Ratcliffe, T., Dabin, S., and Barker, P. (2011). Clinical governance: An international journal, 16(1), 20-28.
Patients with mental illness are at increased risk for major medical comorbidities compared to the general population –in particular, they have higher rates of heart disease and are twice as likely to die from heart disease. The disproportionate rates of heart disease in people with mental illness may be attributed to an increased prevalence of cardiac risk factors –smoking, obesity, hypertension, and dyslipidemia. However, despite increased cardiovascular risk in this population, screening for cardiac risk factors is often not done. From reviews of primary care records, blood pressure and serum cholesterol were less likely to be recorded in charts of schizophrenic patients compared to those of the general population.
Although providing healthcare for people with mental illness can be a challenge, healthcare professionals have a mandate to address physical health issues including screening for cardiac disease. This study, based in the United Kingdom, discusses the use of an audit tool that may be used in one’s practice to assess the adequacy of screening for cardiac disease in patients with mental illness.
The audit tool was developed by the Public Health Department (Coventry Teaching Primary Care Trust) and based on the National Institute of Health and Clinical Excellence’s best practices; in patients with bipolar disorder or schizophrenia, the 2006 guidelines recommended annual review of thyroid function, blood glucose, lipid profile for patients 40 years old and older, blood pressure, weight and height, and tobacco and alcohol use. Two general practices from Coventry, United Kingdom were chosen for their similar sized mental health practices with over 90% of the patients having bipolar disorder or schizophrenia. General practices in England and Wales are required to maintain and provide a register of people with schizophrenia, bipolar disorder, or other psychoses as part of their quality and outcomes framework. Moreover, practices must report the percentage of patients with a review completed in the last fifteen months.
In total, 128 patients were audited -62 bipolar or schizophrenic patients from practice A and 66 patients from practice B. Patients were identified from each practices’ mental health register and their electronic records were audited according to the audit criteria (blood pressure, body mass index, smoking history, alcohol use, lipid profile, and blood glucose recorded in the last 15 months). With regards to methodology, patients’ diagnoses and whether or not each audit criteria was fulfilled were recorded. Patient information was recorded using a reference number and no patient identifiable data were recorded. Data analysis consisted of determining the percentage of patients by diagnosis and practice that fulfilled each audit criteria. A Chi-Square test was used to determine p-values.
According to the results, of the two practices audited, both had the same proportion of patients with schizophrenia or bipolar disorder but practice A statistically outperformed practice B across all of the following audit criteria –smoking history (100% versus 85%, p=0.01), alcohol use (100% versus 6%, p=0.001), blood pressure (81% versus 59%, p=0.05), and body mass index 69% versus 41%, p=0.01). There was no difference by mental health diagnosis. Recording of blood glucose and lipid profile were not statistically significant between the practices (occurred in 50% or less of patients) but were statistically by mental health diagnosis –those with schizophrenia were more likely to be screened for diabetes than those with bipolar disorder. The authors attributed the outperformance of practice A to the physicians having a greater interest in mental & cardiovascular health or providing higher quality medical care than practice B. Patients, perhaps, may also have different health seeking behaviours between the practices.
In summary, this study highlights the gap between standards of practice and actual practice in the care of patients with mental illness. Although the study did not address the factors that contributed to the care gaps between and within each practice, did not assess whether the care gaps extended to patients without mental illness, and did not explore strategies to address resolution of the care gaps, the findings more importantly highlight the need for each of us to question and assess the quality of our own practices to ensure that our patients with mental illness are receiving adequate evidence based preventative health care. Although a yearly chart audit based on evidence based criteria for annual health screening is an important part of any health care professional’s practice and professional development, we acknowledge that certain factors may make this difficult. The practices in the study had mental health registers and electronic medical records in place, facilitating patient identification, selection, and chart review. General practices without a larger mental health patient population and which still utilize paper records may have a more difficulty implementing a chart audit. The authors recommend for healthcare organizations and primary care practices to work together to develop criteria for annual health screening and a framework for evaluating practice.