Quality Of Schizophrenia Care Research Articles

Quality of care and clinical outcomes of chronic obstructive pulmonary disease in patients with schizophrenia. A Danish nationwide study.

To examine the association between schizophrenia and the quality of care and clinical outcomes of chronic obstructive pulmonary disease (COPD). A Danish nationwide population-based cohort study using comprehensive information from Danish registries between 2008 and 2013. Public Danish hospitals. 72 692 COPD patients with hospital contacts including 621 with schizophrenia. COPD care. The quality of COPD care was defined as meeting guideline-recommended process performance measures of care. Potential predictors of COPD care among patients with schizophrenia included patient- (sex, age, alcohol or drug abuse, Global Assessment of Functioning score, duration of schizophrenia), provider- (quality of schizophrenia care), and system-related factors (contact-volume defined as hospital department and clinics' annual average contact volume of COPD patients). Clinical outcomes included 30-day all-cause readmission and 30-day all-cause mortality risk following an admission for exacerbation of COPD. Compared to COPD patients without schizophrenia, COPD patients with schizophrenia had a lower chance of receiving treatment with long-acting muscarinic antagonists (LAMA) or long-acting β2-agonists (LABA) (Relative risk (RR) 0.92, 95% CI: 0.87-0.98). Female sex was associated with a higher chance of receiving LAMA/LABA treatment among COPD patients with schizophrenia. COPD patients with schizophrenia had a higher risk of 30-day mortality (adjusted odds ratio (OR) 1.27, 95% CI: 1.01-1.59) but not a higher risk of readmission compared with COPD patients without schizophrenia. COPD patients with schizophrenia had a slightly lower chance of receiving LAMA/LABA treatment, but a substantially increased risk of death following admission for an exacerbation compared with patients without schizophrenia.

Quality and Predictors of Diabetes Care Among Patients With Schizophrenia: A Danish Nationwide Study.

Patients with schizophrenia have a high prevalence of diabetes, but data on diabetes care quality for these patients are limited. This nationwide study compared the quality of diabetes care among individuals with and without schizophrenia and identified predictors of care quality. In a population-based cohort study, 83,813 individuals with diabetes seen at hospital outpatient clinics between 2005 and 2013, including 669 with comorbid schizophrenia, were identified from Danish registries. High-quality diabetes care was defined as having received ≥80% of guideline-recommended process performance measures. Variables assessed as predictors of diabetes care included patient-specific (sex, age, smoking, substance abuse, Global Assessment of Functioning score, and duration of schizophrenia), provider-specific (quality of schizophrenia care), and system-specific (annual patient contact volume of the diabetes clinic) factors. Compared with individuals with diabetes only, those with diabetes and schizophrenia were less likely to receive high-quality diabetes care (relative risk [RR]=.91, 95% confidence interval [CI]=.88-.95) and less likely to receive several individual process performance measures of diabetes care, including blood pressure monitoring (RR=.98, CI=.96-.99), treatment with antihypertensive drugs (RR=.83, CI=.70-.97) and angiotensin-converting enzyme/angiotensin II receptor inhibitors (RR=.72, CI=.55-.93), screening for albuminuria (RR=.96, CI=.93-.99), eye examination at least once every second year (RR=.97, CI=.94-.99), and foot examination (RR=.96, CI=.93-.99). Predictors of poor diabetes care among individuals with schizophrenia included documented drug abuse and low contact volume of the diabetes clinic. Individuals with schizophrenia received lower-quality diabetes care compared with those without schizophrenia. However, absolute differences in care were modest.

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.

Disparities in Quality of Care among Publicly Insured Adults with Schizophrenia in Four Large U.S. States, 2002–2008

To examine racial/ethnic disparities in quality of schizophrenia care and assess the size of observed disparities across states and over time. Medicaid claims data from CA, FL, NY, and NC. Observational repeated cross-sectional panel cohort study of white, black, and Latino fee-for-service adult beneficiaries with schizophrenia. Main outcome was the relationship of race/ethnicity and year with a composite measure of quality of schizophrenia care derived from 14 evidence-based quality indicators. Quality was assessed for 325,373 twelve-month person-episodes between 2002 and 2008, corresponding to 123,496 Medicaid beneficiaries. In 2002, quality was lowest for blacks in all states. With the exception of FL, quality was lower for Latinos than whites. In CA, blacks had about 43 percent of the individual indicators met compared to 58 percent for whites. Quality improved annually for all groups in CA, NY, and NC. While in CA the improvement was slightly larger for Latinos, in FL quality improved for blacks but declined for Latinos and whites. Quality of schizophrenia care is poor and racial/ethnic disparities exist among Medicaid beneficiaries from four states. The size of the disparities varied across the states, and most of the initial disparities were unchanged by 2008.

Schizophrenia quality indicators for integrated care - results from a feasibility study

Background/Objectives: There is currently a variety of initiatives to improve the quality of care for schizophrenia, but there is no established core set of quality indicators. In 2009, Weinmann and Becker published a set of indicators for the quality monitoring of schizophrenia care. This set contains 12 structural indicators (S1–12) and 22 quality indicators (Q1–12). This study aims to evaluate the feasibility of these indicators.

P03-253 - Schizophrenia quality indicators for integrated care - results from a feasibility study

Introduction/objectivesThere is currently a variety of initiatives to improve the quality of care for schizophrenia, but there is no established core set of quality indicators in schizophrenia. In 2009, Weinmann and Becker published a set of indicators for quality monitoring of schizophrenia care. This study aims to evaluate the feasibility of these indicators.MethodsAdult schizophrenic patients insured by the Federal Association of Local Health Insurance Funds (AOK) were recruited in two large psychiatric hospitals. Participants were evaluated using PANSS, CGI, Camberwell Assessment of Need-European Version (CAN-EU) and the Verona Service Satisfaction Scale (VSSS) at discharge and after six month. Furthermore, 18-month AOK administrative data was available for all patients included. Feasibility of structural and quality indicators described by Weinmann and Becker (2009) will be tested by applying the full set of indicators.Results82 patients with a mean age of 40 and an average GAF score of 44.3 were included. We were able to calculate all indicators. Outpatient data was available with a delay of over six month. Patients had on average 1.6 additional psychiatric diagnoses (S1) and a mean length of stay of 44 days (S6). 67% of the patients were satisfied with the treatment received (Q17). 25% of the patients were re-admitted to an inpatient psychiatric care within 30 days after discharge.ConclusionsThe usage of Quality Indicators seems to be feasible in routine care. However, delay in the availability of outpatient data has to be considered if these indicators are implemented.

The SIEP-DIRECT's Project on the discrepancy between routine practice and evidence in the treatment of schizophrenia. The design, the indicators, and the methodology of the study

The aims of the SIEP-DIRECT'S Project (DIscrepancy between Routine practice and Evidence in psychiatric Community Treatments on Schizophrenia) are: (1) To evaluate the appropriateness of the NICE guidelines for schizophrenia in Italian Departments of Mental Health; (2) to develop and to test a set of SIEP indicators, based on the NICE recommendations, useful to evaluate their real application in mental health services. Based on the NICE recommendations, 103 indicators have been developed, some of them qualitative and the rest quantitative. These indicators investigate five different areas: 14 indicators concern the common elements in all phases of mental health care; 11 the treatment of first episode; 24 the crisis treatment; 41 the recovery promotion; 13 the urgency, including management of violent behaviours and fast soothing. After a pilot study conducted in 2 community mental health services, the indicators were tested in 19 Italian Departments of Mental Health, to obtain a self-evaluation of the quality of care and to verify the application of NICE recommendations in the clinical routine of these Services. Data for the self-evaluation have been obtained from the DSM's psychiatric informative system and from the Direction of the local health authorities or of the DSM. Moreover, for some indicators, information has been gathered from the clinical records, and by means of questionnaires administered to a sample of patients and relatives. Finally, "multidisciplinary" (i.e., involving different types of professionals) or "specialized" (i.e., involving only psychiatrists) focus groups have assessed the degree of similarity between practice and recommendation for 33 indicators. Finally, the focus group methodology has been applied in all services with the aim to judge the appropriateness of each NICE recommendation in the context of the Italian Departments of Mental Health. Most NICE recommendations have been considered useful and appropriated to measure quality of care in the context of the Italian services. The SIEP indicators have been easily used by the services participating in the DIRECT'S Project. The self-evaluation process has provided several data of great relevance to improve the quality of care for schizophrenia and implement clinical guidelines in Italy.

Process measures for the assessment and improvement of quality of care for schizophrenia.

The development of process measures for the assessment and improvement of care for schizophrenia is at an early stage. As part of a national inventory of mental health quality measures, we identified 42 process measures developed to assess the quality of schizophrenia care. A greater proportion of measures assessed pharmacotherapy than assessed psychosocial interventions or other clinical processes, such as assessment, continuity, or coordination. Twenty-five measures (60%) were based on research evidence linking measure conformance with improved patient outcomes, while 17 (40%) were based on clinical consensus or opinion. Only 12 measures (29%) were fully operationalized. Few were tested for validity or reliability. A number of demonstration projects currently under way should expand the pool of well-developed and tested measures. Further research and consensus development will be needed to identify common measurement priorities, reduce the data collection burden, enhance the interpretability of results, and allow for comparisons of clinical practice across facilities and health care systems.

Performance measurement for schizophrenia: adherence to guidelines for antipsychotic dose.

This report describes the development, application, and exploratory evaluation of a clinical performance measure based on recently published schizophrenia guidelines for antipsychotic dose. The performance measure, which assesses adherence to antipsychotic dose recommendations for acute schizophrenia treatment, was calculated at hospital discharge for 116 patients with schizophrenia who had participated in a 6-month outcomes study. The Brief Psychiatric Rating Scale (BPRS) was used to assess symptom severity at 6-month followup. At discharge, almost one-half of the patients were prescribed doses outside the recommended range. For the entire sample, linear regression models showed that the performance measure variable was not significantly associated with followup symptom severity (BPRS total scores). However, a significant association was observed for patients prescribed oral antipsychotics only (n = 69). Patients prescribed recommended doses had lower adjusted mean BPRS totals than patients prescribed doses either greater than (P < 0.05) or less than (P < 0.05) recommended. Our findings suggest that the antipsychotic dose performance measure may be useful for monitoring quality. It assesses a modifiable aspect of care for which clinical improvement is needed, and such improvement is likely to improve patient outcomes. Future research is needed to confirm our findings and to develop and test interventions to improve the quality of care for schizophrenia that incorporate this clinical performance measure.

Patient, provider, and treatment factors associated with poor-quality care for schizophrenia.

Interventions are needed to improve the quality of care for schizophrenia. However, in designing these interventions it would be helpful to understand better which patients are at highest risk for poor-quality care and why care for this disorder is often of poor quality. We study the extent to which patient and treatment factors are associated with poor-quality care in 224 patients randomly sampled from two mental health clinics. Quality of medication management is evaluated using an established method based on national treatment recommendations. Multivariate regression is used to study the effect of patient and treatment factors on treatment quality, controlling for provider. Risk for poor-quality care was greater for patients who were more severely ill, older, and less compliant with treatment recommendations. There were trends toward poor management of symptoms in men and substance abusers, and poor management of side effects in Black patients. Provision of poor-quality care was associated with failure to document symptoms and side effects in the medical record. Interventions to improve care for schizophrenia should attend to the need for accurate clinical assessment and strategies for managing challenging clinical situations.

Quality of public sector care for schizophrenia in Arkansas.

Using process-of-care indicators, we examined the quality of care provided to 139 individuals receiving treatment for schizophrenia in public sector systems. Longitudinal data on services use and medication management were abstracted from medical records. Medication adherence data were obtained by self- and informant reports. Overall, 39% of participants had less than monthly contact with community-based service (CBS) providers. When participants in day treatment or partial hospitalization programs were excluded, less than monthly CBS contact increased to 70%. Of participants, 40%-60% were prescribed medications outside guideline-recommended dose ranges. Up to half of participants reported taking half or less of prescribed antipsychotics. The adverse impact on patient outcomes of these practice patterns is well established. Public sector organizations face powerful challenges to the behavioral changes needed to sustain best practice care. Overcoming these challenges to assure high-quality care for schizophrenia will require tremendous creativity and commitment.

Editor's Introduction: Special Section on Quality of Care and Schizophrenia

There's good news and bad news from the field of schizophrenia quality-of-care research. The good news is that the field is now born. The bad news is that it's still very much in its infancy and its initial findings point to serious deficiencies in the care of persons with this disorder. This issue presents a sampling of studies reflecting the current state of schizophrenia quality-of-care research. Certainly concerns about the quality of care afforded persons with schizophrenia are not new. What has changed recently is the advent of standards against which to judge the quality of schizophrenia care and the growing expectation that quality be an essential feature of the care provided to these patients. We seem to have entered an era of renewed hope in the treatment of persons with schizophrenia. This era is being shaped by at least three forces. First, recent and on-going advances in the neurosciences are yielding a better understanding of how the brain functions and are offering many new opportunities to design treatments for psychosis and other disorders of the brain. These scientific advances have instilled renewed interest and hope for treatment of patients who have lived with disability for many years and have spurred a new activism in efforts to intervene early with patients at the beginnings of this disorder to try to avert disabilities. The most visible manifestations of these new treatment efforts are the new antipsychotic agents, but with them has come renewed interest in psychosocial programs that enable patients to take adventege of the clinical gains made with new medication. A second phenomenon contributing to this 1Center for Mental Health Policy, Vanderbilt University, Nashville, Tennessee. 2Correspondence should be directed to Anthony F. Lehman, M.D.,