The quality of mental health care delivered to patients with schizophrenia and related disorders in the Italian mental health system. The QUADIM project: a multi-regional Italian investigation based on healthcare utilisation databases.

Antonio Lora,Alessio Saponaro,Teresa Di Fiandra,Liliana Allevi,Salvatore Scondotto,Andrea Gaddini,Simona Carbone,Barbara D'Avanzo,Angelo Barbato,Flavia Carle,Giovanni Corrao,Matteo Monzio Compagnoni,Melania Leogrande,Valeria D Tozzi,Lucia Ferrara

doi:10.1017/s2045796022000014

Abstract

To evaluate the quality of mental health care delivered to patients with schizophrenia and related disorders taken-in-care by mental health services in four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily). Thirty-one clinical indicators concerning accessibility, appropriateness, continuity and safety were defined and estimated using healthcare utilisation (HCU) databases, containing data on mental health treatments, hospital admissions, outpatient interventions, lab tests and drug prescriptions. A total of 70 586 prevalent patients with schizophrenia and related disorders treated in 2015 were identified, of whom 1752 were newly taken-in-care by the facilities of regional mental health services. For most patients community care was accessible and moderately intensive. However, care pathways were not implemented based on a structured assessment and only half of the patients received psychosocial treatments. One patient out of ten had access to psychological interventions and psychoeducation. Activities specifically addressed to families involved a third of prevalent patients and less than half of new patients. One patient out of six was admitted to a community residential facility, and one out of ten to a General Hospital Psychiatric Ward (GHPW); higher values were identified in new cases. In general hospitals, few patients had a length of stay (LoS) of more than 30 days, while one-fifth of the admissions were followed by readmission within 30 days of discharge. For two-thirds of patients, continuity of community care was met, and six times out of ten a discharge from a GHPW was followed by an outpatient contact within 2 weeks. For cases newly taken-in-care, the continuity of community care was uncommon, while the readiness of outpatient contacts after discharge was slightly more frequent. Most of the patients received antipsychotic medication, but their adherence to long-term treatment was low. Antipsychotic polytherapy was frequent and the control of metabolic side effects was poor. The variability between regions was high and consistent in all the quality domains. The Italian mental health system could be improved by increasing the accessibility to psychosocial interventions, improving the quality of care for newly taken-in-care patients, focusing on somatic health and mortality, and reducing regional variability. Clinical indicators demonstrate the strengths and weaknesses of the mental health system in these regions, and, as HCU databases, they could be useful tools in the routine assessment of mental healthcare quality at regional and national levels.

Highlights

The 1978 Italian reform of psychiatric services initiated the closure of psychiatric hospitals encouraging the development of a widespread and complex network of community mental health facilities (Lora, 2009; Lora et al, 2012)
It should be stressed that, because healthcare utilisation (HCU) data are used for reimbursing public and accredited service providers, incorrect and incomplete reports lead to legal consequences. This system of clinical indicators could be a useful tool for evaluating the quality of health care in a community-oriented mental health system, such as the Italian one, in an automated and standardised way
Because this system is completely based on a minimum set of HCU data already available in each Italian region, it could be implemented for rapid and periodical evaluations

Summary

Introduction

The 1978 Italian reform of psychiatric services initiated the closure of psychiatric hospitals encouraging the development of a widespread and complex network of community mental health facilities (Lora, 2009; Lora et al, 2012). In recent years, many countries significantly invested in community-based mental health care, the Italian community model was implemented earlier than in the rest of the world, and relevant efforts were made to move away from the institutional model. Two Italian National Health Plans made the same recommendations for implementing and managing mental health facilities all over the country. As the regions were responsible for managing the transition, there is wide variability across regions in the amount of resources devoted to community-based psychiatric care, and the range of services provided still is a cause of concern (Ferrannini et al, 2014). In line with available evidence and best practice, clinical indicators for (i) measuring quality of care sub-dimensions, (ii) allowing benchmarking, (iii) establishing priorities for quality improvement and (iv) supporting accountability in mental health care (Lora et al, 2017) have been developed (Mainz, 2003; Lauriks et al, 2012; Samartzis and Talias, 2019)

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