Morbidity burden and community-based palliative care are associated with rates of hospital use by people with schizophrenia in the last year of life: A population-based matched cohort study.

Glenn Arendts,Katrina Spilsbury,Kate Brameld,Lorna Rosenwax,Brian Kelly

doi:10.1371/journal.pone.0208220

Abstract

ObjectivePeople with schizophrenia face an increased risk of premature death from chronic diseases and injury. This study describes the trajectory of acute care health service use in the last year of life for people with schizophrenia and how this varied with receipt of community-based specialist palliative care and morbidity burden.MethodA population-based retrospective matched cohort study of people who died from 01/01/2009 to 31/12/2013 with and without schizophrenia in Western Australia. Hospital inpatient, emergency department, death and community-based care data collections were linked at the person level. Rates of emergency department presentations and hospital admissions over the last year of life were estimated.ResultsOf the 63508 decedents, 1196 (1.9%) had a lifetime history of schizophrenia. After adjusting for confounders and averaging over the last year of life there was no difference in the overall rate of ED presentation between decedents with schizophrenia and the matched cohort (HR 1.09; 95%CI 0.99–1.19). However, amongst the subset of decedents with cancer, choking or intentional self-harm recorded on their death certificate, those with schizophrenia presented to ED more often. Males with schizophrenia had the highest rates of emergency department use in the last year of life. Rates of hospital admission for decedents with schizophrenia were on average half (HR 0.53, 95%CI 0.44–0.65) that of the matched cohort although this varied by cause of death. Of all decedents with cancer, 27.5% of people with schizophrenia accessed community-based specialist palliative care compared to 40.4% of the matched cohort (p<0.001). Rates of hospital admissions for decedents with schizophrenia increased 50% (95% CI: 10%-110%) when enrolled in specialist palliative care.ConclusionIn the last year of life, people with schizophrenia were less likely to be admitted to hospital and access community-based speciality palliative care, but more likely to attend emergency departments if male. Community-based specialist palliative care was associated with increased rates of hospital admissions.

Highlights

The average life expectancy of people living with schizophrenia in developed countries is around 20 years less than the general population [1, 2] this varies by age of schizophrenia onset and gender. [3] This has been mostly attributed to premature death from cardiovascular disease, respiratory diseases, cancers and injury [4]
Amongst the subset of decedents with cancer, choking or intentional self-harm recorded on their death certificate, those with schizophrenia presented to emergency department (ED) more often
In the last year of life, people with schizophrenia were less likely to be admitted to hospital and access community-based speciality palliative care, but more likely to attend emergency departments if male

Summary

Introduction

The average life expectancy of people living with schizophrenia in developed countries is around 20 years less than the general population [1, 2] this varies by age of schizophrenia onset and gender. [3] This has been mostly attributed to premature death from cardiovascular disease, respiratory diseases, cancers and injury [4]. [12] A study from the United States reports that having any pre-existing psychiatric illness was associated with less acute care hospitalisations and intensive care but higher rates of ED presentations in the last 30 days of life and a greater likelihood of dying in a nursing home. The aim of this study was to describe the trajectory of acute care health service use in the last year of life for people with schizophrenia and how this varied with morbidity burden, cause of death and access to community-based specialist palliative and non-palliative care. We hypothesised that people with schizophrenia would show low rates of community-based specialist palliative care in the last year of life, but that barriers to accessing acute care health services would be reduced in those who did

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Conclusion