Laura E. Jones

Medical Comorbidity in Women and Men with Schizophrenia: A Population-Based Controlled Study

AbstractBACKGROUND: Persons with persistent mental illness are at risk for failure to receive medical services. In order to deliver appropriate preventive and primary care for this population, it is important to determine which chronic medical conditions are most common. OBJECTIVE: We examined chronic medical comorbidity in persons with schizophrenia using validated methodologies. DESIGN: Retrospective analysis of longitudinal administrative claims data from Wellmark Blue Cross/Blue Shield of Iowa. PARTICIPANTS: Subjects with schizophrenia or schizoaffective disorder (N=1,074), and controls (N=726,262) who filed at least 1 claim for medical services, 1996 to 2001. MEASUREMENTS: Case subjects had schizophrenia as the most clinically predominant psychotic disorder, based on psychiatric hospitalization, psychiatrist diagnoses, and outpatient care. Controls had no claims for any psychiatric comorbidity. Using a modified version of the Elixhauser Comorbidity Index, inpatient and outpatient claims were used to determine the prevalence of 46 common medical conditions. Odds ratios (ORs) were adjusted for age, gender, residence, and nonmental health care utilization using logistic regression. RESULTS: Subjects with schizophrenia were significantly more likely to have 1 or more chronic conditions compared with controls. Adjusted OR (95% confidence interval [CI]) were 2.62 (2.09 to 3.28) for hypothyrodisim, 1.88 (1.51 to 2.32) for chronic obstructive pulmonary disease, 2.11 (1.36 to 3.28) for diabetes with complications, 7.54 (3.55 to 15.99) for hepatitis C, 4.21 (3.25 to 5.44) for fluid/electrolyte disorders, and 2.77 (2.23 to 3.44) for nicotine abuse/dependence. CONCLUSIONS: Schizophrenia is associated with substantial chronic medical burden. Familiarity with conditions affecting persons with schizophrenia may assist programs aimed at providing medical care for the mentally ill.

Medical comorbidity in women and men with bipolar disorders: a population-based controlled study.

Objective: Rarely has validated information on chronic medical comorbidity been presented for persons with bipolar disorder. To deliver appropriate health services, it is important to understand the prevalence of chronic medical conditions in this population. This study examines chronic medical comorbidity using validated methodology in persons with bipolar disorder. Methods: This is a retrospective study of a 100% sample of administrative claims (1996–2001) from Wellmark Blue Cross Blue Shield. Three thousand five hundred fifty-seven subjects had bipolar I disorder and did not have claims for schizophrenia or schizoaffective disorder. Controls had no documented claims for psychiatric conditions. Using validated methodology, inpatient and outpatient claims were used to determine prevalence of 44 chronic medical conditions. Odds ratios (ORs) were adjusted for age, gender, residence, and nonmental healthcare utilization. Results: Persons with bipolar disorder were young (mean age, 38.8 years) and significantly more likely to have medical comorbidity, including three or more chronic conditions (41% versus 12%, p < .001) compared with controls. Elevated ORs were found for conditions spanning all organ systems. Hyperlipidemia, lymphoma, and metastatic cancer were the only conditions less likely to occur in persons with bipolar disorder. Conclusion: Bipolar disorders are associated with substantial chronic medical burden. Familiarity with conditions affecting this population may assist in programs aimed at providing medical care for the chronically mentally ill. AIDS = acquired immunodeficiency syndrome; HIV = human immunodeficiency virus; ICD-9 = International Classification of Diseases, Ninth Revision; AOR = adjusted odds ratio; OR = odds ratio; CI = confidence interval; BC/BS = BlueCross BlueShield.

Receipt of diabetes services by insured adults with and without claims for mental disorders.

Objectives: We sought to determine whether receipt of the American Diabetes Associations recommended clinical services was similar among insured subjects with and without mental disorders during the period of 1996 to 2001. Research Design: Our study was a retrospective analysis of Blue Cross/Blue Shield of Iowa administrative claims data, 1996-2001. Subjects: We studied 26,020 adults with diabetes; 6,627 (25%) had a coexisting mental disorder. Measures: Service receipt included hemoglobin A1c (HbA 1 c ) testing, dilated eye examination, cholesterol measurement, and urine protein testing. We used Cox regression to calculate hazard ratios (HRs) for service receipt after adjusting for demographic, disease, and utilization factors. Results: Mental disorder subjects were more likely to be younger, women, urban residents, have diabetes complications and comorbidity, and to have increased healthcare utilization. Although they received more services (mean, 2.6) than subjects without mental disorders (mean, 2.3), they were less likely to have received a HbA 1 c test (HR 0.92; 99.9% confidence interval [CI] 0.87-0.97) and a cholesterol measurement (HR 0.92; 99.9% CI 0.86-0.98). Receipt of a dilated eye examination (HR 0.96; 99.9% CI 0.89-1.04) and urine protein test (HR 0.98; 99.9% CI 0.92-1.04) was similar. Service receipt varied by specific mental disorder categorization. Few subjects (< 6%) strictly adhered to the guidelines of the American Diabetes Association. Conclusions: Receipt of clinical preventive services for both populations was suboptimal. Importantly, subjects with mental disorders were more likely to have diabetic complications, even when controlling for utilization of healthcare services, possibly because of poorer receipt of HbA 1 c testing. Persons with mental disorders should be more aggressively educated about blood sugar control, given the high rate of complications in this population. Medical care directed at persons with comorbid medical and psychiatric disorders may be beneficial.

Relationship Between Depression and Pancreatic Cancer in the General Population

Objective Prior research suggesting a relationship between pancreatic cancer and depression conducted on clinical populations has been subject to recall bias. We reexamined this association using longitudinal population-based data. Methods This was a retrospective cohort study using longitudinal insurance claims data. Results Men with mental disorders were more likely to develop pancreatic cancer than those without psychiatric claims (odds ratio 2.4, confidence interval 1.15–4.78). Depression more commonly preceded pancreatic cancer than it did other gastrointestinal malignancies (odds ratio 4.6, confidence interval 1.07–19.4) or all other cancers (odds ratio 4.1, confidence interval 1.05–16.0). Conclusions Depression and pancreatic cancer are associated in the general population.

Mental disorders and revascularization procedures in a commercially insured sample.

Objective: The objective of this study was to determine if receipt of revascularization was similar among commercially insured adults with mental disorders compared with people without mental disorders. Methods: This was a retrospective analysis of a 100% sample of Blue Cross/Blue Shield of Iowa administrative claims data, 1996 to 2001. Logistic regression was used to calculate unadjusted and adjusted odds ratios (OR) for receipt of angioplasty (PTCA) and bypass graft surgery (CABG) within 30 days of discharge. Results: A total of 3368 adults, aged 18 to 64 years, were hospitalized for myocardial infarction (MI) and 40% (n = 1342) had a mental disorder. Subjects with mental disorders were more likely to be younger, female, urban residents, and to have increased cardiovascular and medical comorbidity. They were similarly likely as subjects without mental disorders to have received PTCA (OR, 1.10; 95% confidence interval [CI], 0.95–1.29) and CABG (OR, 0.89; 95% CI, 0.71–1.11) in analyses adjusted for demographic and clinical characteristics. Revascularization rates did not differ by mental disorder type, with few exceptions. Conclusions: Receipt of revascularization was similar for patients with and without mental disorders. Our results may differ from previous findings as a result of the younger population studied and increased comorbidity in people with mental disorders, which may have resulted in a contraindication for surgical intervention. Conversely, the increased burden of comorbidity could suggest that these patients should have received PTCA at higher rates because of the better prognosis associated with revascularization as compared with medical management. Prospective analyses with review of clinical data and behavioral risk factors are necessary to determine why some patients with mental illness may be less likely to receive cardiac interventions. MI = myocardial infarction; CVD = cardiovascular disease; MHD = mental health disorders; PTCA = percutaneous transluminal coronary angioplasty; CABG = coronary artery bypass graft surgery; CPT = Common Procedural Terminology; ICD = International Classification of Diseases; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; OR = odds ratio; COPD = chronic obstructive pulmonary disease; CI = confidence interval.

Occurrence of cancer among people with mental health claims in an insured population

Objective: The objective of this research is to determine whether people with mental disorders are at increased risk for the subsequent development of malignancies compared with people without mental disorders. Methods: This is a retrospective cohort study of administrative claims data. The study population included 722,139 adults who filed at least one medical claim from 1989 to 1993. The mental disorder cohort included people with a) one psychiatric hospitalization, b) one outpatient psychiatrist visit, or c) two outpatient mental health claims occurring at least 6 months before a cancer claim. The controls were subjects filing claims for medical services who had no mental health visits. We calculated age-stratified odds ratios (ORs) for development of malignancy. Results: People with mental disorders were no more or less likely to develop a malignancy than those without after adjusting for age (women: OR, 1.03; 95% confidence interval [CI], 0.95–1.12; men: OR, 1.10; 95% CI, 0.97–1.24). People with mental disorders, however, developed cancer at younger ages and had increased odds of primary central nervous system tumors (women: OR, 2.12; 95% CI, 1.40–3.21; men: OR, 2.09; 95% CI, 1.22–3.59) and respiratory system cancers (women: OR, 1.57; 95% CI, 1.13–2.19; men: OR, 1.52; 95% CI, 1.09–2.12). Conclusions: Insured people with mental disorder claims had an increased risk of certain malignancies and developed malignancies at younger ages. The increased odds of respiratory tumors are likely secondary to increased rates of smoking among people with mental disorders and support use of smoking cessation interventions in this population. The increased odds for brain tumors may reflect only the early presence of mental symptoms, or a true association between the two conditions. Further study of these findings is mandated. SIR = standardized incidence ratio; OR = odds ratio; CI = confidence interval; ICD-9 = International Classification of Disease Volume 9; SEER = Surveillance Epidemiology and End Result.

Medical comorbidity in women and men with schizophrenia

AbstractBACKGROUND: Persons with persistent mental illness are at risk for failure to receive medical services. In order to deliver appropriate preventive and primary care for this population, it is important to determine which chronic medical conditions are most common. OBJECTIVE: We examined chronic medical comorbidity in persons with schizophrenia using validated methodologies. DESIGN: Retrospective analysis of longitudinal administrative claims data from Wellmark Blue Cross/Blue Shield of Iowa. PARTICIPANTS: Subjects with schizophrenia or schizoaffective disorder (N=1,074), and controls (N=726,262) who filed at least 1 claim for medical services, 1996 to 2001. MEASUREMENTS: Case subjects had schizophrenia as the most clinically predominant psychotic disorder, based on psychiatric hospitalization, psychiatrist diagnoses, and outpatient care. Controls had no claims for any psychiatric comorbidity. Using a modified version of the Elixhauser Comorbidity Index, inpatient and outpatient claims were used to determine the prevalence of 46 common medical conditions. Odds ratios (ORs) were adjusted for age, gender, residence, and nonmental health care utilization using logistic regression. RESULTS: Subjects with schizophrenia were significantly more likely to have 1 or more chronic conditions compared with controls. Adjusted OR (95% confidence interval [CI]) were 2.62 (2.09 to 3.28) for hypothyrodisim, 1.88 (1.51 to 2.32) for chronic obstructive pulmonary disease, 2.11 (1.36 to 3.28) for diabetes with complications, 7.54 (3.55 to 15.99) for hepatitis C, 4.21 (3.25 to 5.44) for fluid/electrolyte disorders, and 2.77 (2.23 to 3.44) for nicotine abuse/dependence. CONCLUSIONS: Schizophrenia is associated with substantial chronic medical burden. Familiarity with conditions affecting persons with schizophrenia may assist programs aimed at providing medical care for the mentally ill.

Increased Risk for Metabolic Syndrome in Persons Seeking Care for Mental Disorders

BACKGROUND An increased risk for metabolic syndrome has been described for persons with psychotic and mood disorders. Our objectives were to determine whether the odds for metabolic syndrome (MetSyn) were increased among insured adults with and without mental illness, and to determine whether this risk extends beyond psychotic and affective disorders. METHOD This was a retrospective analysis of a 100% sample of Blue Cross/Blue Shield of Iowa claims data. Three definitions of MetSyn were examined: 1) presence of any 3 or more components of MetSyn (obesity, hypertriglyceridemia, hypercholesterolemia, hypertension, and glucose intolerance/diabetes mellitus), 2) criteria #1 and/or claim for glucose intolerance/diabetes mellitus, and 3) criteria #1, criteria #2, and/or claim for obesity. ICD-9 codes were used to define obesity, hypertriglyceridemia, hypercholesterolemia, hypertension, and glucose intolerance/diabetes mellitus. Multivariate logistic regression was used to investigate the association between mental illness and MetSyn. RESULTS Prevalence of MetSyn for subjects with any mental illness as compared to those without was 4.9% vs. 2.0% (criteria #1), 8.1% vs. 4.2% (criteria #2), and 13.2% vs. 6.2% (criteria #3). MetSyn was more common (OR = 1.3-1.5) for subjects with any mental illness as compared to those without, regardless of which definition of MetSyn was used. Subjects with sexual disorders (OR = 1.7-1.8), sleep disorders (OR = 1.2-1.7), and mood disorders (OR = 1.3-1.6) had significantly higher odds of MetSyn compared to those without claims for mental disorders, regardless of which definition of MetSyn was used. CONCLUSIONS These results suggest that MetSyn is not only problematic among persons with psychosis and affective disorders, but that it also affects patients with other forms of mental illness. Clinicians should have a heightened awareness of metabolic risk factors, particularly when mental illness is present.

Beyond the Traditional Prognostic Indicators: The Impact of Primary Care Utilization on Cancer Survival

PURPOSE To our knowledge to date, the effect of primary care utilization on health outcomes in cancer patients has not been described. The objective of this study was to investigate the impact of primary care utilization within 6 months of cancer diagnosis on survival in patients with lung cancer. PATIENTS AND METHODS We used electronic medical record data (1997 to 2005) to identify male veterans with incident lung cancers (N = 323). Primary care utilization was assessed in the 6 months after cancer diagnosis. Patients were observed from cancer diagnosis to death or to last date of health care utilization (ie, censoring date). Univariate and multivariate Cox proportional hazards models tested whether primary care utilization was associated with improved survival. Multivariate analyses adjusted for demographic and clinical characteristics. RESULTS During an average follow-up of 16.6 months, 259 patients died. In multivariate analysis, the risk of death was 36% (hazard ratio [HR], 0.64; 95% CI, 0.45 to 0.90), 56% (HR, 0.44; 95% CI, 0.29 to 0.65), and 57% (HR, 0.43; 05% CI, 0.29 to 0.64) lower for patients who had one, two, or at least three primary care visits, respectively, in the first 6 months after cancer diagnosis as compared with those without primary care utilization. The median survival duration (P < .0001, log-rank test) was 3.68, 7.52, 13.88, and 13.75 months for patients with no, one, two, or at least three primary care visits, respectively. CONCLUSION Primary care utilization in the early phase of cancer treatment has a marked effect that results in a reduced mortality risk in patients with incident lung cancer. Additional research is required to determine how and why primary care utilization is an important prognostic indicator of prolonged survival in patients with lung cancer.

Primary care utilization patterns before and after lung cancer diagnosis

The objective of this study was to evaluate change in primary care utilization rates after lung cancer diagnosis in the Veterans Health Administration. We used electronic medical record data (1997-2005) to identify male veterans (n = 323) with incident lung cancers. Primary care utilization rates were assessed in the 12-month period before and after cancer diagnosis. Statistical analysis included paired t-tests. Rates of primary care utilization decreased by 0.02 visits per person-month (VPPM) in the 12-month period after cancer diagnosis (P > 0.05). Utilization for acute conditions decreased by 20% (P < 0.01) in the 12-month period after diagnosis, from 0.32 VPPM before diagnosis to 0.12 VPPM after diagnosis. Utilization for chronic conditions remained stable after diagnosis (0.29 VPPM vs. 0.29 VPPM, P > 0.05). Indications for primary care utilization after diagnosis were similar to indications for utilization prior to diagnosis. Common indications for utilization included hypertension and lower respiratory infections. We speculate that primary care utilization for acute conditions was lower after cancer diagnosis because several of the acute conditions (e.g. upper respiratory infection) treated prior to the cancer may have been harbingers of the cancer diagnosis. Additional research is required to illuminate how primary care can best be delivered during the initial phase of cancer treatment.