Review: Do deficits in cardiac care influence high mortality rates in schizophrenia? A systematic review and pooled analysis

Abstract

We have previously documented inequalities in the quality of medical care provided to those with mental ill health but the implications for mortality are unclear. We aimed to test whether disparities in medical treatment of cardiovascular conditions, specifically receipt of medical procedures and receipt of prescribed medication, are linked with elevated rates of mortality in people with schizophrenia and severe mental illness. We undertook a systematic review of studies that examined medical procedures and a pooled analysis of prescribed medication in those with and without comorbid mental illness, focusing on those which recruited individuals with schizophrenia and measured mortality as an outcome. From 17 studies of treatment adequacy in cardiovascular conditions, eight examined cardiac procedures and nine examined adequacy of prescribed cardiac medication. Six of eight studies examining the adequacy of cardiac procedures found lower than average provision of medical care and two studies found no difference. Meta-analytic pooling of nine medication studies showed lower than average rates of prescribing evident for the following individual classes of medication; angiotensin converting enzyme inhibitors (n = 6, aOR = 0.779, 95% CI = 0.638–0.950, p = 0.0137), beta-blockers (n = 9, aOR = 0.844, 95% CI = 0.690–1.03, p = 0.1036) and statins (n = 5, aOR = 0.604, 95% CI = 0.408–0.89, p = 0.0117). No inequality was evident for aspirin (n = 7, aOR = 0.986, 95% CI = 0.7955–1.02, p = 0.382). Interestingly higher than expected prescribing was found for older non-statin cholesterol-lowering agents (n = 4, aOR = 1.55, 95% CI = 1.04–2.32, p = 0.0312). A search for outcomes in this sample revealed ten studies linking poor quality of care and possible effects on mortality in specialist settings. In half of the studies there was significantly higher mortality in those with mental ill health compared with controls but there was inadequate data to confirm a causative link. Nevertheless, indirect evidence supports the observation that deficits in quality of care are contributing to higher than expected mortality in those with severe mental illness (SMI) and schizophrenia. The quality of medical treatment provided to those with cardiac conditions and comorbid schizophrenia is often suboptimal and may be linked with avoidable excess mortality. Every effort should be made to deliver high-quality medical care to people with severe mental illness.

How does a history of psychiatric hospital care influence access to coronary care: a cohort study

“…Our results concerning coronary mortality, hospitalisations and revascularisation procedures are in line with those reported from studies examining total populations of persons with specific severe mental disorders1 9 13 14 and our results replicate especially the low hospital admission rates and revascularisation rates among persons with psychosis in relation to need indicated by excess coronary mortality 16. Some studies have reported no differences in hospitalisations or revascularisations, but these studies have been based on clinical coronary populations and not total populations of persons with severe mental disorders,30–32 whereas our study covered the total population of persons with mental disorders severe enough to require hospitalisation.…”

Coronary artery disease in adults with schizophrenia: Anatomy, treatment and outcomes

“…Due to limitations of our dataset, we could not determine the "appropriateness" of the use of revascularization in any of our patients, but this treatment difference persisted after adjusting for differences in coronary anatomy. Some have suggested that this treatment disparity, and lack of access to appropriate treatment of CVD more broadly, may be a contributing factor to the premature mortality seen among those with schizophrenia [22,23]. Our findings do not support this.…”

Inequalities in Lung Cancer Care of Elderly Patients With Schizophrenia

“…Inequalities in disease management for individuals with mental illnesses have been reported in the literature and range from suboptimal preventative medical care (29) to poor quality management of chronic diseases and surgical interventions (30, 31). In a meta-analysis of cardiovascular disease management, patients with severe mental illnesses were less likely to receive appropriate prescriptions for cardiovascular disease or to undergo basic cardiac procedures (31). Similarly, another study showed that individuals with mental illnesses received substandard diabetic care and had more diabetic complications(30).…”