A Johns Hopkins study of more than 1,700 patients with
schizophrenia hospitalized for medical or surgical care
unrelated to their mental disorder shows they are at least
twice as likely as similar patients without schizophrenia to
suffer dangerous and expensive adverse events. The adverse
events are associated with poor outcomes, including
death.
The researchers concluded that decreased quality of
care given to patients with schizophrenia might put them at
higher risk for serious infections and other
complications.
A report on the findings appears in the March issue of
the Archives of General Psychiatry.
"The results of our study suggest that having
schizophrenia may be a previously unrecognized or
underappreciated contributor to higher likelihood of
complications and death for patients admitted to a medical
or surgical hospital service," said Gail L. Daumit, an
assistant professor of medicine at the
School of Medicine and first author of the report. The
primary diagnoses in these cases were conditions that
required immediate medical or surgical care.
The Johns Hopkins team, composed of investigators from
the schools of Medicine and
Public Health, evaluated patients discharged from
Maryland acute care hospitals following medical or surgical
treatment in 2001 and 2002. The patients included 1,746 who
had schizophrenia and 732,210 who did not.
Using a set of standard patient safety indicators, or
PSIs, developed by the Agency for Healthcare Research and
Quality, the team found that patients with schizophrenia
were two-and-one-half times more likely than
nonschizophrenics to have hospital-associated infections,
two times more likely to have postoperative respiratory
failure or postoperative deep vein blood clots and two times
more likely to suffer post-operative sepsis (overwhelming
infections throughout the body caused by toxin-producing
bacteria) than patients without schizophrenia.
In addition, patients with schizophrenia who had
respiratory failure or sepsis were twice as likely as those
without respiratory failure or sepsis to be admitted to the
intensive care unit and to die.
The team also found that the median length of hospital
stay for patients with schizophrenia and adverse events was
at least 10 days longer than the stay of schizophrenics
without adverse events, and median hospital charges were at
least $20,000 greater in hospitalizations with adverse
events.
"Much of this increased risk could be due to variation
of quality of care," said Peter Pronovost, the medical
director of the Center for Innovation in Quality Patient
Care and a professor in the
Department of Anesthesiology/Critical Care Medicine at
Johns Hopkins.
Daumit said, "We already were aware that individuals
with schizophrenia have a high risk of premature mortality,
but it wasn't clear until now whether complications during
hospitalization were a contributing factor."
Previous studies by others suggest that health care
professionals might minimize or misinterpret the medical
symptoms of people with schizophrenia and delay diagnosis
and treatment of conditions requiring attention, Daumit
said. This is especially likely if these patients are
hallucinating, behaving aggressively or communicating
poorly.
Other factors contributing to poor outcomes may include
improper use of restraints, excessive medication dosages and
interactions of drugs used to control schizophrenia symptoms
with other medications, Daumit noted. Such drug errors can
cause oversedation, which in turn could cause respiratory
problems, such as pneumonia, she said.
Provonost said that "further research is needed to
evaluate the extent to which having schizophrenia increases
the risk for complications and death, and whether they are
preventable and responsive to interventions to improve
quality of care." He explained that more information about
health care provider and system level factors such as
communication between medical specialties and the
availability of consultation-liaison psychiatric services
would be important to target future quality improvement
efforts.
PSIs are designed to help hospitals identify situations
that might require further study. AHRQ is part of the U.S.
Department of Health and Human Services.
Other authors of the study from the School of Medicine
are Daniel E. Ford, vice dean and professor, and Christopher
B. Anthony, a research assistant, both in the Department of
Medicine. Authors from the School of Public Health are
Donald M. Steinwachs, professor in Health Policy and
Management, and Eliseo Guallar, associate professor in
Epidemiology. This work was supported by the National
Institute of Mental Health.