Objective: To explore the feasibility of disease-specific clinical pathways when used in primary care. Design: A mixed-method sequential exploratory design was used. First, merging and exploring quality interview data across two cases of collaboration between the specialist care and primary care on the introduction of clinical pathways for four selected chronic diseases. Secondly, using quantitative data covering a population of 214,700 to validate and test hypothesis derived from the qualitative findings. Setting: Primary care and specialist care collaborating to manage care coordination. Results: Primary-care representatives expressed that their patients often have complex health and social needs that clinical pathways guidelines seldom consider. The representatives experienced that COPD, heart failure, stroke and hip fracture, frequently seen in hospitals, appear in low numbers in primary care. The quantitative study confirmed the extensive complexity among home healthcare nursing patients and demonstrated that, for each of the four selected diagnoses, a homecare nurse on average is responsible for preparing reception of the patient at home after discharge from hospital, less often than every other year. Conclusions: The feasibility of disease-specific pathways in primary care is limited, both from a clinical and organisational perspective, for patients with complex needs. The low prevalence in primary care of patients with important chronic conditions, needing coordinated care after hospital discharge, constricts transferring tasks from specialist care. Generic clinical pathways are likely to be more feasible and efficient for patients in this setting.Key pointsClinical pathways in hospitals apply to single-disease guidelines, while more than 90% of the patients discharged to community health care for follow-up have multimorbidity. Primary care has to manage the health care of the patient holistically, with all his or her complex needs.Patients most frequently admitted to hospitals, i.e. patients with COPD, heart failure, stroke and hip fracture are infrequent in primary care and represent a minority among patients in need of coordinated community health care.In primary care, the low rate of receiving patients discharged from hospitals of major chronic diseases hampers maintenance of required specific skills, thus constricting the transfer of tasks to primary care. Generic clinical pathways are suggested to be more feasible than disease-specific pathways for most patients with complex needs.

This meta-analysis aims to measure disparities in cardiovascular disease (CVD) screening/treatment in people with mental disorders, given the increased CVD incidence and mortality.Methods. PRISMA/MOOSE compliant systematic search, Pubmed/PsycInfo, last search June 31 st , 2020 (protocol https://osf.io/b8rvs/), with random-effect meta-analysis of observational studies comparing CVD screening/treatment in people with vs. without mental disorders. Primary outcome was Odds Ratios (ORs) for CVD screening/treatment. Sensitivity analyses on screening/treatment separately, on specific procedures, as well as country/confounding subgroup analyses, and meta-regressions were run. Publication bias and quality (Newcastle-Ottawa Scale (NOS)) were assessed. Results. Forty-seven studies (n=24,400,452, 1,283,602 with mental disorders), from North America (k=26), Europe (k=16), Asia (k=4), and Australia (k=1) were meta-analyzed. Lower rates of screening/treatment in mental disorders emerged for any CVD (k=47, OR=0.773, 95%CI=0.742-0.804, p<0.001), coronary artery disease (k=34, OR=0.734, 95%CI=0.690-0.781, p<0.001), cerebrovascular disease (k=8, OR=0.810, 95%CI=0.779-0.842, p<0.001), or other mixed CVDs (k=11, OR=0.839, 95%CI=0.761-0.924, p<0.001).Significant disparities emerged for any screening, any intervention, catheterization/revascularization in coronary artery disease, intravenous thrombolysis for stroke, and treatment with any and specific medications for CVD across all mental disorders (except for CVD medications in mood disorders). Disparities were largest for schizophrenia, and differed across countries. Median quality was high (NOS=8), higher quality studies found larger disparities, and publication bias did not affect results. Conclusions.People with mental disorders (schizophrenia in particular) receive less screening and lower quality treatment for CVD. It is of paramount importance to address under-prescribing of CVD medications and under-utilization of diagnostic and therapeutic procedures across all mental disorders.

Individuals with schizophrenia or substance use disorder have a substantially increased mortality compared to the general population. Despite a high and probably increasing prevalence of comorbid substance use disorder in people with schizophrenia, the mortality in the comorbid group has been less studied and with contrasting results. We performed a nationwide open cohort study from 2009 to 2015, including all Norwegians aged 20–79 with schizophrenia and/or substance use disorder registered in any specialized health care setting in Norway, a total of 125,744 individuals. There were 12,318 deaths in the cohort, and total, sex-, age- and cause-specific standardized mortality ratios (SMRs) were calculated, comparing the number of deaths in patients with schizophrenia, schizophrenia only, substance use disorder only or a co-occurring diagnosis of schizophrenia and substance use disorder to the number expected if the patients had the age-, sex- and calendar-year specific death rates of the general population. The SMRs were 4.9 (95% CI 4.7–5.1) for all schizophrenia patients, 4.4 (95% CI 4.2–4.6) in patients with schizophrenia without substance use disorder, 6.6 (95% CI 6.5–6.8) in patients with substance use disorder only, and 7.4 (95% CI 7.0–8.2) in patients with both schizophrenia and substance use disorder. The SMRs were elevated in both genders, in all age groups and for all considered causes of death, and most so in the youngest. Approximately 27% of the excess mortality in all patients with schizophrenia was due to the raised mortality in the subgroup with comorbid SUD. The increased mortality in patients with schizophrenia and/or substance use disorder corresponded to more than 10,000 premature deaths, which constituted 84% of all deaths in the cohort. The persistent mortality gap highlights the importance of securing systematic screening and proper access to somatic health care, and a more effective prevention of premature death from external causes in this group.

Objective To examine whether individuals with schizophrenia ( SCZ ) or bipolar disorder ( BD ) had equal likelihood of not being diagnosed with cardiovascular disease ( CVD ) prior to cardiovascular death, compared to individuals without SCZ or BD . Methods Multivariate logistic regression analysis including nationwide data of 72 451 cardiovascular deaths in the years 2011–2016. Of these, 814 had a SCZ diagnosis and 673 a BD diagnosis in primary or specialist health care. Results Individuals with SCZ were 66% more likely ( OR : 1.66; 95% CI : 1.39–1.98), women with BD were 38% more likely (adjusted OR : 1.38; 95% CI : 1.04–1.82), and men with BD were equally likely ( OR : 0.88, 95% CI : 0.63–1.24) not to be diagnosed with CVD prior to cardiovascular death, compared to individuals without SMI . Almost all (98%) individuals with SMI and undiagnosed CVD had visited primary or specialized somatic health care prior to death, compared to 88% among the other individuals who died of CVD . Conclusion Individuals with SCZ and women with BD are more likely to die due to undiagnosed CVD , despite increased risk of CVD and many contacts with primary and specialized somatic care. Strengthened efforts to prevent, recognize, and treat CVD in individuals with SMI from young age are needed.

Objective To examine whether severe mental illnesses (i.e., schizophrenia or bipolar disorder) affected diagnostic testing and treatment for cardiovascular diseases in primary and specialized health care. Methods We performed a nationwide study of 72 385 individuals who died from cardiovascular disease, of whom 1487 had been diagnosed with severe mental illnesses. Log‐binomial regression analysis was applied to study the impact of severe mental illnesses on the uptake of diagnostic tests (e.g., 24‐h blood pressure, glucose/HbA1c measurements, electrocardiography, echocardiography, coronary angiography, and ultrasound of peripheral vessels) and invasive cardiovascular treatments (i.e., revascularization, arrhythmia treatment, and vascular surgery). Results Patients with and without severe mental illnesses had similar prevalences of cardiovascular diagnostic tests performed in primary care, but patients with schizophrenia had lower prevalences of specialized cardiovascular examinations (prevalence ratio (PR) 0.78; 95% CI 0.73–0.85). Subjects with severe mental illnesses had lower prevalences of invasive cardiovascular treatments (schizophrenia, PR 0.58; 95% CI 0.49–0.70, bipolar disorder, PR 0.78; 95% CI 0.66–0.92). The prevalence of invasive cardiovascular treatments was similar in patients with and without severe mental illnesses when cardiovascular disease was diagnosed before death. Conclusion Better access to specialized cardiovascular examinations is important to ensure equal cardiovascular treatments among individuals with severe mental illnesses.