007 and March 2009. We compared wait times and triage scores for patients with mental illness to those for all other patients who presented to the emergency department during the study period.

RESULTS

The patients with mental illness (n = 51 381) received higher priority triage scores than other patients, regardless of crowding. The time to assessment by a physician was longer overall for patients with mental illness than for other patients (median 82, interquartile range [IQR] 41-147 min v. median 75 [IQR 36-140] min; p < 0.001). The median time from the decision to admit the patient to hospital to ward transfer was markedly shorter for patients with mental illness than for other patients (median 74 [IQR 15-215] min v. median 152 [IQR 45-605] min; p < 0.001). After adjustment for other variables, patients with mental illness waited 10 minutes longer to see a physician compared with other patients during noncrowded periods (95% confidence interval [CI] 8 to 11), but they waited significantly less time than other patients as crowding increased (mild crowding: -14 [95% CI -12 to -15] min; moderate crowding: -38 [95% CI -35 to -42] min; severe crowding: -48 [95% CI -39 to -56] min; p < 0.001).

INTERPRETATION

Patients with mental illness were triaged appropriately in Ontario's emergency departments. These patients waited less time than other patients to see a physician under crowded conditions and only slightly longer under noncrowded conditions.