Nationwide analysis of medical utilization in people with severe mental illness receiving home care case management

Incidence and risk profiles for pneumonia in patients with schizophrenia receiving home-care case management intervention in Taiwan

BACKGROUND

Home-care case management is a type of community outreach service. However, research on the incidence of infectious diseases in patients receiving home-care case management is limited. This study investigated the incidence of various infectious diseases and risk factors for pneumonia in patients with schizophrenia receiving home-care case management.

METHODS

We used data from Taiwan's National Health Insurance Research Database between January 1, 2000, and December 31, 2019, to construct a schizophrenia cohort receiving home-care case management (n = 19,687). Pneumonia was the most common infectious disease at follow-up (n = 3966). To identify risk factors for pneumonia, a nested case-control study was conducted. Risk-set sampling was conducted to randomly select controls for each pneumonia case. Conditional logistic regression was employed for statistical analysis.

RESULTS

Among various infectious diseases, pneumonia had the highest standardized incidence ratio in our cohort. Of the 3966 patients with pneumonia identified, 56.9% were men. After pairing, 3961 case-control pairs were established. Psychiatric comorbidities, specifically dementia and depressive disorders, were associated with a higher risk of pneumonia (adjusted incidence rate ratios [aIRRs] = 2.73 and 1.34, respectively). In contrast to oral antipsychotics, long-acting injectables were not associated with an increased pneumonia risk, suggesting that long-acting injectables could be a safer treatment option for patients with schizophrenia.

CONCLUSION

Our results revealed a significantly elevated pneumonia risk in this patient population, especially in those with physical and psychiatric comorbidities. The findings advocate for comprehensive care strategies to reduce the risk of pneumonia in this population.

Incidence and Risk Profiles for Suicide Mortality in Patients With Schizophrenia Receiving Homecare Case Management in Taiwan

Case management (CM)-based community therapy for patients with schizophrenia had little effect on reducing suicide mortality. We investigate the long-term suicide mortality outcome and associated risk factors in patients with schizophrenia receiving homecare (CM) in Taiwan. We enrolled a nationwide cohort of patients with schizophrenia who newly received homecare CM intervention (n = 13 317) between January 1, 2001, and December 31, 2015; their data were derived from Taiwan's National Health Insurance Research Database. We calculated the incidence rate of suicide methods. We examined the demographic and medical utilization profile for suicide and then performed a nested case-control study and multivariate regression to identify independent risk factors for suicide mortality. Among the 13 317 patients who received homecare CM intervention, 1766 died during the study period, of whom 213 died by suicide, which is the leading cause of unnatural death. Jumping from a high place, self-poisoning, and hanging were the top 3 suicide methods. Increased medical utilization was noted for both psychiatric and non-psychiatric services within 3 months of suicide mortality. Comorbidities of depressive disorder, nonspecific heart diseases, pneumonia, and gastrointestinal ulcers were identified as independent risk factors for suicide mortality. Suicide was the leading cause of unnatural mortality in patients with schizophrenia receiving homecare CM intervention in Taiwan. We noted the preferred suicide methods, high medical utilization, and comorbidities before suicide. Thus, we suggest that the CM team should assess lethal methods for suicide and ensure that patients adhere to psychiatry treatment for improving the current care model for this specified population.

Excess mortality and risk factors for mortality among patients with severe mental disorders receiving home care case management

AIM

Home care case management (CM) is the main intervention for patients with severe mental disorders (SMDs) requiring outreach care. This study investigated the long-term mortality outcome and associated risk factors in patients who received home care CM.

METHODS

This nationwide study enrolled patients who received home care CM (n = 10,255) between 1 January 1999 and 31 December 2010. Each patient was followed up from the baseline (when patients underwent home case CM for the first time during the study period) to the censor (i.e. mortality or the end of the study). We calculated the standardized mortality ratio (SMR) and presented by age and diagnosis. Multivariate regression was performed to assess independent risk factors for mortality.

RESULTS

Among 10,255 patients who received home care CM, 1409 died during the study period; the overall SMR was 3.13. Specifically, patients with organic mental disorder had the highest SMR (4.98), followed by those with schizophrenia (3.89), major depression (2.98), and bipolar disorder (1.97). In the multivariate analysis, patients with organic mental disorder or dementia had the highest risk, whereas the mortality risk in patients with schizophrenia was comparable to that in patients with bipolar disorder or major depression. Deceased patients had a significantly higher proportion of acute or chronic physical illnesses, including cancer, chronic hepatic disease, pneumonia, diabetes mellitus, cardiovascular disease, and asthma.

CONCLUSION

This study presented the gap of mortality in patients with SMDs receiving home care CM in Taiwan. We highlight the need for effective strategies to improve medical care for this specified population.