Appendectomy for appendicitis in patients with schizophrenia

Association of psychosocial risk factors and liver transplant evaluation outcomes in metabolic dysfunction-associated steatotic liver disease

The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) is a standardized psychosocial assessment tool used in liver transplantation (LT) evaluation and has been primarily studied in patients with alcohol-associated liver disease. We aimed to evaluate the relationship between SIPAT score and metabolic syndrome severity and LT waitlist outcomes in a large cohort of patients with metabolic dysfunction-associated steatotic liver disease (MASLD). We performed a single-center retrospective cohort study of patients with MASLD evaluated for LT from 2014 to 2021. The utility of the previously defined total SIPAT cutoff (<21 [excellent/good candidates] vs. ≥21 [minimally acceptable/high-risk candidates]) was studied. Multivariable logistic regression analyses examined associations between continuous SIPAT scores and LT waitlisting outcomes. The Youden J statistic was used to identify the optimal SIPAT cutoff for patients with MASLD. A total of 480 patients evaluated for transplant with MASLD were included. Only 9.4% of patients had a SIPAT score ≥21. Patients with SIPAT score ≥21 had higher hemoglobin A1c compared to patients with lower psychosocial risk (median [IQR]: 7.8 [6.0-9.7] vs. 6.6 [5.8-7.9]; p = 0.04). There were no other differences in metabolic comorbidities between SIPAT groups. Increasing SIPAT score was associated with decreased odds of listing (OR: 0.82 per 5-point increase; p = 0.003) in multivariable models. A SIPAT of ≥12 was identified as the optimal cutoff in this population, resulting in an adjusted OR for a listing of 0.53 versus SIPAT <12 ( p = 0.001). In this large cohort of patients with MASLD evaluated for LT, few patients met the previously defined high SIPAT cutoff for transplant suitability. Nevertheless, increasing the SIPAT score was associated with waitlist outcomes. Our suggested SIPAT cutoff of ≥12 for patients with MASLD warrants further external validation using data from other centers.

Burden of Social and Behavioral Determinants of Health on Infectious Complications in Emergency General Surgery

Background: Infectious complications lead to worse post-operative outcomes and are used to compare hospital performance in pay-for-performance programs. However, the impact of social and behavioral determinants of health on infectious complication rates after emergency general surgery (EGS) remains unclear. Patients and Methods: All patients undergoing EGS in the 2019 Nationwide Readmissions Database were included. The primary outcome of the study was the rate of infectious complications within 30 days, defined as a composite outcome including all infectious complications occurring during the index hospitalization or 30-day re-admission. Secondary outcomes included specific infectious complication rates. Multivariable regression analyses were used to study the impact of patient characteristics, social determinants of health (insurance status, median household income in the patient's residential zip code), and behavioral determinants of health (substance use disorders, neuropsychiatric comorbidities) on post-operative infection rates. Results: Of 367,917 patients included in this study, 20.53% had infectious complications. Medicare (adjusted odds ratio [aOR], 1.3; 95% confidence interval [CI], 1.26-1.34; p < 0.001), Medicaid (aOR, 1.24; 95% CI,1.19-1.29; p < 0.001), lowest zip code income quartile (aOR, 1.17; 95% CI, 1.13-1.22; p < 0.001), opioid use disorder (aOR,1.18; 95% CI,1.10-1.29; p < 0.001), and neurodevelopmental disorders (aOR, 2.16; 95% CI, 1.90-2.45; p < 0.001) were identified as independent predictors of 30-day infectious complications. A similar association between determinants of health and infectious complications was also seen for pneumonia, urinary tract infection (UTI), methicillin-resistant Staphylococcus aureus (MRSA) sepsis, and catheter-association urinary tract infection (CAUTI). Conclusions: Social and behavioral determinants of health are associated with a higher risk of developing post-operative infectious complications in EGS. Accounting for these factors in pay-for-performance programs and public reporting could promote fairer comparisons of hospital performance.

The Association of Mental Illness With Outcomes of Emergency Surgery for Bowel Obstruction

INTRODUCTION

Bowel obstruction is one of the most common surgical emergencies. The management of SBO is variable and influenced by numerous confounding factors. Recent studies have identified mental health as a health disparity that affects surgical outcomes. We aim to assess whether mental illness is a health disparity and its association with postoperative complications and secondary outcomes for bowel obstruction in Emergency General Surgery (EGS).

METHODS

This was a retrospective study utilizing the National Inpatient Sample. Individuals aged 18-64 who underwent emergency adehesiolysis or bowel resection from 2015 to 2017 were identified. Postoperative complications, in-hospital mortality, length of stay, and total cost for surgical patients with and without mental illness were recorded. Univariate and multivariate analyses were used to evaluate the association between mental health and bowel obstruction.

RESULTS

20,574 patients who underwent surgery for bowel obstruction were identified. 3756 of these patients had mental illness and 16,998 patients did not. Patients with mental illness did not have significantly worse outcomes compared to patients without mental illness. Among 3576 patients with mental illness, sex, race, patient location, insurance, location/teaching status of hospital, hospital control and procedure type were significant predictors of prolonged length of stay, higher cost, and increased postoperative complications.

CONCLUSIONS

Mental health does not appear to be a health disparity in outcomes for bowel obstruction procedures. However, the intersection of mental health with race and insurance status predicts worse outcomes. This essential area should be further explored to determine how marginalized populations are affected in emergency surgical care.

Postsurgical morbidity and mortality favorably informs deep brain stimulation for new indications including schizophrenia and schizoaffective disorder

Background

Deep brain stimulation (DBS) shows promise for new indications like treatment-refractory schizophrenia in early clinical trials. In the first DBS clinical trial for treatment refractory schizophrenia, despite promising results in treating psychosis, one of the eight subjects experienced both a symptomatic hemorrhage and an infection requiring device removal. Now, ethical concerns about higher surgical risk in schizophrenia/schizoaffective disorder (SZ/SAD) are impacting clinical trial progress. However, insufficient cases preclude conclusions regarding DBS risk in SZ/SAD. Therefore, we directly compare adverse surgical outcomes for all surgical procedures between SZ/SAD and Parkinson's disease (PD) cases to infer relative surgical risk relevant to gauging DBS risks in subjects with SZ/SAD.

Design

In the primary analysis, we used browser-based statistical analysis software, TriNetX Live (trinetx.com TriNetX LLC, Cambridge, MA), for Measures of Association using the Z-test. Postsurgical morbidity and mortality after matching for ethnicity, over 39 risk factors, and 19 CPT 1003143 coded surgical procedures from over 35,000 electronic medical records, over 19 years, from 48 United States health care organizations (HCOs) through the TriNetX Research Network™. TriNetXis a global, federated, web-based health research network providing access and statistical analysis of aggregate counts of deidentified EMR data. Diagnoses were based on ICD-10 codes. In the final analysis, logistic regression was used to determine relative frequencies of outcomes among 21 diagnostic groups/cohorts being treated with or considered for DBS and 3 control cohorts.

Results

Postsurgical mortality was 1.01-4.11% lower in SZ/SAD compared to the matched PD cohort at 1 month and 1 year after any surgery, while morbidity was 1.91-2.73% higher and associated with postsurgical noncompliance with medical treatment. Hemorrhages and infections were not increased. Across the 21 cohorts compared, PD and SZ/SAD were among eight cohorts with fewer surgeries, nine cohorts with higher postsurgical morbidity, and fifteen cohorts within the control-group range for 1-month postsurgical mortality.

Conclusions

Given that the subjects with SZ or SAD, along with most other diagnostic groups examined, had lower postsurgical mortality than PD subjects, it is reasonable to apply existing ethical and clinical guidelines to identify appropriate surgical candidates for inclusion of these patient populations in DBS clinical trials.

Risks of complicated acute appendicitis in patients with psychiatric disorders

BACKGROUND

Acute appendicitis often presents with vague abdominal pain, which fosters diagnostic challenges to clinicians regarding early detection and proper intervention. This is even more problematic with individuals with severe psychiatric disorders who have reduced sensitivity to pain due to long-term or excessive medication use or disturbed bodily sensation perceptions. This study aimed to determine whether psychiatric disorder, psychotropic prescription, and treatment compliance increase the risks of complicated acute appendicitis.

METHODS

The diagnosis records of acute appendicitis from four university hospitals in Korea were investigated from 2002 to 2020. A total of 47,500 acute appendicitis-affected participants were divided into groups with complicated and uncomplicated appendicitis to determine whether any of the groups had more cases of psychiatric disorder diagnoses. Further, the ratio of complicated compared to uncomplicated appendicitis in the mentally ill group was calculated regarding psychotropic dose, prescription duration, and treatment compliance.

RESULTS

After adjusting for age and sex, presence of psychotic disorder (odds ratio [OR]: 1.951; 95% confidence interval [CI]: 1.218-3.125), and bipolar disorder (OR: 2.323; 95% CI: 1.194-4.520) was associated with a higher risk of having complicated appendicitis compared with absence of psychiatric disorders. Patients who are taking high-daily-dose antipsychotics, regardless of prescription duration, show high complicated appendicitis risks; High-dose antipsychotics for < 1 year (OR: 1.896, 95% CI: 1.077-3.338), high-dose antipsychotics for 1-5 years (OR: 1.930, 95% CI: 1.144-3.256). Poor psychiatric outpatient compliance was associated with a high risk of complicated appendicitis (OR: 1.664, 95% CI: 1.014-2.732).

CONCLUSIONS

This study revealed a close relationship in the possibility of complicated appendicitis in patients with severe psychiatric disorders, including psychotic and bipolar disorders. The effect on complicated appendicitis was more remarkable by the psychiatric disease entity itself than by psychotropic prescription patterns. Good treatment compliance and regular visit may reduce the morbidity of complicated appendicitis in patients with psychiatric disorders.

Relationship between clozapine exposure and the onset of appendicitis in schizophrenia patients: a retrospective cohort study

OBJECTIVE

Clozapine may cause serious side effects despite benefits in patients with schizophrenia. Thus, an accurate understanding of the side-effect profile of clozapine is extremely important in the management of its administration to patients with schizophrenia. Our aim was to validate the relationship between clozapine exposure and appendicitis onset in patients with schizophrenia.

METHODS

In this study, we retrospectively compared the incidence and cumulative incidence of appendicitis in patients with schizophrenia with and without a history of clozapine exposure. Among the patients with schizophrenia who visited our hospital between June 2009 and August 2021, we extracted those with a history of clozapine treatment. Patients with a history of taking clozapine were defined as the clozapine exposure group, while the others were defined as the clozapine non-exposure group. Patients with a history of appendectomy before their initial visit to our hospital or with a history of clozapine use at other hospitals were excluded.

RESULTS

There were 65 patients in the clozapine exposure group and 400 patients in the clozapine non-exposure group who met the inclusion criteria. The exposure group exhibited a remarkably higher incidence of appendicitis during the observation period than the non-exposure group (863 cases vs. 124 cases per 100,000 person-years). In particular, if limited to the period of clozapine exposure, the incidence of appendicitis is extremely high, at 2,086 cases per 100,000 person-years. Moreover, multivariable analysis showed that clozapine exposure was an independent factor contributing to the onset of appendicitis.

CONCLUSIONS

Clozapine exposure is associated with appendicitis onset in patients with schizophrenia.

Pain management in people with severe mental illness: an agenda for progress

Supplemental Digital Content is Available in the Text.

Acceptability and face validity of two mental health screening tools for use in the routine surgical setting

Background

Preoperative assessment of mental health rarely occurs within routine surgery. Any screening tool selected to form part of this process must be deemed practical, acceptable and valid by clinicians and consumers alike. This study aims to assess the acceptability and face validity of two existing mental health screening tools to select one for further development and use in the routine surgical setting.

Methods

A survey of clinicians and consumers was conducted from October 2020 to March 2021 at a tertiary hospital in Sydney, Australia. Using a Likert scale (1–5, lowest to highest rating), the clinicians evaluated four domains for acceptability and two for validity (six overall) and the consumers four domains for acceptability and one for validity (five overall) on the preoperative use of the amended Kessler Psychological Distress Scale (K10) and the Somatic and Psychological Health Report-12 (SPHERE-12). Consensus was achieved through a rating of 4 or 5 being given by 70% or more of participants with domains able to remain unchanged. Free text responses were analysed into themes.

Results

A total of 73 participants (51 clinicians; 22 consumers) were included. The K10 received consensus scores (≥ 70%) in four out of six domains for clinicians (4/4 acceptability; 0/2 validity), and all five domains for consumers (4/4 acceptability; 1/1 validity). The SPHERE-12 received consensus scores (≥ 70%) in three domains for clinicians (3/4 acceptability; 0/2 validity), and three domains for consumers (3/4 acceptability; 0/1 validity). Six qualitative themes were described including (1) amendments to tool structure and language; (2) scale response options; (3) difficulty with somatic questions; (4) practicality and familiarity with K10; (5) challenges for specific patient cohorts and (6) timing considerations for patients.

Conclusion

Adequate acceptability was established for the K10. However further development is required to strengthen its validity for this specific surgical cohort and purpose. Future research to determine the feasibility and acceptability of implementing and using the K10 in the routine surgical setting is now needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00672-w.

Improving Surgical Quality for Patients with Mental Health Illnesses: A Narrative Review

OBJECTIVE

To establish and define disparities in care for patients presenting with surgical disease who have pre-existing mental health diagnoses.

SUMMARY BACKGROUND DATA

Mental illness affects approximately 6.7 million Canadians. For them, stigma, comorbid disorders, and sequelae of psychiatric diagnoses can be barriers patients face to receive equitable healthcare. The goal of this review is to define inequities in surgical care for patients with pre-existing mental illness.

METHODS

We search OVID Medline, Pubmed, EMBASE, and the Cochrane review files using a combination of search terms using a PICO (population, intervention, comparison, outcome) model focusing on surgical care for patients with mental illness.

RESULTS

The literature on mental illness in surgical patients focused primarily on preoperative and postoperative disparities in surgical care between patients with and without a diagnosis of mental illness. Preoperatively, patients were 7.5-40% less likely to be deemed surgical candidates, were less likely to receive testing, and were more likely to present at later stages of their disease or have delayed surgical care. Similar themes arose in the postoperative period: patients with mental illness were more likely to require ICU admission, were up to 3 times more likely to have a prolonged length of hospital stay, had a 14-270% increased likelihood of having postoperative complications, and had significantly higher healthcare costs.

CONCLUSIONS

Surgical patients with preexisting psychiatric diagnoses have a propensity for worse perioperative outcomes compared to patients without reported mental illness. Taking a thorough psychiatric history can potentially help surgical teams address disparities and access to care as well as anticipate and prevent adverse outcomes.

Vascular surgery receipt and outcomes for people with serious mental illnesses: Retrospective cohort study using a large mental healthcare database in South London

OBJECTIVE

Vascular surgery can be common among people with serious mental illness (SMI) given the high prevalence of cardiovascular disease. However, post-operative outcomes following vascular surgery have received little investigation, particularly in a subpopulation of SMI.

METHODS

We conducted a retrospective observational study using data from the South London and Maudsley NHS Foundation Trust (SLaM) via its Clinical Record Interactive Search (CRIS) platform and linkage with Hospital Episode Statistic (HES). Vascular surgery recipients were identified using OPCS version 4 codes. Length of stay (LOS) was modelled using Incidence Rate Ratios (IRRs), and 30-day emergency hospital readmissions using Odds Ratios (ORs) for people with SMI compared with the general population.

RESULTS

Vascular surgery was received by 152 patients with SMI diagnoses (schizophrenia, schizoaffective disorder, bipolar disorder) and 8821 catchment residents without any mental health conditions. People with active SMI symptoms more likely to be admitted to hospital via emergency route OR: 1.80 (95% CI: 1.06, 3.07) and more likely to stay longer in the hospital for vascular surgery IRR: 1.35 (1.01, 1.80) and more likely to be readmitted to hospital via emergency route within 30 days OR: 1.53 (1.02, 2.67). People with SMI who had major open vascular surgery and peripheral endovascular surgery more likely to have worse post-operative outcomes.

CONCLUSION

Our study highlights the risks faced by people with SMI following vascular surgery. These suggest tailored guidelines and policies are needed, based on the identification of pre-operative risk factors, allowing for focused post-vascular surgery care to minimise adverse outcomes.

Exploratory analysis on the association of mental health disorders with in-hospital postoperative complications and mortality in head and neck cancer surgery

BACKGROUND

The objective was to assess the association of mental health disorders with in-hospital complication and mortality rates in patients undergoing head and neck cancer surgery.

METHODS

In this exploratory retrospective study, the Nationwide Inpatient Sample was queried from 2003 to 2014 for all patients with a diagnosis of head and neck cancer who underwent surgery. Univariate cross-tabulation, logistic regression, and propensity score matching (PSM) were used to compare demographics, procedure-related variables, and in-hospital postoperative complications and mortality between patients with and without selected comorbid mental health disorders.

RESULTS

Of 39 600 included patients, 3390 (8.6%) had a selected comorbid mental health disorder diagnosis. After PSM, patients with selected mental health disorders had increased risk of overall medical complications on multivariable analysis (OR 1.28 [CI 1.12-1.46], P < 0.001) but not overall surgical complications or mortality.

CONCLUSIONS

Patients with a mental health disorder diagnosis have increased risk of in-hospital medical, certain surgical, and total complications.

Comparison of Reconstructive Plastic Surgery Rates and 30-Day Postoperative Complications Between Patients With and Without Psychiatric Diagnoses

BACKGROUND

Psychiatric comorbidity is associated with greater 30-day postoperative complication rates in various surgical specialties, but is not well characterized for reconstructive plastic surgery.

OBJECTIVES

The aim of this study was to compare reconstructive plastic surgery rates and 30-day postoperative complications between patients with and without psychiatric diagnoses.

METHODS

This was a retrospective cohort study comparing patients with and without psychiatric diagnoses. Data for January 1, 2007 to December 31, 2015 were collected from the IBM MarketScan Commercial and Medicare Supplemental Databases. Rates of reconstructive plastic surgery, demographic data, covariant diagnoses, and 30-day postoperative complications were collected. Differences between the 2 groups were assessed by multivariable logistic regression.

RESULTS

Among 1,019,128 patients (505,715 with psychiatric diagnoses and 513,423 without psychiatric diagnoses) assessed, reconstructive plastic surgery rates were between 4.8% and 7.0% in those with psychiatric diagnoses, compared with 1.6% in patients without psychiatric diagnoses. The greatest odds of undergoing reconstructive plastic surgery were in patients with body dysmorphic disorder (BDD) (adjusted odds ratio [aOR], 3.16; 95% confidence interval [CI], 1.76-5.67) and anxiety disorder (aOR, 3.08; 95% CI, 2.97-3.17). When assessing 1,234,206 patients (613,400 with psychiatric diagnoses and 620,806 without psychiatric diagnoses), all of whom underwent reconstructive plastic surgery, 2-fold greater odds of any 30-day postoperative complication was associated with psychiatric diagnoses (aOR, 2.01; 95% CI, 1.28-3.11), as well as greater odds of specific complications (surgical site infection, bleeding, and hospital admission). Eating disorder diagnosis was associated with the greatest odds of a complication (aOR, 4.17; 95% CI, 3.59-4.86), followed by nasal surgery (aOR, 3.65; 95% CI, 2.74-4.89), and BDD (aOR, 3.16; 95% CI, 1.76-5.67).

CONCLUSIONS

Diagnosis of a psychiatric condition is associated with greater rates of reconstructive plastic surgery, and 2-fold greater odds of 30-day postoperative complications.

LEVEL OF EVIDENCE: 4

Impact of psychiatric comorbidities on outcomes related to thyroid and parathyroid operations

BACKGROUND

We examined the effect of psychiatric comorbidities on perioperative surgical outcomes and the leading causes of readmissions in patients who underwent thyroid and parathyroid operations.

METHOD

Patient information was retrieved from the Nationwide Readmission Database (2010-2017). Multivariate analysis was used to identify predictors for hospital readmissions.

RESULTS

A total of 181,007 and 53,808 patients underwent thyroid and parathyroid operations, respectively. Of those, 8,468 (4.7%) and 6,112 (11.4%) patients were readmitted within 30 days. Psychiatric comorbidities were more frequent in readmitted cohorts after thyroidectomies (14.9% vs 10.4%; P < .001) and parathyroidectomies (16.8% vs 11.5%; P < .001), with anxiety being the most frequent cause (thyroid: 7.87%, parathyroid: 6.8%). Psychiatric comorbidities were associated with greater risk of in-hospital mortality (thyroid: odds ratio = 2.07, 95% confidence interval = 1.13-3.53; P = .015 and parathyroid: odds ratio = 1.67, 95% confidence interval = 1.04-2.70; P = .005), postoperative complications (thyroid: odds ratio = 1.528, 95% confidence interval = 1.473-1.585; P < .001 and parathyroid: odds ratio = 3.26, 95% confidence interval = 2.84-3.73; P < .001), prolonged duration of stay (thyroid: beta coefficient = 1.142, 95% confidence interval = 1.076-1.207; P < .001 and parathyroid: beta coefficient = 2.15, 95% confidence interval = 1.976-2.32; P < .001), and 30-day readmissions (thyroid: hazard ratio = 1.18, 95% confidence interval = 1.03-1.18; P = .047 and parathyroid: hazard ratio = 1.23, 95% confidence interval = 1.11-1.36; P < .001). Psychosis had the greatest risk of readmission (thyroid: hazard ratio = 1.51 and parathyroid: hazard ratio = 1.42), and dementia (odds ratio = 2.58) had the greatest risk of postoperative complications.

CONCLUSION

Concomitant psychiatric conditions after thyroid and parathyroid operations were associated with increased risk of postoperative complications, prolonged hospital stays, and greater rates of readmissions.

Frequency and predictors of perioperative psychiatric symptom worsening among patients with psychiatric disorders

OBJECTIVE

This study aimed to clarify the frequency of perioperative psychiatric symptom worsening among patients with psychiatric disorders and investigate factors predictive of symptom aggravation.

METHOD

This study adopted a retrospective cohort study design. The sample consisted of perioperative inpatients who were diagnosed with psychiatric disorders on admission and received psychiatric intervention between January 1, 2015 and November 31, 2017.

RESULTS

Of 176 inpatients who met our inclusion criteria, 15 (8.5%) exhibited symptom worsening. Factors associated with symptom worsening included changes in surface morphology during surgery (p<0.01; odds ratio (OR)=10.58; 95% confidence interval (CI), 3.40-32.87), otolaryngological surgery (p=0.01; OR=6.95; 95% CI, 1.81-26.75), stay in the intensive care unit (p<0.01; OR=5.65; 95% CI, 1.79-17.81), and surgery duration longer than 180min (p=0.03; OR=3.40; 95% CI, 1.04-11.13).

CONCLUSION

This was the first retrospective analysis to focus on the perioperative worsening of psychiatric symptoms. As only few inpatients exhibited symptom aggravation, general hospitals without psychiatric beds can receive perioperative patients with psychiatric comorbidity. However, caution should be exercised to address the potential worsening of symptoms in cases of surface-morphology changing surgery, otolaryngological surgery, long-duration operations, and when ICU stay is required.

Impact of serious mental illness on surgical patient outcomes

BACKGROUND

People with comorbid mental illness have poorer health status and disparate access to healthcare. Several studies internationally have reported mixed findings regarding the association between mental illness and surgical patient outcomes. This study examines the surgical outcomes in people with decompensated serious mental illness (SMI) within the setting of the Australian universal healthcare system.

METHODS

Retrospective cohort study involving elective overnight surgical patients aged 18 years and above who attended a large public tertiary referral hospital in Sydney, Australia, between 2010 and 2014. Patients were identified using ICD-10-AM diagnosis codes. Outcomes measure including in-hospital mortality, post-operative complications, morbidity, admission and time in intensive care, length and cost of hospitalization, discharge destination and 28-day re-admission rates were examined.

RESULTS

Of 23 343 surgical patient admissions, 451 (2%) patients had decompensated comorbid SMI with a subset of 47 (0.2%) having a specific psychotic illness. Patients with SMI comorbidity had significantly higher in-hospital mortality (2% versus 0%), post-operative complications (22% versus 8%), total comorbidity (7.6 versus 3.4 secondary codes), admissions (29% versus 9%) and time in intensive care (34.6 h versus 5.0 h), stay in hospital (12.2 days versus 4.6 days), admission costs ($24 162 versus $12 336), re-admission within 28 days (14% versus 10%) and discharges to another facility (11% versus 3%).

CONCLUSION

Patients with comorbid SMI had significantly worse surgical outcomes and incur much higher costs compared with the general surgical population. These results strongly highlight that specific perioperative interventions are needed to proactively improve the identification, management and outcomes for these disadvantaged patients.

Increased Complications for Schizophrenia and Bipolar Disorder Patients Undergoing Total Joint Arthroplasty

BACKGROUND

Although it has been shown that anxiety and depression are associated with increased complications after total joint arthroplasty (TJA), the outcomes of TJA in patients with a history of psychosis are unknown. This study evaluated the influence of bipolar and schizophrenic disorders on complications after TJA, particularly aseptic and septic revisions.

METHODS

A retrospective review of 156 TJAs (125 primaries and 31 revisions) was performed at a single institution from 2000 to 2015. Bipolar and schizophrenic patients were identified based on International Classification of Diseases, Ninth Revision codes or by those actively taking anti-psychotic medications, followed by manual chart review to confirm diagnoses. The psychosis patient cohort was matched 3:1 for a variety of factors. Revisions and readmissions were evaluated. Survivorship curves were generated.

RESULTS

Patients with schizophrenia or bipolar disorder had an increased odds of developing peri-prosthetic joint infection at 90 days (odds ratio [OR] 3.34, P = .049), 2 years (OR 3.94, P = .004), and at any time point (OR 4.32, P = .002). Psychosis patients had increased odds of aseptic and mechanical revisions at all endpoints, particularly from dislocation. Psychosis patients had a higher number of post-operative emergency department visits (P < .001), and were more likely to be discharged to a rehabilitation facility (P < .001).

CONCLUSIONS

Patients with bipolar affective disorder or schizophrenia may have multiple barriers to self-care after TJA, and are at an increased risk for undergoing revision TJA for prosthetic joint infection and mechanical causes. Increased pre-operative education and screening of this patient population may be necessary prior to performing TJA.

Parity of esteem: Addressing the inequalities between mental and physical healthcare

Parity of esteem means valuing mental health as much as physical health in order to close inequalities in mortality, morbidity or delivery of care. There is clear evidence that patients with mental illness receive inferior medical, surgical and preventive care. This further exacerbated by low help-seeking, high stigma, medication side-effects and relatively low resources in mental healthcare. As a result, patients with severe mental illness die 10–20 years prematurely and have a high rate of cardiometabolic complications and other physical illnesses. Many physical healthcare guidelines and policy recommendations address parity of esteem, but their implementation to date has been poor. All clinicians should be aware that inequalities in care are adversely influencing mental health outcomes, and managers, healthcare organisations and politicians should provide resources and education to address this gap.

Learning Objectives

• Understand the concept of parity of esteem

• Be aware of the current inequalities in mental healthcare

• Appreciate how parity of esteem may be improved

Perforated appendicitis in patients with schizophrenia: a retrospective cohort study

OBJECTIVE

Altered pain sensitivity may affect the outcome of appendicitis in patients with schizophrenia. We aimed to compare the prevalence of perforation in appendicitis between patients with and without schizophrenia.

DESIGN

Retrospective cohort study with random matching.

SETTING

A single tertiary medical centre in Japan.

PARTICIPANTS

From 1985 to 2013, 1821 cases of appendicitis requiring appendectomy were collected. Patients with schizophrenia and a cohort of randomly selected control subjects without schizophrenia who underwent appendectomy were identified.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the rate of perforated appendicitis in patients with and without schizophrenia. Secondary outcome was the odds of perforated appendicitis by different clinical factors.

RESULTS

62 patients with schizophrenia and randomly sampled 200 non-schizophrenic patients were compared. The prevalence of perforation was 53% in patients with schizophrenia versus 17% in controls (p<0.0001). The adjusted OR for perforation were 4.87 (95% CI: 2.33 to 10.2) for schizophrenia, 3.35 (95% CI 1.51 to 7.45) for age >55 years and 2.18 (95% CI: 1.12 to 4.27) for delayed presentation.

CONCLUSION

Appendiceal perforation was more frequent in patients with schizophrenia than controls, which may be partly attributable to delayed presentation and altered responses to pain.

Active Mental Illnesses Adversely Affect Surgical Outcomes

Depression, anxiety, posttraumatic stress disorder (PTSD), and substance abuse are linked to higher rates of morbidity and mortality after various surgical procedures. Comparable data in general surgery are lacking. Records from 183 consecutive patients undergoing elective general surgery procedures at a single tertiary hospital were reviewed. Patients with depression, anxiety, PTSD, and substance abuse or any combination of these at the time of surgery were classified as having “active mental illness” (AMI). Thirty-day complications, readmissions, and emergency room (ER) visits were identified. Univariate analysis was performed followed by creation of multivariate regression models. 41.5 per cent (n = 76) met criteria for the AMI group and 58.5 per cent (n = 107) were without a mental illness (WAMI). The two groups had similar incidence of medical comorbidities and similar mean values of serum albumin and creatinine. The AMI group had higher rates of readmissions (14.5 vs 3.7 %, P = 0.009) and ER (19.7 vs 8.4 %, P = 0.025) visits compared with the WAMI group. Differences in length of stay and 30-day complications did not reach statistical significance. In patients undergoing elective general surgery, depression, anxiety, PTSD, and substance abuse are associated with higher rates of readmission and ER visits. These results suggest a need for further research on the impact of specific mental illnesses on postoperative complications.

Cancer in patients with schizophrenia: What is the next step?

People with schizophrenia, who constitute approximately 0.3-1% of the general population, have a nearly 20% shorter life expectancy than the general population. The incidence of varied types of cancers in patients with schizophrenia is controversial. The majority of previous research has demonstrated that patients who have schizophrenia and cancer have early mortality compared to the general population with cancer. The causes of early mortality in patients with schizophrenia and cancer might be attributed to a lower cancer screening rate and lack of effective treatment, including: (i) patient factors, such as poor lifestyle, passive attitude toward treatment, or comorbidity; (ii) physician factors, such as physician bias, which may decrease the delivery of care for individuals with mental disorders; and (iii) hospital administration factors, such as stigma and discrimination. Additional studies on patients with schizophrenia and cancer are warranted and should include the following: a comprehensive review of previous studies; a focus on differentiating the specific types of cancer; and methods for improvement. To decrease the early mortality of patients with schizophrenia, the following measures are proposed: (i) enhance early detection and early treatment, such as increasing the cancer screening rate for patients with schizophrenia; (ii) provide effective, timely treatment and rehabilitation; (iii) improve patients' psychiatric symptoms and cognitive impairment; (iv) promote healthy behavior in the general population and emphasize healthy lifestyles in vulnerable populations; and (v) remove the stigma of schizophrenia. To reduce disparities in physical health, public health strategies and welfare policies must continue to focus on this group of patients.

Patient Safety Events and Harms During Medical and Surgical Hospitalizations for Persons With Serious Mental Illness

OBJECTIVE

This study explored the risk of patient safety events and associated nonfatal physical harms and mortality in a cohort of persons with serious mental illness. This group experiences high rates of medical comorbidity and premature mortality and may be at high risk of adverse patient safety events.

METHODS

Medical record review was conducted for medical-surgical hospitalizations occurring during 1994-2004 in a community-based cohort of Maryland adults with serious mental illness. Individuals were eligible if they died within 30 days of a medical-surgical hospitalization and if they also had at least one prior medical-surgical hospitalization within five years of death. All admissions took place at Maryland general hospitals. A case-crossover analysis examined the relationships among patient safety events, physical harms, and elevated likelihood of death within 30 days of hospitalization.

RESULTS

A total of 790 hospitalizations among 253 adults were reviewed. The mean number of patient safety events per hospitalization was 5.8, and the rate of physical harms was 142 per 100 hospitalizations. The odds of physical harm were elevated in hospitalizations in which 22 of the 34 patient safety events occurred (p<.05), including medical events (odds ratio [OR]=1.5, 95% confidence interval [CI]=1.3-1.7) and procedure-related events (OR=1.6, CI=1.2-2.0). Adjusted odds of death within 30 days of hospitalization were elevated for individuals with any patient safety event, compared with those with no event (OR=3.7, CI=1.4-10.3).

CONCLUSIONS

Patient safety events were positively associated with physical harm and 30-day mortality in nonpsychiatric hospitalizations for persons with serious mental illness.

Promoting physical health for people with schizophrenia by reducing disparities in medical and dental care

OBJECTIVE

Acquiring a diagnosis of schizophrenia reduces life expectancy for many reasons including poverty, difficulties in communication, side-effects of medication and access to care. This mortality gap is driven by natural deaths; cardiovascular disease is a major cause, but outcomes for people with severe mental illness are worse for many physical health conditions, including cancer, fractures and complications of surgery. We set out to examine the literature on disparities in medical and dental care experienced by people with schizophrenia and suggest possible approaches to improving health.

METHOD

This narrative review used a targeted literature search to identify the literature on physical health disparities in schizophrenia.

RESULTS

There is evidence of inequitable access to and/or uptake of physical and dental health care by those with schizophrenia.

CONCLUSION

The goal was to reduce the mortality gap through equity of access to all levels of health care, including acute care, long-term condition management, preventative medicine and health promotion. We suggest solutions to promote health, wellbeing and longevity in this population, prioritising identification of and intervention for risk factors for premature morbidity and mortality. Shared approaches are vital, while joint education of clinicians will help break down the artificial mind-body divide.

Serious mental illnesses associated with receipt of surgery in retrospective analysis of patients in the Veterans Health Administration

Background

The STOPP study (Surgical Treatment Outcomes for Patients with Psychiatric Disorders) analyzed variation in rates and types of major surgery by serious mental illness status among patients treated in the Veterans Health Administration (VA). VA patients are veterans of United States military service who qualify for federal care by reason of disability, special service experiences, or poverty.

Methods

STOPP conducted a secondary data analysis of medical record extracts for seven million VA patients treated Oct 2005-Sep 2009. The retrospective study aggregated inpatient surgery events, comorbid diagnoses, demographics, and postoperative 30-day mortality.

Results

Serious mental illness -- schizophrenia, bipolar disorder, posttraumatic stress disorder, or major depressive disorder, was identified in 12 % of VA patients. Over the 4-year study period, 321,131 patients (4.5 %) underwent surgery with same-day preoperative or immediate post-operative admission including14 % with serious mental illness. Surgery patients were older (64 vs. 61 years) and more commonly African-American, unmarried, impoverished, highly disabled (24 % vs 12 % were Priority 1), obese, with psychotic disorder (4.3 % vs 2.9 %). Among surgery patients, 3.7 % died within 30 days postop. After covariate adjustment, patients with pre-existing serious mental illness were relatively less likely to receive surgery (adjusted odds ratios 0.4-0.7).

Conclusions

VA patients undergoing major surgery appeared, in models controlling for comorbidity and demographics, to disproportionately exclude those with serious mental illness. While VA preferentially treats the most economically and medically disadvantaged veterans, the surgery subpopulation may be especially ill, potentially warranting increased postoperative surveillance.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The measurable cost of complications for outpatient cosmetic surgery in patients with mental health diagnoses

BACKGROUND

Mental health conditions, including psychiatric and substance abuse diagnoses, have been associated with poor postoperative outcomes, but no studies have quantified the relationship to date.

OBJECTIVE

The authors examine the association between mental health conditions and immediate postoperative outcomes as defined by further hospital-based acute care within 30 days of surgery.

METHODS

California State Ambulatory Surgery, Inpatient, and Emergency Department Databases were used to identify all adult patients undergoing outpatient cosmetic plastic surgery between January 2007 and October 2011. Patients were subgrouped by the presence of mental health or substance abuse conditions. Primary outcome was the need for hospital-based acute care (admission or emergency department visit) within 30 days after surgery. Multivariable logistic regression models compared outcomes between groups.

RESULTS

Of 116,597 patients meeting inclusion criteria, 3.9% and 1.4% had either a psychiatric or substance abuse diagnosis, respectively. Adjusting for medical comorbidities, patients with psychiatric disorders more frequently required hospital-based acute care within 30 days postoperatively than those without mental illness diagnoses (11.1% vs 3.6%; adjusted odds ratio [AOR], 1.78 [95% confidence interval, 1.59-1.99]). This was true both for hospital admissions (3.5% vs 1.1%; AOR, 1.61 [1.32-1.95]) and emergency department visits (8.8% vs 2.7%; AOR, 1.88 [1.66-2.14]). The most common acute diagnoses were surgical in nature, including postoperative infection, hemorrhage, and hematoma; the median hospital admission charge was $35 637. Similar findings were noted among patients with a substance abuse diagnosis.

CONCLUSIONS

Mental health conditions are independently associated with the need for more frequent hospital-based acute care following surgery, thus contributing to added costs of care. A patient's mental health should be preoperatively assessed and appropriately addressed before proceeding with any elective procedure.

LEVEL OF EVIDENCE

4.

Disparities in oral cancer survival among mentally ill patients

Background

Many studies have reported excess cancer mortality in patients with mental illness. However, scant studies evaluated the differences in cancer treatment and its impact on survival rates among mentally ill patients. Oral cancer is one of the ten most common cancers in the world. We investigated differences in treatment type and survival rates between oral cancer patients with mental illness and without mental illness.

Methods

Using the National Health Insurance (NHI) database, we compared the type of treatment and survival rates in 16687 oral cancer patients from 2002 to 2006. The utilization rate of surgery for oral cancer was compared between patients with mental illness and without mental illness using logistic regression. The Cox proportional hazards model was used for survival analysis.

Results

Oral cancer patients with mental disorder conferred a grave prognosis, compared with patients without mental illness (hazard ratios [HR] = 1.58; 95% confidence interval [CI] = 1.30–1.93; P<0.001). After adjusting for patients’ characteristics and hospital characteristics, patients with mental illness were less likely to receive surgery with or without adjuvant therapy (odds ratio [OR] = 0.47; 95% CI = 0.34–0.65; P<0.001). In multivariate analysis, oral cancer patients with mental illness carried a 1.58-times risk of death (95% CI = 1.30–1.93; P<0.001).

Conclusions

Oral cancer patients with mental illness were less likely to undergo surgery with or without adjuvant therapy than those without mental illness. Patients with mental illness have a poor prognosis compared to those without mental illness. To reduce disparities in physical health, public health strategies and welfare policies must continue to focus on this vulnerable group.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Epidemiology and outcomes associated with surgical site infection following bariatric surgery

BACKGROUND

Surgical site infection (SSI) is a frequent problem complicating bariatric surgery. However, the potential risk factors, risk stratification, and outcomes of SSIs in this patient population remain poorly defined. The aim of this prospective case-control study was to characterize better the risk factors and to improve risk stratification for SSIs following bariatric surgery.

METHODS

Patients studied had SSI following Roux-en-Y gastric bypass surgery (RYGBS) between November 2006 and March 2009 at Harper University Hospital and were each matched with 3 controls based on type of operative procedure, surgeon, and year of surgery. Thirty-day outcomes included mortality, hospital readmissions, outpatient procedures, and emergency room visits. A scoring system (BULCS score) was compared with the National Nosocomial Infections Surveillance system risk index using logistic regression.

RESULTS

In multivariate analysis, duration of surgery (odds ratio [OR], 3.3; 95% confidence interval [CI]: 1.62-6.74), diagnosis of bipolar disorder (OR, 3.341; 95% CI: 1.0-12.27), use of prophylactic antibiotics other than cefazolin (OR, 4.2; 95% CI: 1.47-11.69), and sleep apnea (OR, 1.8; 95% CI: 1.05-2.97) were significantly associated with SSI. Patients with SSI were more likely to have return emergency visits (OR, 4.96; 95% CI: 2.9-8.48), readmission (OR, 6.53; 95% CI: 3.44-12.42), and outpatient procedures following surgery (OR, 4.75; 95% CI: 1.32-17.14) than were controls without SSI. The BULCS score was a stronger predictor of SSI than the National Nosocomial Infections Surveillance system (C-statistic, -0.62 vs 0.55, respectively).

CONCLUSION

SSI following bariatric surgery was associated with receipt of antibiotic prophylaxis other than cefazolin and comorbid conditions including sleep apnea and bipolar disorder. The BULCS score performed favorably as a predictor and risk adjuster for SSI following bariatric surgery. SSI was associated with increased health care resource utilization.

When patients do not hurt: silent acute abdomen in a patient with schizophrenia

The phenomenon of pain insensitivity in schizophrenia and other psychotic disorders has been described since the early 20th century. Medical conditions often present atypically in the seriously mentally ill patient. Emergency physicians, primary care practitioners, surgeons and psychiatrists must maintain a high index of suspicion for acute abdomen in seriously mentally ill patients who may exhibit a diminished or absent perception of pain. The authors present a case of an atypical presentation of acute abdomen in a patient with schizophrenia.

Poor clinical outcomes among pneumonia patients with schizophrenia

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

The incidence and relative risk factors for developing cancer among patients with schizophrenia: a nine-year follow-up study

OBJECTIVE

To estimate the incidence and relative risk of developing cancer as well as the mortality rate after cancer diagnosis for patients with schizophrenia compared with the general population.

METHODS

Our population for this study was identified before the end of 1999. The study included 59,257 patients with schizophrenia and 178,156 age- and gender-matched individuals without schizophrenia as controls, who were selected from the 23,981,020 subjects in the National Health Insurance Research Database (NHIRD), which consists of 96% of the entire Taiwanese population. From the 2000 to 2008 NHIRD, we calculated the cancer incidence and survival time after cancer diagnosis in each of the two groups. Based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), the cancers were divided into nine groups.

RESULTS

During the nine-year follow-up period, 1145 (1.93%) of the patients with schizophrenia and 5294 (2.97%) of the control group developed cancer. The patients with schizophrenia had a significantly lower cancer incidence than those in the control group in both the male (OR=0.50, 95% CI, 0.46-0.55) and female (OR=0.81, 95% CI, 0.74-0.88) populations. Patients with schizophrenia were less likely to develop cancer than individuals in the control group for every cancer type except breast and cervical/uterine cancer. After adjustment using the Cox regression model, patients with schizophrenia had an overall decreased cancer risk (adjusted hazard ratio 0.71, 95% CI, 0.66-0.76) compared to the control population. For all cancer patients, the mortality adjusted hazard ratio for patients with schizophrenia versus the control group was 1.36 (95% CI, 1.24-1.50) after adjusting for other variables.

CONCLUSIONS

Although the likelihood of developing cancer among patients with schizophrenia (0.64) was less than that of the non-schizophrenia group, the mortality rate among patients with schizophrenia was higher than that of the control group.

Increased risk of avoidable hospitalization among patients with schizophrenia

OBJECTIVE

Some studies suggest that hospitalizations for certain conditions, called ambulatory care sensitive conditions (ACSCs), are potentially avoidable. However, almost no study has addressed the risk of ACSC hospitalizations specifically for patients with severe mental illness. Our study examines the risk of ACSC hospitalizations among patients with schizophrenia in Taiwan, using a 5-year, nationwide, population-based database.

METHODS

Our study included 2503 patients with schizophrenia and 20 024 matched patients without schizophrenia. Poisson regression analysis was then performed in which the number of ACSC hospitalizations from 2002 to 2006 (including ruptured appendix, asthma, cellulitis, congestive heart failure, diabetes, gangrene, hypokalemia, immunizable conditions, malignant hypertension, pneumonia, pyelonephritis, and perforated or bleeding ulcer) was regressed against the independent variable of whether or not a patient had a schizophrenia diagnosis in 2001.

RESULTS

Results show that 9.83% of patients with schizophrenia and 4.71% of patients in the comparison group experienced ACSC hospitalizations from 2002 to 2006. After adjusting for each patient's sex, age, level of urbanization, geographic location of residence within a community, and monthly income, patients with schizophrenia had a 3.26-fold higher (95% CI 3.00 to 3.54, P < 0.001) risk of experiencing ACSC hospitalizations than the comparison participants. After excluding the conditions of diabetes, hypertension, and asthma, patients with schizophrenia independently had a 2.46-fold higher risk of ACSC hospitalizations (95% CI 2.12 to 2.86, P < 0.001), compared with participants in the comparison group.

CONCLUSIONS

We conclude that schizophrenia patients are at a higher risk for hospitalizations owing to ACSCs, despite a national health insurance system providing universal coverage to citizens.

Ethnicity and Race Variations in Receipt of Surgery among Veterans with and without Depression

To examine equity in one aspect of care provision in the Veterans Health Administration, this study analyzed factors associated with receipt of coronary artery bypass graft (CABG), vascular, hip/knee, or digestive system surgeries during FY2006-2009. A random sample of patients (N = 317, 072) included 9% with depression, 17% African-American patients, 5% Hispanics, and 5% women. In the four-year followup, 18,334 patients (6%) experienced surgery: 3,109 hip/knee, 3,755 digestive, 1,899 CABG, and 11,330 vascular operations. Patients with preexisting depression were less likely to have surgery than nondepressed patients (4% versus 6%). In covariate-adjusted analyses, minority patients were slightly less likely to receive vascular operations compared to white patients (Hispanic OR = 0.88, P < .01; African-American OR = 0.93, P < .01) but more likely to undergo digestive system procedures. Some race-/ethnicity-related disparities of care for cardiovascular disease may persist for veterans using the VHA.

Inequalities in healthcare provision for people with severe mental illness

There are many factors that contribute to the poor physical health of people with severe mental illness (SMI), including lifestyle factors and medication side effects. However, there is increasing evidence that disparities in healthcare provision contribute to poor physical health outcomes. These inequalities have been attributed to a combination of factors including systemic issues, such as the separation of mental health services from other medical services, healthcare provider issues including the pervasive stigma associated with mental illness, and consequences of mental illness and side effects of its treatment. A number of solutions have been proposed. To tackle systemic barriers to healthcare provision integrated care models could be employed including co-location of physical and mental health services or the use of case managers or other staff to undertake a co-ordination or liaison role between services. The health care sector could be targeted for programmes aimed at reducing the stigma of mental illness. The cognitive deficits and other consequences of SMI could be addressed through the provision of healthcare skills training to people with SMI or by the use of peer supporters. Population health and health promotion approaches could be developed and targeted at this population, by integrating health promotion activities across domains of interest. To date there have only been small-scale trials to evaluate these ideas suggesting that a range of models may have benefit. More work is needed to build the evidence base in this area.

National estimates of adverse events during nonpsychiatric hospitalizations for persons with schizophrenia

OBJECTIVE

Persons with schizophrenia comprise a vulnerable population that may be disproportionately susceptible to medical injuries. The objective of this study was to determine the association between diagnosis of schizophrenia and adverse events during non-psychiatric hospitalizations.

METHODS

We studied U.S. hospital discharges from 2002-2007 using the Nationwide Inpatient Sample. We determined the nationally weighted association of schizophrenia with the Agency for Healthcare Research and Quality's Patient Safety Indicators after adjusting for patient, hospitalization, and hospital characteristics.

RESULTS

There were 269,387 non-psychiatric hospitalizations with schizophrenia, and 37,092,651 without. Hospitalizations with schizophrenia had elevated adjusted odds ratios for PSIs compared with those without schizophrenia for decubitus ulcer (1.43, 95% CI: 1.36-1.51); infection from medical care (1.19, 95% CI: 1.08-1.30); postoperative respiratory failure (1.96, 95% CI: 1.67-2.30); sepsis (1.59, 95% CI: 1.25-2.02); and pulmonary embolism/deep venous thrombosis (1.23, 95% CI: 1.13-1.35). Adjusted odds ratios for iatrogenic pneumothorax (1.12, 95% CI: 0.94-1.33) and postoperative hemorrhage (1.07, 95% CI: 0.88-1.31) were not significantly different in persons with schizophrenia, while the adjusted OR for accidental puncture (OR=0.66, 95% CI: 0.58-0.74) was reduced in persons with schizophrenia.

CONCLUSIONS

Persons with schizophrenia are more likely to experience the most common types of medical injuries. Improved understanding of factors related to hospital quality of care and outcomes in this group will be important to plan interventions to enhance patient safety for persons with schizophrenia.

Do patients with schizophrenia receive state-of-the-art lung cancer therapy? A brief report

OBJECTIVE

Patients with schizophrenia sometimes receive substandard medical care. This study explored such disparities among lung cancer patients with underlying schizophrenia.

METHODS

This retrospective study focused on patients with pre-existing schizophrenia (or in some instances schizoaffective disorder) and a lung cancer diagnosis made between 1980 and 2004. 'Disparity' was defined as a patient's having been prescribed less aggressive therapy for a potentially curable cancer based on state-of-the-art treatment standards for the time and for the cancer stage. Qualitative methods were used to assess healthcare providers' decision-making.

RESULTS

29 patients were included. The median age was 59 years; 38% were men. Twenty-three had non-small cell lung cancer and 6 small cell lung cancer; 17 had potentially curable cancers. Five of 17 had a 'disparity' in cancer care: (1) no cancer therapy was prescribed because of chronic obstructive pulmonary disease; (2) no cancer therapy was prescribed because of infection; (3) no chemotherapy was prescribed because the patient declined it; radiation was provided; (4) no chemotherapy was prescribed because of the patient's schizophrenia symptoms; radiation was administered; and (5) no surgery was performed because of disorientation from a lobotomy; radiation was prescribed. Comments from healthcare providers suggest reflection and ethical adjudication in decision-making.

CONCLUSION

Schizophrenia was never the sole reason for no cancer treatment in patients with potentially curable lung cancer. This study provides the impetus for others to begin to assess the effect of schizophrenia on lung cancer management in other healthcare settings.

Postoperative complications in the seriously mentally ill: a systematic review of the literature

OBJECTIVE

To determine the knowledge base on clinical outcomes of surgery among persons diagnosed with serious mental illness.

BACKGROUND

Despite a burgeoning literature during the last 20 years regarding perioperative risk management, little is known about intraoperative and postoperative complications among patients with schizophrenia and other serious mental illnesses.

METHODS

A systematic literature search of Medline (1966-August 2007) and review of studies was conducted. Eligible studies were of any design with at least 10 patients diagnosed with serious mental illness, reporting perioperative medical, surgical, or psychiatric complications.

RESULTS

The search identified 1367 potentially relevant publications; only 12 met eligibility criteria. Of 10 studies of patients with schizophrenia, 9 had fewer than 100 patients, whereas one large retrospective study reported higher rates of postoperative complications among 466 schizophrenia patients compared with 338,257 controls. These studies suggest that patients with schizophrenia, compared with those without mental illness, may have higher pain thresholds, higher rates of death and postoperative complications, and differential outcomes (eg, confusion, ileus) by anesthetic technique. Two studies evaluated outcomes in patients with major depressive disorder and found higher rates of postoperative delirium and postoperative confusion. Both schizophrenia and depression patients experienced more postoperative confusion or delirium when psychiatric medications were discontinued preoperatively. We identified no studies of perioperative outcomes in patients with bipolar or posttraumatic stress disorder.

CONCLUSIONS

There are few studies of perioperative outcomes in patients with serious mental illness. Future research should assess surgical risks among patients with serious psychiatric conditions using rigorous methods and well-defined clinical outcomes.

Do psychiatric departments in general hospitals have an impact on the physical health of mental patients?

PURPOSE OF REVIEW

Recent literature has increased awareness of the physical health problems that affect mental-health patients. The close association of psychiatric departments with other medical departments can lead to improved communication and support between all medical specialties. This review assesses the impact these developments have on the physical health of individuals with psychiatric disorders.

RECENT FINDINGS

The current literature shows that mentally ill individuals have increased physical illness comorbidity. They do not regularly attend screening programmes or follow-up appointments. They also have an increased incidence of unwanted events while hospitalized. These disturbing findings cannot be wholly explained by lifestyle factors and antipsychotic medication and it seems that stigma against mental illness has an effect as well.

SUMMARY

No evidence has emerged that the medical screening of psychiatric patients has improved overall. Psychiatrists may be coming more sensitive to the fact that their patients need close monitoring, not only of their mental state but also their blood pressure, sugar glucose and weight. Sensitizing clinicians to the needs of psychiatric patients is a slow procedure. There is a great need for studies on specific interventions aimed at specific medical conditions that coexist more frequently with psychiatric disorders.

Disparities in appendicitis rupture rate among mentally ill patients

BACKGROUND

Many studies have been carried out that focus on mental patients' access to care for their mental illness, but very few pay attention on these same patients' access to care for their physical diseases. Acute appendicitis is a common surgical emergency. Our population-based study was to test for any possible association between mental illness and perforated appendicitis. We hypothesized that there are significant disparities in access to timely surgical care between appendicitis patients with and without mental illness, and more specifically, between patients with schizophrenia and those with another major mental illness.

METHODS

Using the National Health Insurance (NHI) hospital-discharge data, we compared the likelihood of perforated appendix among 97,589 adults aged 15 and over who were hospitalized for acute appendicitis in Taiwan between the years 1997 to 2001. Among all the patients admitted for appendicitis, the outcome measure was the odds of appendiceal rupture vs. appendicitis that did not result in a ruptured appendix.

RESULTS

After adjusting for age, gender, ethnicity, socioeconomic status (SES) and hospital characteristics, the presence of schizophrenia was associated with a 2.83 times higher risk of having a ruptured appendix (odds ratio [OR], 2.83; 95% confidence interval [CI], 2.20-3.64). However, the presence of affective psychoses (OR, 1.15; 95% CI: 0.77-1.73) or other mental disorders (OR, 1.58; 95% CI: 0.89-2.81) was not a significant predictor for a ruptured appendix.

CONCLUSION

These findings suggest that given the fact that the NHI program reduces financial barriers to care for mentally ill patients, they are still at a disadvantage for obtaining timely treatment for their physical diseases. Of patients with a major mental illness, schizophrenic patients may be the most vulnerable ones for obtaining timely surgical care.