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Feature Story

Fewer than half of schizophrenia patients get proper treatment

Fewer than half of the patients under treatment for schizophrenia, a serious brain disorder, are receiving proper doses of antipsychotic medications or appropriate psychosocial interventions. This finding is from a national study on schizophrenia, funded by the Agency for Health Care Policy and Research (contract 290-92-0054) and the National Institute of Mental Health (NIMH), and published recently in NIMH's Schizophrenia Bulletin. The study identified gaps in effective care for people with schizophrenia and opportunities for improvement in all aspects of treatment.

Appropriate medication is the cornerstone to treating the illness, but medication alone is not enough, according to Anthony F. Lehman, M.D., principal investigator of the Schizophrenia Patient Outcomes Research Team (PORT) project. The most effective approach integrates appropriate medication management with psychosocial treatments. Dr. Lehman is Director of the Center for Mental Health Services Research at the University of Maryland School of Medicine.

Schizophrenia may be the most disabling of all mental illnesses. The symptoms, which can be devastating to the individual and his or her family and friends, impair a persons ability to make decisions, manage emotions, interact with others, and think clearly. The symptoms commonly include hallucinations, delusions, confused thinking, and blunted or altered emotions or senses. It is not a multiple-personality disorder, as is often thought. Typically, schizophrenia has an early onset (usually between the ages of 16 and 30). Up to 2 million people are treated for the illness each year, and up to 100,000 patients with schizophrenia are in public mental health hospitals on any given day.

The study's new evidence-based analysis is intended to inform health professionals of more effective medical approaches to treatment of patients suffering from schizophrenia. The 5-year scientific study found that the key to improving outcomes for patients is adoption of a comprehensive and individualized strategy—combining proper doses of appropriate medications, patient and family education and support, and for high-risk patients, assertive community treatment.

The researchers analyzed published research on schizophrenia and assessed the quality of evidence for schizophrenia treatment. Then, to better understand how to improve care, they studied how this evidence compares with current clinical practice. Their study evaluated care of schizophrenic patients in outpatient and inpatient settings in both urban and rural settings. The overall rates at which patients treatments conformed to the study recommendations were generally below 50 percent. An exception was the rate of prescription for antipsychotic medications, which was found to be around 90 percent, although not always at an appropriate dosage. Other findings include:

  • Younger patients are more likely than older patients to be offered psychotherapy and vocational rehabilitation. Minority patients are more likely than others to be on higher doses of antipsychotic medications and less likely to be prescribed an antidepressant when depressed.
  • Psychosocial treatments are often prescribed at the point of hospital discharge but follow-through in the community is low. Failure to offer these treatments for outpatients may be a serious problem in ongoing community-based care.
  • Psychosocial treatment varies in conformance rates based on location. Patients in some States are more likely than those in other States to be prescribed a vocational intervention and less likely to be prescribed a family intervention or psychotherapy.

The complete PORT findings are published in the Schizophrenia Bulletin 24(1), 1998. Reprints of "At issue: Translating research into practice: The Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations," pp. 1-10 (AHCPR Publication No. 98-R036) and "Patterns of usual care for schizophrenia: Initial results from the Schizophrenia Patient Outcomes Research Team (PORT) client survey," pp. 11-20 (AHCPR Publication No. 98-R037) are available from the AHCPR Publications Clearinghouse.

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Smoking Cessation

Physicians counseling can help patients quit smoking

One in four adults in the United States is a smoker. Smokers who are briefly counseled by their doctor to quit smoking and offered nicotine replacement therapy (either nicotine gum or patch) are more likely to quit smoking than patients who are not counseled. But physicians often don't ask patients if they smoke or counsel them to quit smoking if they do, according to a recent study supported in part by the Agency for Health Care Policy and Research (HS07892).

Boston researchers analyzed 1991 to 1995 data from the National Ambulatory Medical Care Survey (NAMCS) to assess recent national patterns in routine outpatient care of smokers. The NAMCS is an ongoing annual survey that U.S. office-based physicians complete during each patient's visit. The data showed that physicians' treatment of smokers improved little in the first half of the 1990s. The exception was a transient peak in counseling and nicotine replacement use in 1993, a year after the introduction of the transdermal nicotine patch.

Physicians asked patients if they smoked at 67 percent of all visits in 1991, and this proportion did not increase over time. Smoking counseling by physicians increased from 16 percent of smokers' visits in 1991 to 29 percent in 1993, and then decreased to 21 percent of smokers visits in 1995. Nicotine replacement therapy followed a similar pattern, increasing from 0.4 percent of smokers' visits in 1991 to 2.2 percent in 1993, and decreasing to 1.3 percent of smokers' visits in 1995.

There was a nearly six-fold variation in physicians' smoking counseling practices depending on the reason for the patients visit. Physicians were more likely to address smoking behavior if the patient's presenting problem was caused or exacerbated by smoking or if the patient had a chronic smoking-related illness. But smoking cessation guidelines released in 1996 by AHCPR recommend that smoking should be addressed even when patients are seen for problems unrelated to smoking. In addition, national health promotion objectives for the year 2000 call for increasing to 75 percent the proportion of primary care providers who routinely advise smoking cessation and provide assistance to patients who smoke. The study's authors recommend routine assessment of patient smoking status as if it were a vital sign.

See "National patterns in the treatment of smokers by physicians," by Anne N. Thorndike, M.D., Nancy A. Rigotti, M.D., Randall S. Stafford, M.D., Ph.D., and Daniel E. Singer, M.D., in the February 25, 1998, Journal of the American Medical Association 279(8), pp. 604-608.

More intensive smoking cessation efforts by clinicians could greatly increase the number of smokers who quit each year

Each year, less than 5 percent of smokers successfully quit. About 1.7 million more smokers would quit each year if physicians would advise each of their patients who smoked to quit, according to a study supported by the Agency for Health Care Policy and Research (contract 290-95-2002). Physicians should implement the recommendations of the AHCPR-sponsored 1996 Smoking Cessation Clinical Practice Guideline to screen all patients for smoking status during routine office visits or hospitalizations and advise those who smoke to quit.

The guideline recommends 15 smoking cessation interventions that clinicians can use. These range from minimal counseling with no nicotine replacement—such as nicotine gum or nicotine patch—to intensive counseling by a smoking cessation specialist in combination with nicotine replacement. The researchers developed cost-effectiveness models which assumed that these interventions would be provided to 75 percent of U.S. smokers 18 years of age and older (the proportion of current U.S. smokers who have made a previous attempt to quit smoking). Analysis showed that the guideline would cost $6.3 billion (about $32 per person) to implement in its first year. In return, society could expect to gain 1.7 million new quitters, about 60 percent of whom would quit as a result of counseling and use of the nicotine patch.

This is at an average cost of $3,779 per quitter, $2,587 per life-year saved, and $1,915 for every quality-adjusted life year (QALY) saved. Costs per QALY saved ranged from $1,108 to $4,542. More intensive interventions conducted by smoking cessation specialists, along with the aid of nicotine gum or the nicotine patch, were the most cost effective. The average baseline "no intervention" quit rate was 8.8 percent versus 10.7 percent for minimal counseling, 12.1 percent for brief counseling, and 18.7 percent for full counseling lasting more than 10 minutes, all excluding nicotine replacement. The baseline and intervention quit rates for intensive counseling (4 to 7 sessions) were 10.4 percent and 22.6 percent, respectively. Smokers who used the nicotine patch or gum along with counseling were more likely to quit than those who received counseling alone (2.1 to 2.6 and 1.4 to 1.6 times, respectively).

See "Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation," by Jerry Cromwell, Ph.D., William J. Bartosch, M.P.A., Michael C. Fiore, M.D., M.P.H., and others, in the December 3, 1997 Journal of the American Medical Association 278(21), pp. 1759-1766.

Editor's note: Copies of the following smoking cessation guideline documents are available from AHCPR Publication Clearinghouse:

Copies of the full guideline document, Smoking Cessation: Clinical Practice Guideline No. 18, may be purchased from the Government Printing Office (S/N 017-026-00159-0; $6.00 per copy).

People who quit smoking are much less likely to be hospitalized than those who continue to smoke

A recent study funded by the Agency for Health Care Policy and Research shows that people who give up smoking are no more likely to be hospitalized than persons who never smoked. The finding is from the largest and most comprehensive study to date on how people's biomedical risk factors influence their likelihood of someday needing costly inpatient care.

AHCPR sponsored the development of a clinical practice guideline for clinicians, released in 1996, that recommends proven treatments to help patients stop smoking. The Agency later released data showing smoking cessation to be extremely cost effective when compared with other routine interventions. For example, at an average cost of $2,600 per year of life saved, smoking cessation treatment costs nearly 40 times less than treatment to reduce cholesterol levels.

The Rutgers University-led study also found that men who smoke are one-third more likely to be hospitalized than those who do not smoke. Middle-aged women who smoke also have a greater probability of hospitalization than their nonsmoking counterparts but to a lesser degree than male smokers.

Based on calculations of the maximum proportion of hospitalizations that could be attributed to a specific risk factor, the researchers estimate that if smoking were eliminated among middle-aged men, hospital admissions for all men aged 45 to 64 would decline by as much as 12.5 percent. According to AHCPR intramural researchers, a decline of this proportion in the 1995 hospital admissions of all men in this age group would have amounted to about $5.4 billion in savings. AHCPR's estimate is based on data from its Healthcare Cost and Utilization Project.

The researchers used data collected over a 16-year period—from 1971 to 1987—on a nationally representative sample of nearly 6,500 men and women participating in the National Health and Nutrition Examination Survey I of the National Center for Health Statistics. At the start of the survey, each subject underwent a physical examination, laboratory tests, and a medical interview to collect baseline data. Each participant was at least 45 years of age at the start of the survey. The participants' hospital admission and other health outcomes data were collected periodically thereafter.

The study also looked at the influence on hospital admission of other biomedical factors. Among the chronic diseases the researchers found to significantly increase the probability of inpatient care were arthritis, bronchitis and other lung conditions, diabetes, and ulcers. Actual risk rates varied according to age group and sex. The study also found that having elevated serum cholesterol did not increase the risk of hospitalization, and having higher levels of serum albumin—which has been shown to be associated with a lower risk of death—actually reduced the likelihood of hospital care.

According to the authors, the findings make it possible for researchers to not only examine the relation between risk factors and hospitalization, but also to estimate the impact on hospital admission rates of risk-reduction interventions, such as smoking cessation.

The study is from a research project led by Rutgers University's Louise B. Russell, Ph.D. The other authors are with Rutgers, the Robert Wood Johnson Medical School of the University of Medicine and Dentistry of New Jersey, and Harvard Medical School.

Details are in "Biomedical risk factors for hospital admission in older adults," by Jane E. Miller, Ph.D., Dr. Russell, Diane M. Davis, B.A., and others, in the March 1998 issue of Medical Care, 36(3), pp. 411-421.

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Health Care Delivery

Specialists see more privately insured patients than HMO patients

Specialists tend to see a smaller proportion of HMO patients than non-HMO patients, with about 45 percent of non-HMO and a third of HMO patients seeing specialists in 1992. However, the HMO patients specialists do see, usually have been seen before for the same problem. On the other hand, non-HMO patients who refer themselves to specialists are typically prescribed fewer medications, have fewer chronic diseases, and thus are less sick than HMO patients referred by their primary care doctor. This suggests a more selective, problem-oriented role for specialists in the HMO system, conclude Carolyn M. Clancy, M.D., of the Agency for Health Care Policy and Research, and Peter Franks, M.D., of the University of Rochester.

The researchers analyzed 1985 to 1992 data from the National Ambulatory Care Survey to examine the associations of patient and physician demographics and HMO insurance status with use of primary and specialty care. Analysis showed that self-referring patients were more likely to be older, white, and to have private insurance and less apt to be covered by Medicaid or to be self-payers. In the non-HMO group, black race, self-pay status, and Medicaid coverage were associated with a reduced likelihood of seeing a specialist (odds ratios of 0.67, 0.81, and 0.51, respectively; equal odds is 1). These disparities were not significant in the HMO group and may reflect increased access to care for HMO patients.

During a period when the majority of HMOs used explicit incentives to restrict direct access to specialists (gatekeeping and higher coinsurance for direct access to specialists), these results offer some assurance that HMO patients are less likely to have lower use of specialists solely on the basis of their race or insurance status compared with non-HMO patients, conclude the researchers. They point out that as competition between health plans and apparent dissatisfaction with gatekeepers increases, pressures mount to expand direct access to specialists. And, as a greater number of Medicaid patients are required to join HMOs, increased vigilance will be needed to keep socioeconomic disparities in check.

See "Utilization of specialty and primary care: The impact of HMO insurance and patient-related factors," by Drs. Clancy and Franks, in the December 1997 Journal of Family Practice 45(6), pp. 500-508. Reprints (AHCPR Publication No. 98-R016) are available from the AHCPR Publications Clearinghouse.

Organized system of care may improve management of diabetes and other chronic diseases

The care of patients with chronic diseases, especially diabetes mellitus, has been less than ideal, according to many experts. This study, which is a direct outgrowth of an earlier AHCPR-funded study (HS 08091), concludes that a new model of care holds promise to improve care substantially, not only for diabetes, but for all chronic diseases. The current study was funded by the Centers for Disease Control and Prevention.

The IDEAL care model uses clinic leadership to establish clinic-wide diabetes care guidelines, a trained quality improvement team, and step-by-step procedures that must be followed by all clinic staff. Individualized patient management plans include prescriptions for medications, diet, and exercise; psychosocial assessment and support; patient education about diabetes and its care; social support; followup information about tests and consultations; monitoring; and encouragement of patients in the self-management of their condition.

Essentially, the system requires physicians to make use of every office visit by patients with diabetes, explains principal investigator Leif I. Solberg, M.D., of Group Health Foundation/Health Partners. Physicians use the visit to check on patient progress with the management plan; involve family members and friends in the management plan as appropriate; and offer patients the option of periodic group visits (mini-clinics). Group visits combine clinician followup with group support meetings, educational presentations, and individualized care with other health professionals, such as a dietitian or podiatrist.

The IDEAL model was prepilot-tested at several primary care clinics under contract to a large managed care organization. Mean glycosylated hemoglobin (HbA1c values) of diabetic patients at time 0, 12, and 18 months decreased from 8.9 percent to 8.4 percent and then to 7.9 percent in the study clinic, whereas they remained at 8.9 percent, 8.9 percent, and 8.8 percent in a similar nonintervention clinic used for comparison. Higher HbA1c values represent higher blood sugar levels and more uncontrolled diabetes which, in turn, increases the risk for serious complications over time. The care model is currently being tested in an ongoing community trial of 13 primary care clinics, with the goal of reducing by 10 percent the mean HbA1c level of all diabetes patients within an 18-month period.

For more details, see "Using continuous quality improvement to improve diabetes care in populations: The IDEAL Model," by Dr. Solberg, Laurel A. Reger, M.B.A., Teresa L. Pearson, C.D.E, and others, in the November 1997 Joint Commission Journal on Quality Improvement 23(11), pp. 581-592.

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