Mental illness, access to hospitals with invasive cardiac services, and receipt of cardiac procedures by Medicare acute myocardial infarction patients

Differences in TAVR Utilization in Aortic Stenosis Among Patients With and Without Psychiatric Comorbidities

Background

Transcatheter aortic valve replacement (TAVR) is one of the primary treatment modalities for aortic stenosis (AS). Disparities affecting certain groups could result in lower utilization of this life-saving procedure. This study aims to investigate the effects of associated psychiatric conditions on the likelihood of TAVR in hospitalized AS patients.

Methods

Our retrospective observational study used the National Inpatient Sample to identify hospitalized patients with AS. Using the International Classification of Diseases, 10th Revision, Clinical Modification patients were stratified into those without psychiatric comorbidities, and those with psychiatric comorbidities. The primary outcome was comparing the odds of TAVR between AS patients with and without psychiatric comorbidities. The secondary outcome assessed the association between TAVR and specific psychiatric comorbidities, using multivariable logistic regression while adjusting for prespecified covariates.

Results

The study included 1,549,785 AS patients, of which 26% had psychiatric comorbidities. Patients with any psychiatric comorbidity had a significantly reduced likelihood of TAVR (adjusted odds ratio [aOR], 0.76; P < .001). For 2 psychiatric comorbidities, (aOR, 0.80; P < .001), and for more than 2 comorbid mental disorders (aOR, 0.46; P < .001). Lower TAVR odds were observed in patients with depression (aOR, 0.79), anxiety (aOR, 0.79), bipolar disorder (aOR, 0.74), substance use (aOR, 0.73), and psychotic disorders (aOR, 0.61), with P values < .001. There was no significant difference in the odds of surgical aortic valve replacement between those with and without psychiatric comorbidities.

Conclusions

AS patients with psychiatric conditions face reduced TAVR likelihood. Further research is needed to confirm, explore, and address factors contributing to this disparity.

Clinical characteristics and outcomes of people with severe mental disorders hospitalized due to COVID-19: A nationwide population-based study

OBJETIVE

Hospitalized COVID-19 patients with severe mental illness (SMI) have worse outcomes than counterparts without SMI. Barriers in access to acute care medical procedures among SMI patients may partially explain this phenomenon. Here, we examined differences in critical care admission and in-hospital mortality between hospitalized COVID-19 patients with and without SMI.

METHODS

This population-based study used Spain's nationwide electronic health records. Based on International Classification Diseases, Tenth Revision, ICD-10-CM codes, we identified all patients aged ≥15 years hospitalized due to COVID-19 between July 1st-December 31st, 2020, and compared patients with and without SMI in terms of (i) critical care admission and (ii) in-hospital mortality - overall and stratified by age. We used logistic regression models including sex, age, and comorbidity burden as measured by Charlson Comorbidity Index Score as covariates.

RESULTS

Of 118,691 hospital admissions due to COVID-19 of people aged ≥15 years, 1512 (1.3%) included a diagnosis of SMI. Compared to non-SMI patients, SMI patients had higher in-hospital mortality (OR,95%CI: 1.63,1.42-1.88) and were less frequently admitted to critical care (OR,95%CI: 0.70,0.58-0.85). Admission to critical care in SMI patients was lower than for non-SMI counterparts only among individuals aged ≥60 years. The magnitude of the difference in in-hospital mortality between SMI and non-SMI patients decreased as age increased.

CONCLUSIONS

Individuals with SMI had reduced critical care admission and increased in-hospital mortality compared non-SMI counterparts, suggesting that differences in delivery of acute care medical procedures may partially explain higher risk of negative outcomes among COVID-19 patients with SMI.

Use and outcomes of mechanical ventilation for people with severe mental disorders admitted due to natural causes: A nationwide population-based study

OBJECTIVE

To characterize temporal trends and outcomes of invasive mechanical ventilation (MV) for people with severe mental disorders (SMD) admitted due to natural causes.

METHODS

We identified all 224,507 hospitalizations of patients aged 15-69 who underwent MV in Spain between 2000 and 2015, excluding poisonings and injuries, and divided them by presence of an SMD diagnosis. We compared the two study groups regarding demographic and clinical characteristics and examined time trends in the incidence of MV and in-hospital mortality.

RESULTS

SMD patients were younger and had fewer comorbidities and lower in-hospital mortality than the non-SMD group. However, among patients admitted due to circulatory diseases, SMD patients had higher mortality risk (OR = 1.39; 95%CI = 1.22-1.59). In the SMD group, the increase in MV use quadrupled that of non-SMD patients (Average Annual Percent Change = 6.9%; 95%CI = 5.5-8.3 vs. 1.5%; 0.9-2.0, respectively). Overall in-hospital mortality declined similarly in both study groups. While the SMD group's circulatory-specific mortality also decreased, by 2015 it remained elevated in comparison to non-SMD patients (44% vs. 38%, respectively).

CONCLUSION

The increase in MV use due to natural causes among people with SMD outpaced that of non-SMD patients, with comparable decreasing trends in mortality. Although declining, SMD patients' higher circulatory-specific mortality risk requires further investigation.

Factors associated with emergency medical service delays in suspected ST-elevation myocardial infarction in Victoria, Australia: A retrospective study

OBJECTIVE

To assess the effect of patient and system characteristics on emergency medical service (EMS) delays prior to arrival at hospital in suspected ST-elevation myocardial infarction (STEMI).

METHODS

This was a retrospective observational study of 1739 patients who presented with suspected STEMI to the EMS in Melbourne, Australia between October 2011 and January 2014. Our primary outcome measure was call-to-hospital time, defined as the time in minutes from emergency call to hospital arrival. We examined the association of patient and system characteristics on call-to-hospital time using multivariable linear regression.

RESULTS

The mean call-to-hospital time was 60.1 min (standard deviation 20.5) and the median travel distance was 13.0 km (interquartile range 7.2-23.1). In the multivariable model, patient characteristics associated with longer call-to-hospital time were age ≥75 years (2.3 min; 95% confidence interval [CI] 0.6-4.0), female sex (1.9 min; 95% CI 0.3-3.4), pre-existing mental health disorder (4.0 min; 95% CI 1.9-6.1) or musculoskeletal disease (2.7 min; 95% CI 1.0-4.4), absence of chest pain (3.0 min; 95% CI 1.1-4.8), and presentation with clinical complications. System factors associated with call-to-hospital time include lower dispatch priority (12.7 min; 95% CI 9.0-16.5) and non-12-lead electrocardiography (ECG) capable ambulance first on scene (4.5 min; 95% CI 3.1-5.8). Patients who were not initially attended by a 12-lead capable ambulance were less likely to receive a 12-lead ECG within 10 min (18.5% vs 71.0%, P < 0.001).

CONCLUSION

A range of patient and system factors may influence EMS delays in STEMI. However, optimising dispatch prioritisation and widespread availability of prehospital 12-lead ECG could lead to substantial reduction in time to treatment.

Assessing mental health stigma: Nurse practitioners' attitudes regarding managing patients with mental health disorders

BACKGROUND

A contributing factor in the provision of suboptimal mental health care is the presence of stigmatizing attitudes among health care providers. Although numerous studies have investigated stigmatizing attitudes among physicians, nurses in psychiatric settings, and various populations of students, mental health stigma among nurse practitioners (NPs) has not yet been addressed.

PURPOSE

The purpose of this study was to assess NPs' attitudes and beliefs regarding working with individuals with a mental health disorder.

METHODS

A cross-sectional descriptive design was used. Nurse practitioners attending a national practice conference completed a survey for demographic and practice information and a standardized measure for assessing stigmatizing attitudes regarding three mental health conditions: (a) anxiety/depression, (b) attention deficit hyperactivity disorder, and (c) substance use disorders (SUDs).

RESULTS

A total of 141 NPs participated in this study. The most favorable attitudes were reported for working with individuals with anxiety/depression, and the least favorable attitudes were reported for working with those with an SUD.

IMPLICATIONS FOR PRACTICE

Stigmatizing attitudes are present among practicing NPs. Effective bias-reducing interventions are indicated to improve the patient-centered care NPs provide to individuals with mental health disorders.

Patients with stroke and psychiatric comorbidities have lower carotid revascularization rates

OBJECTIVE

We investigated whether mental illness is associated with lower rates of carotid endarterectomy (CEA)/carotid artery stenting (CAS) after stroke due to carotid stenosis.

METHODS

In this retrospective cross-sectional study, ischemic stroke cases due to carotid stenosis were identified in the 2007-2014 Nationwide (National) Inpatient Sample. Psychiatric conditions were identified by secondary ICD-9-CM diagnosis codes for schizophrenia/psychoses, bipolar disorder, depression, anxiety, or substance use disorders. Using logistic regression, we tested the association between psychiatric conditions and CEA/CAS, controlling for demographic, clinical, and hospital factors.

RESULTS

Among 37,474 included stroke cases, 6,922 (18.5%) had a psychiatric comorbidity. The presence of any psychiatric condition was associated with lower odds of CEA/CAS (adjusted odds ratio [OR] 0.84, 95% confidence interval [CI] 0.78-0.90). Schizophrenia/psychoses (OR 0.72, 95% CI 0.55-0.93), depression (OR 0.83, 95% CI 0.75-0.91), and substance use disorders (OR 0.73, 95% CI 0.65-0.83) were each associated with lower odds of CEA/CAS. The association of mental illness and CEA/CAS was dose-dependent: compared to patients without mental illness, patients with multiple psychiatric comorbidities (OR 0.74, 95% CI 0.62-0.87) had lower odds of CEA/CAS than those with only one psychiatric comorbidity (OR 0.86, 95% CI 0.79-0.92; p value for trend <0.001).

CONCLUSION

The odds of carotid revascularization after stroke is lower in patients with mental illness, particularly those with schizophrenia/psychoses, depression, substance use disorders, and multiple psychiatric diagnoses.

Acute Myocardial Infarction in Severe Mental Illness: Prevalence, Clinical Outcomes, and Process of Care in U.S. Hospitalizations

BACKGROUND

Severe mental illness (SMI) is associated with increased cardiovascular mortality. We sought to examine the prevalence, clinical outcomes, and management strategy of patients with SMI presenting with acute myocardial infarction (AMI).

METHODS

All AMI hospitalizations from the National Inpatient Sample were included, stratified by mental health status into 5 groups: no SMI, schizophrenia, other non-organic psychoses (ONOP), bipolar disorder, and major depression. Regression analyses were performed to assess the association (adjusted odds ratios [ORs], P ≤ 0.001 for all outcomes) between SMI subtypes and clinical outcomes.

RESULTS

Of 6,968,777 AMI hospitalizations between 2004 and 2014, 439,544 patients (6.5%) had an SMI diagnosis. Although patients with schizophrenia and ONOP experienced higher crude rates of in-hospital mortality and stroke compared with those without SMI, only schizophrenic patients were at increased odds of mortality (OR, 1.10; 95% confidence interval [CI], 1.04-1.16), whereas ONOP was the only group at increased odds of stroke (OR, 1.53; 95% CI, 1.42-1.65) after multivariate adjustment. Patients with ONOP were the only group associated with increased odds of in-hospital bleeding compared with those without SMI (OR, 1.11; 95% CI, 1.04-1.17). All those with SMI subtypes were less likely to receive coronary angiography and percutaneous coronary intervention, with the schizophrenia group being at least odds of either procedure (OR, 0.46; 95% CI, 0.45-0.48 and OR, 0.57; 95% CI, 0.55-0.59, respectively).

CONCLUSION

Schizophrenia and ONOP are the only SMI subtypes associated with adverse clinical outcomes after AMI. However, all patients with SMI were less likely to receive invasive management for AMI, with female gender and schizophrenia diagnosis being the strongest predictors of conservative management. A multidisciplinary approach between psychiatrists and cardiologists could improve the outcomes of this high-risk population.

Inequalities in access to health and social care among adults with multiple sclerosis: A scoping review of the literature

Variations in access to health care are known to contribute to differences in life expectancy, morbidity and health-related quality-of-life across population subgroups. We undertook a scoping review to identify what is known about in-country variations in access to services for adults with multiple sclerosis and to identify gaps in the literature to inform future research and national policies. We searched MEDLINE, CINAHL, EMBASE, PSYCHINFO, SocINDEX and Social Science Abstracts from inception to end of December 2016 for quantitative studies which had investigated differences in access to prevention services, healthcare services, treatments and social care between inequality groups, defined using the PROGRESS-PLUS framework. A total of 4959 unique abstracts yielded 36 papers which met our eligibility criteria. Only 3 studies were cohort studies and only 4 were population-based; most were from the United States (n = 27). There were 6 studies on access to MS focused care and 6 on access to Disease Modifying drugs. There were 3 studies on access to prevention/lifestyle programmes and none on access to welfare services or information support. There were no papers examining inequalities in access for 'vulnerable' groups, such as, those with learning disability. In the available studies, there was evidence of inequalities in access to services with a trend for worse access among men, older age groups, those from lower socio-economic groups or the least educated, non-caucasians, those with mental health problems and those from rural areas. In the studies on access to disease modifying treatments, older age and lower socioeconomic status were consistently associated with a lower rate of uptake, while race and gender were not. Inequalities or disparities in access to all levels of services and treatments will need to be addressed through a strategic research agenda with an emphasis on population-based studies and development and evaluation of interventions to reduce inequality.

Review of the effects of self-stigma and perceived social stigma on the treatment-seeking decisions of individuals with drug- and alcohol-use disorders

Substance-use disorders are a public health crisis globally and carry with them significant morbidity and mortality. Stigma toward people who abuse these substances, as well as the internalization of that stigma by substance users, is widespread. In this review, we synthesized the available evidence for the role of perceived social stigma and self-stigma in people’s willingness to seek treatment. While stigma may be frequently cited as a barrier to treatment in some samples, the degree of its impact on decision-making regarding treatment varied widely. More research needs to be done to standardize the definition and measurement of self- and perceived social stigma to fully determine the magnitude of their effect on treatment-seeking decisions.

Quality of Care and Outcomes of Heart Failure Among Patients With Schizophrenia in Denmark

Research on the association between schizophrenia and the quality of care and clinical outcomes of heart failure (HF) remains sparse. This nationwide study compared the quality of care and clinical outcomes of HF among Danish patients with and without schizophrenia. In a population-based cohort study, we identified 36,718 patients with incident HF with hospital contacts, including 108 with schizophrenia, using Danish registries between 2004 and 2013. High quality of HF care was defined as receiving ≥ 80% guideline-recommended process-performance measures of care. Potential predictors of HF care among patients with schizophrenia included patient-specific factors (age, gender, Global Assessment of Functioning [GAF] score, alcohol or drug abuse, duration of schizophrenia); provider-specific factors (quality of schizophrenia care); and system-specific factors (patient-volume defined as hospital departments and clinics yearly average patient-volume of patients with incident HF). Clinical outcomes included 4-week all-cause readmission and 1-year all-cause mortality after a first-time hospital contact with incident HF. Results showed that compared with patients with incident HF who have no schizophrenia, patients with incident HF who have schizophrenia had a lower chance of receiving high-quality HF care (relative risk 0.66, 95% confidence interval 0.48 to 0.91). A high GAF score was associated with a higher chance of receiving high-quality HF care among patients with incident HF who have schizophrenia. Patients with incident HF who have schizophrenia had a higher risk of 1-year mortality (adjusted hazard ratio 2.83, 95% confidence interval 1.59 to 5.04), but not a higher risk of readmission than patients with incident HF who have no schizophrenia. In conclusion, efforts are warranted to reduce the high mortality among patients with incident HF who have schizophrenia.

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

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

Examining the impact of comorbid serious mental illness on rehospitalization among medical and surgical inpatients

OBJECTIVE

Multiple barriers to quality health care may affect the outcomes of postacute treatment for individuals with serious mental illness (SMI). This study examined rehospitalization for medical and surgical inpatients with and without a comorbid diagnosis of SMI which included psychotic disorders, bipolar disorder and major depression.

METHODS

We examined hospital discharge records for medical and surgical inpatients from a large urban health system. Descriptive statistics and logistic regression models compared 7-, 30-, 60-, 90- and 180-day rehospitalization among medical and surgical inpatients with SMI (n=3221) and without an SMI diagnosis (n=70,858).

RESULTS

Within 6 months following discharge, hospitalized medical patients without an SMI diagnosis (34.3%) and with an SMI diagnosis (43.4%) were rehospitalized (P<.001), while surgical patients without an SMI diagnosis (20.3%) and with an SMI diagnosis (30.0%) were rehospitalized (P<.001). Odds of rehospitalization among medical patients were 1.5 to 2.4 times higher for those with an SMI diagnosis compared to those without an SMI diagnosis (P<.001).

CONCLUSIONS

Medical patients with a comorbid psychotic or major mood disorder diagnosis have an increased likelihood of a medical rehospitalization as compared to those without a comorbid SMI diagnosis. These findings support prior literature and suggest the importance of identifying targeted interventions aimed at lowering the likelihood of rehospitalization among inpatients with a comorbid SMI diagnosis.

Inpatient and outpatient costs in patients with coronary artery disease and mental disorders: a systematic review

Background

To systematically review in- and outpatient costs in patients with coronary artery disease (CAD) and comorbid mental disorders.

Methods

A comprehensive database search was conducted for studies investigating persons with CAD and comorbid mental disorders (Medline, EMBASE, PsycINFO, Psyndex, EconLit, IBSS). All studies were included which allowed a comparison of in- and outpatient health care costs (assessed either monetarily or in terms of health care utilization) of CAD patients with comorbid mental disorders (mood, anxiety, alcohol, eating, somatoform and personality disorders) and those without. Random effects meta-analyses were conducted and results reported using forest plots.

Results

The literature search resulted in 7,275 potentially relevant studies, of which 52 met inclusion criteria. Hospital readmission rates were increased in CAD patients with any mental disorder (pooled standardized mean difference (SMD) = 0.34 [0.17;0.51]). Results for depression, anxiety and posttraumatic stress disorder pointed in the same direction with heterogeneous SMDs on a primary study level ranging from −0.44 to 1.26. Length of hospital stay was not increased in anxiety and any mental disorder, while studies on depression reported heterogeneous SMDs ranging from −0.08 to 0.82. Most studies reported increased overall and outpatient costs for patients with comorbid mental disorders. Results for invasive procedures were non-significant respectively inconclusive.

Conclusions

Comorbid mental disorders in CAD patients are associated with an increased healthcare utilization in terms of higher hospital readmission rates and increased overall and outpatient health care costs. From a health care point of view, it is requisite to improve the diagnosis and treatment of comorbid mental disorders in patients with CAD to minimize incremental costs.