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Quality of Medical Care and Excess Mortality in Older Patients With Mental Disorders
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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