Department of Liaison Psychiatry, Leicester General Hospital, Leicester, UK.
J Psychopharmacol. 2010 Nov;24(4 Suppl):69-80. doi: 10.1177/1359786810382056.
We have previously documented inequalities in the quality of medical care provided to those with mental ill health but the implications for mortality are unclear. We aimed to test whether disparities in medical treatment of cardiovascular conditions, specifically receipt of medical procedures and receipt of prescribed medication, are linked with elevated rates of mortality in people with schizophrenia and severe mental illness. We undertook a systematic review of studies that examined medical procedures and a pooled analysis of prescribed medication in those with and without comorbid mental illness, focusing on those which recruited individuals with schizophrenia and measured mortality as an outcome. From 17 studies of treatment adequacy in cardiovascular conditions, eight examined cardiac procedures and nine examined adequacy of prescribed cardiac medication. Six of eight studies examining the adequacy of cardiac procedures found lower than average provision of medical care and two studies found no difference. Meta-analytic pooling of nine medication studies showed lower than average rates of prescribing evident for the following individual classes of medication; angiotensin converting enzyme inhibitors (n = 6, aOR = 0.779, 95% CI = 0.638-0.950, p = 0.0137), beta-blockers (n = 9, aOR = 0.844, 95% CI = 0.690-1.03, p = 0.1036) and statins (n = 5, aOR = 0.604, 95% CI = 0.408-0.89, p = 0.0117). No inequality was evident for aspirin (n = 7, aOR = 0.986, 95% CI = 0.7955-1.02, p = 0.382). Interestingly higher than expected prescribing was found for older non-statin cholesterol-lowering agents (n = 4, aOR = 1.55, 95% CI = 1.04-2.32, p = 0.0312). A search for outcomes in this sample revealed ten studies linking poor quality of care and possible effects on mortality in specialist settings. In half of the studies there was significantly higher mortality in those with mental ill health compared with controls but there was inadequate data to confirm a causative link. Nevertheless, indirect evidence supports the observation that deficits in quality of care are contributing to higher than expected mortality in those with severe mental illness (SMI) and schizophrenia. The quality of medical treatment provided to those with cardiac conditions and comorbid schizophrenia is often suboptimal and may be linked with avoidable excess mortality. Every effort should be made to deliver high-quality medical care to people with severe mental illness.
我们之前已经记录了精神健康状况不佳的人群在医疗服务质量方面的不平等现象，但对死亡率的影响尚不清楚。我们旨在检验心血管疾病治疗方面的医疗差异（具体表现为接受医疗程序和处方药物的情况）是否与精神分裂症和严重精神疾病患者的死亡率升高有关。我们进行了一项系统综述，研究了合并精神疾病患者和无合并精神疾病患者的医疗程序，并对处方药物进行了汇总分析，重点是招募精神分裂症患者并将死亡率作为研究结果的研究。在 17 项心血管疾病治疗充分性的研究中，有 8 项研究了心脏手术，9 项研究了心脏药物的使用是否充分。在研究心脏手术充分性的 8 项研究中，有 6 项发现医疗服务的提供低于平均水平，有 2 项研究没有发现差异。对 9 项药物研究进行的荟萃分析显示，以下几类药物的处方率明显低于平均水平：血管紧张素转换酶抑制剂（n = 6，比值比[aOR] = 0.779，95%置信区间[CI] = 0.638-0.950，p = 0.0137）、β受体阻滞剂（n = 9，aOR = 0.844，95% CI = 0.690-1.03，p = 0.1036）和他汀类药物（n = 5，aOR = 0.604，95% CI = 0.408-0.89，p = 0.0117）。阿司匹林（n = 7，aOR = 0.986，95% CI = 0.7955-1.02，p = 0.382）的不平等现象并不明显。有趣的是，对于较老的非他汀类降胆固醇药物，发现的处方量高于预期（n = 4，aOR = 1.55，95% CI = 1.04-2.32，p = 0.0312）。在这个样本中搜索结果发现，有 10 项研究将护理质量差与专业环境下的死亡风险联系起来。在一半的研究中，与对照组相比，患有精神疾病的患者的死亡率明显更高，但没有足够的数据来证实因果关系。尽管如此，间接证据支持这样的观察结果，即严重精神疾病（SMI）和精神分裂症患者的护理质量缺陷正在导致高于预期的死亡率。那些患有心脏疾病和合并精神分裂症的人的医疗待遇往往不尽如人意，可能与可避免的超额死亡有关。应该尽一切努力为严重精神疾病患者提供高质量的医疗服务。
