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Iturralde E, Rubinsky AD, Nguyen KH, Anderson C, Lyles CR, Mangurian C. Serious Mental Illness, Glycemic Control, and Neighborhood Factors within an Urban Diabetes Cohort. Schizophr Bull 2024; 50:653-662. [PMID: 37597839 PMCID: PMC11059791 DOI: 10.1093/schbul/sbad122] [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] [Indexed: 08/21/2023]
Abstract
BACKGROUND AND HYPOTHESIS Serious mental illness (SMI) may compromise diabetes self-management. This study assessed the association between SMI and glycemic control, and explored sociodemographic predictors and geographic clustering of this outcome among patients with and without SMI. STUDY DESIGN We used electronic health record data for adult primary care patients with diabetes from 2 San Francisco health care delivery systems. The primary outcome was poor glycemic control (hemoglobin A1c >9.0%), which was modeled on SMI diagnosis status and sociodemographics. Geospatial analyses examined hotspots of poor glycemic control and neighborhood characteristics. STUDY RESULTS The study included 11 694 participants with diabetes, 21% with comorbid SMI, of whom 22% had a schizophrenia spectrum or bipolar disorder. Median age was 62 years; 52% were female and 79% were Asian, Black, or Hispanic. In adjusted models, having schizophrenia spectrum disorder or bipolar disorder was associated with greater risk for poor glycemic control (vs participants without SMI, adjusted relative risk [aRR] = 1.24; 95% confidence interval, 1.02, 1.49), but having broadly defined SMI was not. People with and without SMI had similar sociodemographic correlates of poor glycemic control including younger versus older age, Hispanic versus non-Hispanic White race/ethnicity, and English versus Chinese language preference. Hotspots for poor glycemic control were found in neighborhoods with more lower-income, Hispanic, and Black residents. CONCLUSIONS Poor diabetes control was significantly related to having a schizophrenia spectrum or bipolar disorder, and to sociodemographic factors and neighborhood. Community-based mental health clinics in hotspots could be targets for implementation of diabetes management services.
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Affiliation(s)
- Esti Iturralde
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States
| | - Anna D Rubinsky
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, United States
- Academic Research Services, Information Technology, University of California San Francisco, San Francisco, CA, United States
| | - Kim H Nguyen
- Department of Medicine, Center for Vulnerable Populations at ZSFG, University of California San Francisco, San Francisco, CA, United States
| | - Chelsie Anderson
- Department of Surgery, University of California San Francisco, San Francisco, CA, United States
| | - Courtney R Lyles
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, United States
- Department of Medicine, Center for Vulnerable Populations at ZSFG, University of California San Francisco, San Francisco, CA, United States
| | - Christina Mangurian
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, United States
- Department of Medicine, Center for Vulnerable Populations at ZSFG, University of California San Francisco, San Francisco, CA, United States
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, United States
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Cohen AS, Cardenas-Turanzas M, Champagne-Langabeer T. Roles of Hospital Type and Community Setting in Rate of Screening for Metabolic Disorders Among Psychiatric Patients. Psychiatr Serv 2024:appips20230472. [PMID: 38566560 DOI: 10.1176/appi.ps.20230472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Globally, rates of metabolic disorders continue to climb, leading to significant disease morbidity and mortality. Individuals with mental illness are particularly prone to obesity, and some medications, such as antipsychotics, may increase the risk for metabolic disorders. The American Psychiatric Association and the American Diabetes Association recommend that patients taking antipsychotic medications receive regular screening for metabolic disorders. This study examined hospital and community factors associated with screening these patients for such disorders. METHODS The authors combined Centers for Medicare and Medicaid Services (CMS) hospital-level data on screening for metabolic disorders among patients with an antipsychotic prescription with community data, including urbanization classification, social vulnerability, and metabolic disease presence and risk factors. Data were merged at the county level and evaluated with a nonparametric multivariate regression model. RESULTS The CMS data set included 1,497 U.S. hospitals with data on screening for metabolic disorders among patients with an antipsychotic prescription. Screening rates varied by type of facility; acute care and critical access hospitals outperformed freestanding psychiatric facilities (p<0.001). No other variables examined in the multivariate model were associated with screening for metabolic disorders. CONCLUSIONS Despite common resource limitations, screening for metabolic disorders may be driven more by logistics and less by time, finances, or a community's primary care network. Identifying the specific logistical challenges of freestanding psychiatric facilities could aid in the development of targeted interventions to improve the rates of screening for and treatment of not only metabolic disorders but also other common comorbid conditions.
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Affiliation(s)
- A Sarah Cohen
- Center for Behavioral Emergency and Addiction Research, D. Bradley McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston
| | - Marylou Cardenas-Turanzas
- Center for Behavioral Emergency and Addiction Research, D. Bradley McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston
| | - Tiffany Champagne-Langabeer
- Center for Behavioral Emergency and Addiction Research, D. Bradley McWilliams School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston
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Merino D, Gérard AO, Destere A, Saidessalam H, Askenazy F, Montastruc F, Drici MD, Thümmler S. Cardiac and metabolic safety profile of antipsychotics in youths: A WHO safety database analysis. Psychiatry Res 2024; 334:115786. [PMID: 38387164 DOI: 10.1016/j.psychres.2024.115786] [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: 08/24/2023] [Revised: 02/03/2024] [Accepted: 02/10/2024] [Indexed: 02/24/2024]
Abstract
A significant heterogeneity prevails in antipsychotics (APs) safety monitoring recommendations. Youths are deemed more vulnerable to cardiometabolic side effects. We aimed to assess age-dependent reporting of cardiac and metabolic disorders in youths, relying on the WHO safety database (VigiBase®). VigiBase® was queried for all reports of cardiac, glucose, lipid and nutritional disorders involving APs. Patients <18 years were classified as pediatric population. Disproportionality analyses relied on the Information Component (IC): the positivity of the lower end of its 95 % confidence interval was required to suspect a signal. We yielded 4,672 pediatric reports. In disproportionality analysis, nutritional disorders were leading in youths (IC 3.9 [3.9-4.0]). Among healthcare professionals' reports, stronger signals were detected in youths than in adults. Children had the greatest signal with nutritional disorders (IC 4.7 [4.6-4.8]). In adolescents, aripiprazole was ascribed to non-alcoholic steatohepatitis (NASH). Our findings, based on real-world data, support the hypothesis of a greater propensity for nutritional disorders in youths, despite limitations of pharmacovigilance studies. We suggest specific safety profiles, such as aripiprazole and NASH. Pending more answers from population-based studies, a careful anamnesis should seek for risk factors before AP initiation. A cautious monitoring is warranted to allow earlier identification of side effects.
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Affiliation(s)
- Diane Merino
- University Department of Child and Adolescent Psychiatry, Children's Hospitals of Nice, CHU-Lenval, Nice, France; Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital CHU de Nice, Nice, France; Université Côte d'Azur, CoBTeK, Nice, France
| | - Alexandre O Gérard
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital CHU de Nice, Nice, France; Université Côte d'Azur, Laboratory of Molecular Physio Medicine (LP2M), UMR 7370, CNRS, Nice, France
| | - Alexandre Destere
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital CHU de Nice, Nice, France; Université Côte d'Azur, Inria, CNRS, Laboratoire J.A. Dieudonné, Maasai team, Nice, France
| | - Haitam Saidessalam
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital CHU de Nice, Nice, France
| | - Florence Askenazy
- University Department of Child and Adolescent Psychiatry, Children's Hospitals of Nice, CHU-Lenval, Nice, France; Université Côte d'Azur, CoBTeK, Nice, France
| | - François Montastruc
- Department of Medical and Clinical Pharmacology, Centre of PharmacoVigilance and Pharmacoepidemiology, Faculty of Medicine, Toulouse University Hospital, Toulouse, France
| | - Milou-Daniel Drici
- Department of Pharmacology and Pharmacovigilance Center of Nice, University Hospital CHU de Nice, Nice, France
| | - Susanne Thümmler
- University Department of Child and Adolescent Psychiatry, Children's Hospitals of Nice, CHU-Lenval, Nice, France; Université Côte d'Azur, CoBTeK, Nice, France.
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Iturralde E, Fazzolari L, Slama NE, Alexeeff SE, Sterling SA, Awsare S, Koshy MT, Shia M. Telehealth Collaborative Care Led by Clinical Pharmacists for People With Psychosis or Bipolar Disorder: A Propensity Weighted Comparison With Usual Psychiatric Care. J Clin Psychiatry 2024; 85:23m14917. [PMID: 38301189 PMCID: PMC10868914 DOI: 10.4088/jcp.23m14917] [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] [Indexed: 02/03/2024]
Abstract
Objective: People with psychosis or bipolar disorder (severe and persistent mental illness [SPMI]) are at high risk for poor psychiatric and chronic illness outcomes, which could be ameliorated through improved health care quality. This study assessed whether a telehealth, collaborative care program managed by psychiatric clinical pharmacists (SPMI Population Care) was associated with improved health care quality for adults with SPMI in a large California health system. Methods: This retrospective cohort study used electronic health record data to compare 968 program enrollees at 6 demonstration sites (Population Care) to 8,339 contemporaneous patients with SPMI at 6 non-program sites (Usual Care). SPMI diagnoses were based on ICD-10-CM diagnostic codes. Primary outcomes were optimal psychotropic medication adherence, guideline-recommended glycemic screening, annual psychiatrist visit, and emergency department use. Difference-in-difference analyses assessed change in outcomes from 12 months pre- to 12 months post-enrollment using overlap weighting with high dimensional propensity scores to balance participant characteristics across groups. Participant data were collected from January 1, 2020, to June 30, 2022. Results: From pre- to post-enrollment, Population Care was associated with greater achievement of psychotropic medication adherence and glycemic screening (+6 and +9 percentage points), but unexpectedly with a decrease in annual psychiatrist visits (-6 percentage points) and no significant change in emergency department use, relative to Usual Care. More than 75% of Population Care participants attended an intake and ≥ 1 follow-up visits. Participants with psychosis (26% of sample) had similar results as those with bipolar disorder. Conclusions: Clinical pharmacist-led telehealth collaborative care has potential to improve psychopharmacologic treatment adherence and recommended disease preventive screening for people with psychosis or bipolar disorder.
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Affiliation(s)
- Esti Iturralde
- Division of Research, Kaiser Permanente Northern California, Oakland
- Drs Iturralde and Fazzolari are co-first authors
- Corresponding Author: Esti Iturralde, PhD, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612
| | - Lisa Fazzolari
- Permanente Medical Group, Kaiser Permanente Northern California, Oakland
- Drs Iturralde and Fazzolari are co-first authors
| | - Natalie E Slama
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Stacey E Alexeeff
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Stacy A Sterling
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Sameer Awsare
- Permanente Medical Group, Kaiser Permanente Northern California, Oakland
| | - Maria T Koshy
- Permanente Medical Group, Kaiser Permanente Northern California, Oakland
| | - Macy Shia
- Permanente Medical Group, Kaiser Permanente Northern California, Oakland
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Habuchi F, Ishida N, Matsushita R, Ishizaki J, Suga Y. Analysis of Atypical Antipsychotics-Induced Adverse Events Related to Diabetes Mellitus in Patients With Dementia Using the Japanese Adverse Drug Event Report Database. Ann Pharmacother 2023:10600280231213507. [PMID: 38124305 DOI: 10.1177/10600280231213507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Patients with dementia are prescribed low-dose atypical antipsychotics (AAPs) to treat psycho-behavioral symptoms. Although AAPs are known to cause diabetes mellitus-related adverse events (DMAEs), information regarding AAPs-induced DMAEs experienced by patients with dementia is lacking. OBJECTIVE To use the Japan Adverse Drug Event Report (JADER) database to assess the onset tendencies and patterns of DMAEs attributable to AAPs prescribed to patients with dementia. METHODS We performed an analysis using dementia cases from the JADER database that were registered from April 2004 to December 2022. Data in the JADER database are completely anonymized; thus, we did not require institutional review board approval for using the JADER database in our study. The reporting odds ratio and proportional reporting ratio (PRR) were used to assess the onset tendencies of DMAEs with AAPs. In addition, Weibull shape parameters were used to assess the patterns of DMAEs that occur with the use of AAPs. RESULTS We identified AAPs associated with DMAEs. In particular, low doses of quetiapine showed the potential to induce DMAEs. An analysis of the onset of DMAEs showed the early failure patterns for AAPs (median onset = 38 days). CONCLUSION AND RELEVANCE The AAPs may cause DMAEs in patients with dementia. Low doses of quetiapine may induce DMAEs. Health care workers should focus on the development of DMAEs during the early administration period of AAPs. These results may assist with the safe management of patients with dementia who use AAPs.
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Affiliation(s)
- Fuga Habuchi
- Division of Pharmacy, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Natsuko Ishida
- Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical & Health Science, Kanazawa University, Kanazawa, Japan
| | - Ryo Matsushita
- Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical & Health Science, Kanazawa University, Kanazawa, Japan
| | - Junko Ishizaki
- Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical & Health Science, Kanazawa University, Kanazawa, Japan
| | - Yukio Suga
- Clinical Pharmacy and Healthcare Sciences, Faculty of Pharmacy, Institute of Medical, Pharmaceutical & Health Science, Kanazawa University, Kanazawa, Japan
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Hsueh L, Iturralde E, Slama NE, Spalding SR, Sterling SA. Cardiometabolic Monitoring and Sociodemographic and Clinical Characteristics of Youths Prescribed Antipsychotic Medications. Psychiatr Serv 2023; 74:801-808. [PMID: 37016828 PMCID: PMC10539018 DOI: 10.1176/appi.ps.20220151] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
OBJECTIVE This study examined time trends and patient characteristics related to guideline-recommended cardiometabolic risk factor monitoring among youths treated with antipsychotic medications. METHODS This observational study assessed participant sociodemographic and clinical characteristics and year of antipsychotic medication initiation, with receipt of glycemic and lipid testing within 2 years of initiation as the primary outcome. Electronic health records and pharmacy data from Kaiser Permanente Northern California for 4,568 youths (ages 10-21 years) who began antipsychotic medication treatment during 2013-2017 were included. RESULTS Mean±SD age of the sample was 17.0±3.0 years, 52% were male, and 50% were Asian American, Native Hawaiian, or Pacific Islander; Black; Latino; or another or unknown race-ethnicity. Overall, 54% of the sample completed glycemic and lipid monitoring within 2 years of medication initiation (41% within 1 year). With each study year, monitoring rates increased by 5% in this cohort, after the analyses were adjusted for participant factors (p=0.001). In the fully adjusted analysis, youths with a psychotic disorder were 23% more likely to receive cardiometabolic monitoring than those without a psychotic disorder or bipolar disorder (p<0.001). Monitoring was also more common among younger versus older adolescents and among those with risperidone (vs. quetiapine) medication, obesity, or more frequent use of outpatient health care. Youths with (vs. without) substance use disorder were 19% less likely to complete monitoring (p<0.001). CONCLUSIONS Cardiometabolic monitoring increased modestly over time, but close to half of the studied youths did not receive glycemic or lipid testing. Additional clinical strategies may be needed to increase monitoring overall and among harder-to-reach youth subgroups.
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Affiliation(s)
- Loretta Hsueh
- Division of Research, Kaiser Permanente Northern California (Hsueh, Iturralde, Slama, Sterling), and Permanente Medical Group (Spalding), Oakland
| | - Esti Iturralde
- Division of Research, Kaiser Permanente Northern California (Hsueh, Iturralde, Slama, Sterling), and Permanente Medical Group (Spalding), Oakland
| | - Natalie E Slama
- Division of Research, Kaiser Permanente Northern California (Hsueh, Iturralde, Slama, Sterling), and Permanente Medical Group (Spalding), Oakland
| | - Scott R Spalding
- Division of Research, Kaiser Permanente Northern California (Hsueh, Iturralde, Slama, Sterling), and Permanente Medical Group (Spalding), Oakland
| | - Stacy A Sterling
- Division of Research, Kaiser Permanente Northern California (Hsueh, Iturralde, Slama, Sterling), and Permanente Medical Group (Spalding), Oakland
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7
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Hwong AR, Chagwedera DN, Thomas M, Niu G, Quan J, Vittinghoff E, Schillinger D, Newcomer JW, Gonzalez A, Essock S, Mangurian C. CRANIUM: a quasi-experimental study to improve metabolic screening and HIV testing in community mental health clinics compared to usual care. BMC Psychiatry 2022; 22:687. [PMID: 36348280 PMCID: PMC9644536 DOI: 10.1186/s12888-022-04293-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Individuals with serious mental illness often do not receive guideline-concordant metabolic screening and human immunodeficiency virus (HIV) testing, contributing to increased morbidity and premature mortality. This study evaluates the effectiveness of CRANIUM (Cardiometabolic Risk Assessment and treatment through a Novel Integration model for Underserved populations with Mental illness), an intervention to increase metabolic screening and HIV testing among patients with serious mental illness in a community mental health clinic compared to usual care. METHODS The study used a quasi-experimental design, prospectively comparing a preventive care screening intervention at one community mental health clinic (n = 536 patients) to usual care at the remaining clinics within an urban behavioural health system (n = 4,847 patients). Psychiatrists at the intervention site received training in preventive health screening and had access to a primary care consultant, screening and treatment algorithms, patient registries, and a peer support specialist. Outcomes were the change in screening rates of A1c, lipid, and HIV testing post-intervention at the intervention site compared to usual care sites. RESULTS Rates of lipid screening and HIV testing increased significantly at the intervention site compared to usual care, with and without multivariable adjustment [Lipid: aOR 1.90, 95% CI 1.32-2.75, P = .001; HIV: aOR 23.42, 95% CI 5.94-92.41, P < .001]. While we observed a significant increase in A1c screening rates at the intervention site, this increase did not persist after multivariable adjustment (aOR 1.37, 95% CI .95-1.99, P = .09). CONCLUSIONS This low-cost, reverse integrated care model targeting community psychiatrist practices had modest effects on increasing preventive care screenings, with the biggest effect seen for HIV testing rates. Additional incentives and structural supports may be needed to further promote screening practices for individuals with serious mental illness.
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Affiliation(s)
- Alison R Hwong
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA. .,UCSF National Clinician Scholars Program, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
| | | | - Marilyn Thomas
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Grace Niu
- Department of Epidemiology and Biostatistics, UCSF, San Francisco, CA, USA
| | - Judy Quan
- Department of Epidemiology and Biostatistics, UCSF, San Francisco, CA, USA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, UCSF, San Francisco, CA, USA
| | - Dean Schillinger
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.,UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - John W Newcomer
- Thriving Mind South Florida, Miami, FL, USA.,Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Ana Gonzalez
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Susan Essock
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA.,Department of Psychiatry, Columbia University, New York, NY, USA
| | - Christina Mangurian
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA.,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.,UCSF Philip R. Lee Institute for Health Policy Studies, San Francisco, CA, USA
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8
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Trigueiro AJP, Ramirez J, Hennessey E, Beqiri M. Metabolic Syndrome Identification in Patients Treated With Second-Generation Antipsychotic Medications. J Psychosoc Nurs Ment Health Serv 2022; 60:11-18. [PMID: 35316124 DOI: 10.3928/02793695-20220314-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The purpose of the current project was to assess missed opportunities to identify metabolic syndrome in patients treated with second-generation antipsychotic medication in a community hospital's inpatient psychiatric unit between January 1 and December 31, 2020. Data on demographics, metabolic syndrome risk factors, body mass index, medications, related diagnoses, and primary care providers (PCPs) were collected via retrospective chart review of 194 patients. This project used a nonexperimental design and heterogenous nonrandom convenience sample. Descriptive statistics, chi-square tests, one-tailed t tests, and binary logistic regression were used. The overall rate of metabolic syndrome was 47.4% (n = 92). A positive PCP status was significant for treatment with antihypertensives, statins, and antihyperglycemics (p < 0.05). Findings indicate the need to increase system-wide assessment of metabolic syndrome and integrate care coordination with PCPs. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.].
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Crang MC, Savage TA, Schraeder C. An Educational Intervention for Mental Health Staff to Assess Clients' Diabetic Self-Care Skills for Self-Management and Safe Transition into the Community. J Psychosoc Nurs Ment Health Serv 2021; 60:27-32. [PMID: 34432590 DOI: 10.3928/02793695-20210818-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The current project's objective was to increase mental health assessor's knowledge about type 2 diabetes after attending a nurse practitioner's presentation. Mental health assessors, primarily social workers, help transition individuals with severe mental illness (SMI) and comorbidities from inpatient nursing homes back into the community. The assessor's knowledge about individual comorbidities, such as diabetes, is crucial for a successful long-term community transition. Mental health assessors were given the Diabetes Knowledge Test 2 pre- and post-educational intervention. The post-test intervention revealed assessors' knowledge increased by 25% in knowledge about diabetes and 225% in ability to use a glucometer. Mental health assessors also maintained their increased knowledge 3 months post-intervention. Emboldened with this knowledge, mental health assessors are better prepared to facilitate safe transfer of individuals with diabetes and SMI back into the community. Mental health assessors may also help prevent unnecessary emergency department visits and/or hospitalizations. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].
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10
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Garcia ME, Goldman EL, Thomas M, Chan S, Mitsuishi F, Schillinger D, Mangurian C. Accuracy of Primary Care Medical Home Designation in a Specialty Mental Health Clinic. Psychiatr Q 2021; 92:601-607. [PMID: 32829448 PMCID: PMC8774075 DOI: 10.1007/s11126-020-09829-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
To assess whether primary care medical homes (PCMHs) are accurately identified for patients receiving care in a specialty mental health clinic within an integrated public delivery system. This study reviewed the electronic records of patients in a large urban mental health clinic. The study defined 'matching PCMH' if the same primary care clinic was listed in both the mental health and medical electronic records. This study designated all others as 'PCMH unknown.' This study assessed whether demographic factors predicted PCMH status using chi-square tests. Among 229 patients (66% male; mean age 49; 36% White, 30% Black, and 17% Asian), 72% had a matching PCMH. Sex, age, race, psychiatric diagnosis, and psychotropic medication use were not associated with matching PCMH. To improve care coordination and health outcomes for people with severe mental illness, greater efforts are needed to ensure the accurate designation of PCMHs in all mental health patient electronic records.
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Affiliation(s)
- Maria E Garcia
- Center for Aging in Diverse Communities, Multiethnic Health Equity Research Center, Division of General Internal Medicine, Department of Medicine, University of California, 1701 Divisadero St. Room 536, San Francisco, CA, USA.
| | - Elizabeth L Goldman
- Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Marilyn Thomas
- Department of Epidemiology, University of California, Berkeley, CA, USA
| | - Stephen Chan
- Department of Medicine, University of California, Davis, CA, USA
| | - Fumi Mitsuishi
- Department of Psychiatry, University of California, San Francisco, CA, USA
| | - Dean Schillinger
- Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Christina Mangurian
- Department of Psychiatry, San Francisco General Hospital, University of California, San Francisco, CA, USA
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11
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Bernardo M, Rico-Villademoros F, García-Rizo C, Rojo R, Gómez-Huelgas R. Real-World Data on the Adverse Metabolic Effects of Second-Generation Antipsychotics and Their Potential Determinants in Adult Patients: A Systematic Review of Population-Based Studies. Adv Ther 2021; 38:2491-2512. [PMID: 33826090 PMCID: PMC8107077 DOI: 10.1007/s12325-021-01689-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/26/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION To assess the risk of occurrence and potential determinants of metabolic disorders in adult patients treated with second-generation antipsychotics (SGAs) under real-world practice conditions. METHODS MEDLINE, EMBASE, and PsycInfo were searched in July 2019 from database inception. We included population-based, longitudinal, comparative studies that report the results of the outcomes of interest for adult participants, including diabetes, ketoacidosis, hyperosmolar hyperglycemic state, weight gain/obesity, dyslipidemia, hypertension, and metabolic syndrome. Two reviewers independently extracted data on the study design, study quality, and study outcomes. RESULTS We included 40 studies. Most studies showed that clozapine and olanzapine were associated with an increased likelihood of developing diabetes, while the results for risperidone and quetiapine were mixed. Although less well studied, ziprasidone and aripiprazole appeared to not be associated with the occurrence of diabetes. Information on antipsychotic-induced weight gain/obesity is extremely scarce. Regarding dyslipidemia, aripiprazole was not associated with an increased likelihood of developing dyslipidemia, clozapine was associated with an increased likelihood of developing dyslipidemia, and risperidone, olanzapine, quetiapine, and ziprasidone showed mixed results. Two studies suggested an association between ziprasidone and the occurrence of hypertension. Several studies found that the occurrence of a metabolic disorder acted as a risk factor for the development of other metabolic disorders. We did not find information on brexpiprazole, cariprazine, or lurasidone, and data on any long-acting SGA were lacking. CONCLUSION Although there are relevant differences among SGAs concerning the risk of metabolic disorders, it appears that none of the SGAs included in our review are fully devoid of these disturbances.
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Affiliation(s)
- Miquel Bernardo
- Department of Psychiatry, Hospital Clínic, University of Barcelona, Idibaps, Cibersam, Barcelona, Spain.
| | | | - Clemente García-Rizo
- Department of Psychiatry, Hospital Clínic, University of Barcelona, Idibaps, Cibersam, Barcelona, Spain
| | - Rosa Rojo
- Faculty of Health Sciences, Alfonso X El Sabio University, Villanueva de la Cañada, Madrid, Spain
| | - Ricardo Gómez-Huelgas
- Internal Medicine Department, Instituto de Investigación Biomedica de Malaga-IBIMA, Regional University Hospital of Malaga, Malaga, Spain
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Hwong AR, Schmittdiel J, Schillinger D, Newcomer JW, Essock S, Zhu Z, Dyer W, Young-Wolff KC, Mangurian C. Smoking cessation treatment for individuals with comorbid diabetes and serious mental illness in an integrated health care delivery system. Addict Behav 2021; 114:106697. [PMID: 33129613 DOI: 10.1016/j.addbeh.2020.106697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 08/11/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Smoking is a significant modifiable risk factor for mortality for persons with serious mental illness (SMI), who have a life expectancy 15-20 years shorter than the general population. Individuals with SMI and comorbid diabetes who are smokers face an even higher risk of cardiovascular complications and early death. Yet despite high rates of smoking among people with SMI, tobacco cessation interventions have not been broadly offered to this population. METHODS We conducted a retrospective cohort study using electronic health records from 2014 in a large integrated care delivery system to examine whether use of smoking cessation pharmacotherapy among smokers with type 2 diabetes varies by serious mental illness (SMI) diagnosis. We analyzed smoking cessation medication prescription fills among adult smokers with diabetes, comparing those with SMI (N = 634) and without SMI (N = 18,021). Risk ratios were adjusted for age, gender, race, urban area type, and medical facility. RESULTS Of the SMI group, 19.09% filled at least one smoking cessation prescription compared to 9.73% of the non-SMI group (adjusted risk ratio 1.80 [95% CI 1.52-2.13]; p < .001). For the SMI group, primary care providers wrote 80.24% of prescriptions, while psychiatrists wrote 8.81% of prescriptions. CONCLUSIONS These findings offer an example of a delivery system with higher uptake of smoking cessation pharmacotherapy among people with SMI than without SMI, and highlight the opportunity to provide more smoking cessation interventions in mental health care settings.
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Stockbridge EL, Webb NJ, Dhakal E, Garg M, Loethen AD, Miller TL, Nandy K. Antipsychotic medication adherence and preventive diabetes screening in Medicaid enrollees with serious mental illness: an analysis of real-world administrative data. BMC Health Serv Res 2021; 21:69. [PMID: 33461561 PMCID: PMC7812734 DOI: 10.1186/s12913-020-06045-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 12/25/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is excess amenable mortality risk and evidence of healthcare quality deficits for persons with serious mental illness (SMI). We sought to identify sociodemographic and clinical characteristics associated with variations in two 2015 Healthcare Effectiveness Data and Information Set (HEDIS) measures, antipsychotic medication adherence and preventive diabetes screening, among Medicaid enrollees with serious mental illness (SMI). METHODS We retrospectively analyzed claims data from September 2014 to December 2015 from enrollees in a Medicaid specialty health plan in Florida. All plan enrollees had SMI; analyses included continuously enrolled adults with antipsychotic medication prescriptions and schizophrenia or bipolar disorder. Associations were identified using mixed effects logistic regression models. RESULTS Data for 5502 enrollees were analyzed. Substance use disorders, depression, and having both schizophrenia and bipolar disorder diagnoses were associated with both HEDIS measures but the direction of the associations differed; each was significantly associated with antipsychotic medication non-adherence (a marker of suboptimal care quality) but an increased likelihood of diabetes screening (a marker of quality care). Compared to whites, blacks and Hispanics had a significantly greater risk of medication non-adherence. Increasing age was significantly associated with increasing medication adherence, but the association between age and diabetes screening varied by sex. Other characteristics significantly associated with quality variations according to one or both measures were education (associated with antipsychotic medication adherence), urbanization (relative to urban locales, residing in suburban areas was associated with both adherence and diabetes screening), obesity (associated with both adherence and diabetes screening), language (non-English speakers had a greater likelihood of diabetes screening), and anxiety, asthma, and hypertension (each positively associated with diabetes screening). CONCLUSIONS The characteristics associated with variations in the quality of care provided to Medicaid enrollees with SMI as gauged by two HEDIS measures often differed, and at times associations were directionally opposite. The variations in the quality of healthcare received by persons with SMI that were identified in this study can guide quality improvement and delivery system reform efforts; however, given the sociodemographic and clinical characteristics' differing associations with different measures of care quality, multidimensional approaches are warranted.
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Affiliation(s)
- Erica L Stockbridge
- Department of Advanced Health Analytics and Solutions, Magellan Health, Inc, 4800 N Scottsdale Rd #4400, Scottsdale, AZ, 85251, USA.
| | - Nathaniel J Webb
- Department of Health Behavior & Health Systems, School of Public Health, University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, TX, 76107, USA
| | - Eleena Dhakal
- Department of Biostatistics and Epidemiology, School of Public Health, University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, TX, 76107, USA
| | - Manasa Garg
- Department of Health Behavior & Health Systems, School of Public Health, University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, TX, 76107, USA
- Loopback Analytics, 14900 Landmark Blvd # 240, Dallas, TX, 75254, USA
| | - Abiah D Loethen
- Department of Advanced Health Analytics and Solutions, Magellan Health, Inc, 4800 N Scottsdale Rd #4400, Scottsdale, AZ, 85251, USA
| | - Thaddeus L Miller
- Department of Health Behavior & Health Systems, School of Public Health, University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, TX, 76107, USA
| | - Karabi Nandy
- Department of Population and Data Sciences, UT Southwestern Medical Center, Room E1.401A, South Campus, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
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14
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Abstract
Individuals diagnosed with schizophrenia or bipolar disorder have a life expectancy 15-20 years shorter than that in the general population. The rate of unnatural deaths, such as suicide and accidents, is high for these patients. Despite this increased proportion of unnatural deaths, physical conditions account for approximately 70% of deaths in patients with either schizophrenia or bipolar disorder, with cardiovascular disease contributing 17.4% and 22.0% to the reduction in overall life expectancy in men and women, respectively. Risk factors for cardiovascular disease, such as smoking, unhealthy diet and lack of exercise, are common in these patients, and lifestyle interventions have been shown to have small effects. Pharmacological interventions to reduce risk factors for cardiovascular disease have been proven to be effective. Treatment with antipsychotic drugs is associated with reduced mortality but also with an increased risk of weight gain, dyslipidaemia and diabetes mellitus. These patients have higher risks of both myocardial infarction and stroke but a lower risk of undergoing interventional procedures compared with the general population. Data indicate a negative attitude from clinicians working outside the mental health fields towards patients with severe mental illness. Education might be a possible method to decrease the negative attitudes towards these patients, thereby improving their rates of diagnosis and treatment.
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15
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Jakobs KM, Posthuma A, de Grauw WJC, Schalk BWM, Akkermans RP, Lucassen P, Schermer T, Assendelft WJJ, Biermans MJC. Cardiovascular risk screening of patients with serious mental illness or use of antipsychotics in family practice. BMC FAMILY PRACTICE 2020; 21:153. [PMID: 32727372 PMCID: PMC7391510 DOI: 10.1186/s12875-020-01225-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 07/19/2020] [Indexed: 12/02/2022]
Abstract
Background Patients with serious mental illness (SMI) and patients on antipsychotics (AP) have an elevated risk for cardiovascular diseases. In the Netherlands, the mental healthcare for these patients is increasingly taken care of by family practitioners (FP) as a result of a shift from secondary to primary care. Therefore, it is essential to increase our knowledge regarding the characteristics of this patient group and the (somatic) care provided by their FPs. The aim was to examine the rate of cardiovascular risk screening in patients with SMI or the use of AP in family practice. Methods We performed a retrospective cohort study of 151.238 patients listed in 24 family practices in the Netherlands. From electronic medical records we extracted data concerning diagnoses, measurement values of CVR factors, medication and frequency of visits over a 2 year period. Primary outcome was the rate of patients who were screened for CVR factors. We compared three groups: patients with SMI/AP without diabetes or CVD (SMI/AP-only), patients with SMI/AP and diabetes mellitus (SMI/AP + DM), patients with SMI/AP and a history of cardiovascular disease (SMI/AP + CVD). We explored factors associated with adequate screening using multilevel logistic regression. Results We identified 1705 patients with SMI/AP, 834 with a SMI diagnosis, 1150 using AP. The screening rate for CVR in the SMI/AP-only group (n = 1383) was adequate in 8.5%. Screening was higher in the SMI/AP − +DM (n = 206, 68.4% adequate, OR 24.6 (95%CI, 17.3–35.1) and SMI/AP + CVD (n = 116, 26.7% adequate, OR 4.2 (95%CI, 2.7–6.6). A high frequency of visits, age, the use of AP and a diagnosis of COPD were associated with a higher screening rate. In addition we also examined differences between patients with SMI and patients using AP without SMI. Conclusion CVR screening in patients with SMI/AP is performed poorly in Dutch family practices. Acceptable screening rates were found only among SMI/AP patients with diabetes mellitus as comorbidity. The finding of a large group of AP users without a SMI diagnosis may indicate that FPs often prescribe AP off-label, lack information about the diagnosis, or use the wrong code.
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Affiliation(s)
- Kirsti M Jakobs
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands.
| | - Anne Posthuma
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Wim J C de Grauw
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Bianca W M Schalk
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Reinier P Akkermans
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Peter Lucassen
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Tjard Schermer
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Willem J J Assendelft
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Marion J C Biermans
- Department of Primary and Community Care (117-ELG), Radboud University Medical Centre, Radboud Institute for Health Sciences, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
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Birth dimensions, severe mental illness and risk of type 2 diabetes in a
cohort of Danish men born in 1953. Eur Psychiatry 2020; 62:1-9. [DOI: 10.1016/j.eurpsy.2019.08.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 11/23/2022] Open
Abstract
Abstract
Background:
Birth dimensions have been associated with increased risk of both,
severe mental illness and type 2 diabetes in adulthood, however, any
influence on their co-occurrence has never been examined. This cohort
study examine whether birth weight/ponderal index explain or modify the
later association between severe mental illness and risk of type 2
diabetes.
Methods:
The Metropolit cohort included 10,863 Danish men born in 1953 with
information from age at conscription (between1971-84) until February
15th, 2018. Severe mental illness was defined
as the exposure and information was retrieved from the national Danish
health registries. Information on type 2 diabetes diagnosis or oral
antidiabetic prescriptions was also obtained, as they were the outcome
of interest. Information on birth weight/ponderal index was available
from birth certificates. Cox proportional hazards regression models were
used to estimate the associations and interactions were tested.
Results:
After 47.1 years of follow-up, 848 (7.8%) and 1320 (12.2%) men
developed a severe mental illness or diabetes, respectively. Men with
severe mental illness presented higher risk of subsequent diabetes (HR =
1.92; 95%CI, 1.61–2.30). This association was stronger in severe mental
ill men with low birth weight (HR = 3.58; 95%CI, 2.11–6.07), than in
those normal birth weight (HR = 1.79; 95%CI, 1.45–2.20). This effect
modification was most evident for men diagnosed with
schizophrenia.
Conclusions:
Birth information on birth weight/ponderal index could be of
interest in diabetes screening on severe mental ill populations
(especially in schizophrenia) since they might play a critical role in
the increased risk of type 2 diabetes following severe mental
illness.
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Comorbid Diabetes and Severe Mental Illness: Outcomes in an Integrated Health Care Delivery System. J Gen Intern Med 2020; 35:160-166. [PMID: 31705468 PMCID: PMC6957587 DOI: 10.1007/s11606-019-05489-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 05/02/2019] [Accepted: 09/25/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Diabetes prevalence is twice as high among people with severe mental illness (SMI) when compared to the general population. Despite high prevalence, care outcomes are not well understood. OBJECTIVE To compare diabetes health outcomes received by people with and without comorbid SMI, and to understand demographic factors associated with poor diabetes control among those with SMI. DESIGN Retrospective cohort study PARTICIPANTS: 269,243 adults with diabetes MAIN MEASURES: Primary outcomes included optimal glycemic control (A1c < 7) or poor diabetes control (A1c > 9) in 2014. Secondary outcomes included control of other cardiometabolic risk factors (hypertension, dyslipidemia, smoking) and recommended diabetes monitoring. KEY RESULTS Among this cohort, people with SMI (N = 4,399), compared to those without SMI (N = 264,844), were more likely to have optimal glycemic control, adjusting for various covariates (adjusted relative risk (aRR) 1.25, 95% CI 1.21-1.28, p < .001) and less likely to have poor control (aRR 0.92, 95% CI 0.87-0.98, p = 0.012). Better blood pressure and lipid control was more prevalent among people with SMI when compared to those without SMI (aRR 1.03; 95% CI 1.02-1.05, p < .001; aRR 1.02; 95% CI 1.00-1.05, p = 0.044, respectively). No differences were observed in recommended A1c or LDL testing, but people with SMI were more likely to have blood pressure checked (aRR 1.02, 95% CI 1.02-1.03, p < .001) and less likely to receive retinopathy screening (aRR 0.80, 95% CI 0.71-0.91, p < .001) than those without SMI. Among people with diabetes and comorbid SMI, younger adults and Hispanics were more likely to have poor diabetes control. CONCLUSIONS Adults with diabetes and comorbid SMI had better cardiometabolic control than people with diabetes who did not have SMI, despite lower rates of retinopathy screening. Among those with comorbid SMI, younger adults and Hispanics were more vulnerable to poor A1c control.
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Mangurian CV, Schillinger D, Newcomer JW, Vittinghoff E, Essock SM, Zhu Z, Dyer WT, Schmittdiel JA. Diabetes and Prediabetes Prevalence by Race and Ethnicity Among People With Severe Mental Illness. Diabetes Care 2018; 41:e119-e120. [PMID: 29898903 PMCID: PMC6014538 DOI: 10.2337/dc18-0425] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/22/2018] [Indexed: 02/03/2023]
Affiliation(s)
- Christina V Mangurian
- Department of Psychiatry, USCF Weill Institute of Neurosciences, University of California, San Francisco, San Francisco, CA .,USCF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA
| | - Dean Schillinger
- USCF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA.,Division of General Internal Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA
| | - John W Newcomer
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL
| | - Eric Vittinghoff
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Susan M Essock
- Department of Psychiatry, Columbia University, New York, NY
| | - Zheng Zhu
- Kaiser Permanente Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Wendy T Dyer
- Kaiser Permanente Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Julie A Schmittdiel
- Kaiser Permanente Division of Research, Kaiser Permanente Northern California, Oakland, CA
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