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Benjamin G. Druss, MD, MPH; W. David Bradford, PhD; Robert A. Rosenheck, MD; Martha J. Radford, MD; Harlan M. Krumholz, MD

Arch Gen Psychiatry. 2001;58:565-572.

Background  This study investigated whether differences in quality of medical care might explain a portion of the excess mortality associated with mental disorders in the year after myocardial infarction.

Methods  This study examined a national cohort of 88 241 Medicare patients 65 years and older who were hospitalized for clinically confirmed acute myocardial infarction. Proportional hazard models compared the association between mental disorders and mortality before and after adjusting 5 established quality indicators: reperfusion, aspirin, ß-blockers, angiotensin-converting enzyme inhibitors, and smoking cessation counseling. All models adjusted for eligibility for each procedure, demographic characteristics, cardiac risk factors and history, admission characteristics, left ventricular function, hospital characteristics, and regional factors.

Results  After adjusting for the potential confounding factors, presence of any mental disorder was associated with a 19% increase in 1-year risk of mortality (hazard ratios [HR], 1.19; 95% confidence interval [CI], 1.04-1.36). After adding the 5 quality measures to the model, the association was no longer significant (HR, 1.10; 95% CI, 0.96-1.26). Similarly, while schizophrenia (HR, 1.34; 95% CI, 1.01-1.67) and major affective disorders (HR, 1.11; 95% CI, 1.02-1.20) were each initially associated with increased mortality, after adding the quality variables, neither schizophrenia (HR, 1.23; 95% CI, 0.86-1.60) nor major affective disorder (HR, 1.05; 95% CI, 0.87-1.23) remained a significant predictor.

Conclusions  Deficits in quality of medical care seemed to explain a substantial portion of the excess mortality experienced by patients with mental disorders after myocardial infarction. The study suggests the potential importance of improving these patients' medical care as a step toward reducing their excess mortality.

From the Departments of Psychiatry (Dr Druss and Rosenheck) and Epidemiology and Public Health (Drs Druss, Rosenheck, and Krumholz), Yale University School of Medicine, VA Northeast Program Evaluation Center and the VA-Connecticut Mental Illness Research, Education and Clinical Center (Drs Druss and Rosenheck), Yale-New Haven Hospital Center for Outcomes Research and Evaluation (Drs Radford and Krumholz), and the Section of Cardiovascular Medicine, Department of Medicine, Yale University (Drs Radford and Krumholz), New Haven, Conn; the Center for Health Care Research, Medical University of South Carolina, Charleston (Dr Bradford); and Qualidigm, Middletown, Conn (Drs Radford and Krumholz).

Corresponding author: Benjamin G. Druss, MD, MPH, 950 Campbell Ave/116A, West Haven, CT 06516 (e-mail: benjamin.druss{at}yale.edu).

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