Inequalities in the provision of cardiovascular screening to people with severe mental illnesses in primary care: Cohort study in the United Kingdom THIN Primary Care Database 2000–2007

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Abstract

Background

People with severe mental illnesses (SMI), including schizophrenia, are at increased risk of cardiovascular disease (CVD). Guidelines recommend regular CVD screening and in the United Kingdom, since 2004, General Practitioners are remunerated for annual reviews.

Objectives

To compare annual rates of CVD screening provision in people with and without SMI between 2000 and 2008.

Method

We identified 18,696 people with SMI and 95,512 people without SMI in the UK The Health Improvement Network (THIN) primary care database. We compared the rates of measurement of blood pressure (BP), glucose, cholesterol and body mass index (BMI).

Results

Prior to 2004, all people with SMI, were significantly less likely to receive each measurement, (including people above and below 60 years of age). In 2003; adjusted incidence rate ratios (95% CI) for screening in people with SMI under 60 years compared to people without SMI were: BMI: 0.62 (0.58–0.65); BP: 0.59 (0.56–0.62); glucose: 0.66 (0.61–0.70) and cholesterol: 0.54 (0.49–0.59). By 2007 people with SMI under 60 were equally likely receive a measurement of BMI: 1.00 (0.96–1.04), glucose: 1.00 (0.96–1.05) and cholesterol: 0.95 (0.90–1.0); the gap in screening for BP had narrowed 0.87 (0.83–0.90). However people with SMI over 60 years of age remained significantly less likely to be screened. There was little difference in screening according to social deprivation.

Conclusions

In UK primary care, people with SMI over 60 years of age remain less likely than the general population to receive annual CVD screening despite higher risk of developing CVD.

Introduction

People with severe mental illnesses (SMI) such as schizophrenia and bipolar disorder die early from cardiovascular disease including myocardial infarction and stroke (Osborn et al., 2007a, Osborn et al., 2007b, Tiihonen et al., 2009). There are several reasons for this including high rates of smoking and obesity, poor diet and lack of exercise (Osborn et al., 2006, Osborn et al., 2007a, Osborn et al., 2007b). Antipsychotic and other psychiatric medications may increase weight and cause abnormalities in the regulation of serum glucose and lipids (Marder et al., 2004). The National Institute for Health and Clinical Excellence, 2006, National Institute for Health and Clinical Excellence, 2009 in England recommends that people with SMI have regular reviews of their physical health, with a focus on cardiovascular screening. International guidelines recommend that everyone prescribed antipsychotic medications should have regular measurement of cardiovascular risk factors including glucose, lipids and body mass index (Marder et al., 2004, Citrome and Yeomans, 2005).

There is a consensus that the physical health care of people with SMI is primarily the responsibility of primary care services (National Institute for Health and Clinical Excellence, 2006, National Institute for Health and Clinical Excellence, 2009). In the United Kingdom, the care of people with SMI is included in the General Medical Services GP contract (NHS Employers, 2005). This includes a Quality and Outcomes Framework (QOF), whereby practices receive remuneration for keeping a register of people who have a diagnosis of SMI and for offering them an annual review. The precise contents of this annual review are not specified under QOF. The indicators state that age-appropriate health promotion and prevention advice should be given during the review. Therefore, although best practice would include cardiovascular risk assessment, this is not part of the current national contract. A national consultation is currently underway, and there are proposals to specifically include CVD risk factor screening in QOF from 2011. There is small-scale evidence that CVD care and screening may be inferior in people with SMI. People with SMI are less likely to receive appropriate pharmacological interventions once they have developed coronary heart disease (Hippisley-Cox et al., 2007). They may also be less likely to be screened for cardiovascular risk factors before they develop CVD. A study of 195 people with schizophrenia from 22 UK General Practices revealed that people with SMI were significantly less likely to receive screening for all cardiovascular risk factors (Roberts et al., 2007). We do not know whether the introduction of QOF has improved cardiovascular screening in SMI or whether there is a need to more actively promote or incentivise CVD risk screening in this group.

We aimed to explore national inequalities in the provision of cardiovascular screening to people with SMI in a large representative sample of patients in primary care and to assess whether provision of screening had improved over time and since the introduction of QOF in 2004.

A secondary aim was to determine whether any inequalities in CVD screening for people with SMI were associated with social deprivation. We hypothesized that the competing demands of working with deprived populations would make it more difficult to meet standards of physical health care for people with SMI.

Section snippets

Study design

Retrospective cohort study.

Setting/population

Adults in the United Kingdom registered with a practice contributing to the primary care database The Health Improvement Network (THIN) during the Jan 2000–Dec 2007 period.

Data source

THIN provides anonymized clinical data from 420 general practices in England, Scotland, Wales and Northern Ireland. The database includes around 6 million patients and is a powerful resource for epidemiological and health services research. Since most people with SMI are registered with primary care,

Sample

We identified 18,696 people with SMI and 95,512 comparison patients without an SMI diagnosis. The characteristics of the two cohorts are described in Table 1. The mean follow-up was 5.7 years for people with SMI and 6.9 years for people without SMI. The majority of the SMI cohort had a diagnosis of schizophrenia, bipolar disorder or schizo-affective disorder.

The unadjusted screening results can be viewed graphically in Fig. 1, Fig. 2, Fig. 3, Fig. 4, and the proportions screened for each risk

Discussion

There has been a yearly increase in the proportion of people with SMI who receive cardiovascular screening over the last decade in UK primary care. Since the introduction of financial incentives for GPs in the Quality and Outcomes Framework (QOF) policy in 2004 there has been an increase in recording of glucose, BMI, cholesterol and Blood pressure for people with SMI. Before 2004, there were marked inequalities and people with SMI were half as likely to be screened for CVD risk factors,

Role of funding source

GB was funded by the UCLH/UCL Comprehensive Biomedical Research Centre. The funder had no role in the study design, data extraction, analysis or interpretation of the data, in the writing of the report or the decision to submit the paper for publication.

Contributors

DO, IN, IP, RR, and KW designed the study. HL wrote the analysis plan, extracted and cleaned the data. GB performed the data analysis, with input and data interpretation from all authors. DO and GB wrote the first draft of the manuscript and all authors commented extensively and approved the final draft.

Conflict of interest

All authors confirm that they have no conflicts of interest that could influence the work in this manuscript.

Acknowledgements

None.

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