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To evaluate the quality of mental health care delivered to patients with schizophrenia and related disorders taken-in-care by mental health services in four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily).
Thirty-one clinical indicators concerning accessibility, appropriateness, continuity and safety were defined and estimated using healthcare utilisation (HCU) databases, containing data on mental health treatments, hospital admissions, outpatient interventions, lab tests and drug prescriptions.
A total of 70 586 prevalent patients with schizophrenia and related disorders treated in 2015 were identified, of whom 1752 were newly taken-in-care by the facilities of regional mental health services. For most patients community care was accessible and moderately intensive. However, care pathways were not implemented based on a structured assessment and only half of the patients received psychosocial treatments. One patient out of ten had access to psychological interventions and psychoeducation. Activities specifically addressed to families involved a third of prevalent patients and less than half of new patients. One patient out of six was admitted to a community residential facility, and one out of ten to a General Hospital Psychiatric Ward (GHPW); higher values were identified in new cases. In general hospitals, few patients had a length of stay (LoS) of more than 30 days, while one-fifth of the admissions were followed by readmission within 30 days of discharge. For two-thirds of patients, continuity of community care was met, and six times out of ten a discharge from a GHPW was followed by an outpatient contact within 2 weeks. For cases newly taken-in-care, the continuity of community care was uncommon, while the readiness of outpatient contacts after discharge was slightly more frequent. Most of the patients received antipsychotic medication, but their adherence to long-term treatment was low. Antipsychotic polytherapy was frequent and the control of metabolic side effects was poor. The variability between regions was high and consistent in all the quality domains.
The Italian mental health system could be improved by increasing the accessibility to psychosocial interventions, improving the quality of care for newly taken-in-care patients, focusing on somatic health and mortality, and reducing regional variability. Clinical indicators demonstrate the strengths and weaknesses of the mental health system in these regions, and, as HCU databases, they could be useful tools in the routine assessment of mental healthcare quality at regional and national levels.
One critical barrier to the uptake of mental health programmes is the so-called physical healthcare gap, a concern raised by the unattended physical comorbidity and early mortality of persons with severe mental illness.
To evaluate the extension of physical healthcare gap among persons with severe mental illness under chronic drug therapies.
A population-based cohort study was carried out, using Lombardy healthcare utilisation databases. Prevalent patients treated with blood pressure-, lipid- or glucose-lowering agents were identified in January 2017. Among these, those who were receiving care for depression, schizophrenia, bipolar disorder or personality disorder formed the study cohort. A reference cohort was randomly selected from prevalent patients treated with chronic therapies without signs of severe mental disorders, to be matched with study cohort members for gender, age and number of previous contacts with the National Health System. One-year adherence to healthcare was measured through the proportion of days covered (drug adherence), and exposure to selected recommendations (clinical control adherence).
The 55 162 patients with severe mental illness were less likely to have high adherence to blood pressure-lowering, lipid-lowering or antidiabetic agents than the reference cohort by −24% (95% CI −26 to −22%), −10% (95% CI −14 to −6%) and −25% (95% CI −29 to −21%), respectively. The 9250 patients with diabetes and severe mental illness had −18% (95% CI −22% to −13%) reduced likelihood to meet recommendations for the clinical management of diabetes, compared with the reference cohort.
Adherence to chronic drug therapies was sensibly worse among patients living with mental illness than those without signs of mental disorders.
Ageing is an important determinant of atherosclerosis development rate, mainly by the creation of a chronic low-grade inflammation. Diet, and particularly its fat content, modulates the inflammatory response in the fasting and postprandial states. Our aim was to study the effects of dietary fat on the expression of genes related to inflammation (NF-κB, monocyte chemoattractant protein 1 (MCP-1), TNF-α and IL-6) and plaque stability (matrix metalloproteinase 9, MMP-9) during the postprandial state of twenty healthy, elderly people who followed three diets for 3 weeks each: (1) Mediterranean diet (Med Diet) enriched in MUFA with virgin olive oil; (2) SFA-rich diet; and (3) low-fat, high-carbohydrate diet enriched in n-3 PUFA (CHO-PUFA diet) by a randomised crossover design. At the end of each period, after a 12-h fast, the subjects received a breakfast with a composition similar to the one when the dietary period ended. In the fasting state, the Med Diet consumption induced a lower gene expression of the p65 subunit of NF-κB compared with the SFA-rich diet (P = 0·019). The ingestion of the Med Diet induced a lower gene postprandial expression of p65 (P = 0·033), MCP-1 (P = 0·0229) and MMP-9 (P = 0·041) compared with the SFA-rich diet, and a lower gene postprandial expression of p65 (P = 0·027) and TNF-α (P = 0·047) compared with the CHO-PUFA diet. Direct plasma quantification mostly reproduced the findings. Our data suggest that consumption of a Med Diet reduces the postprandial inflammatory response in mononuclear cells compared with the SFA-rich and CHO-PUFA diets in elderly people. These findings may be partly responsible for the lower CVD risk found in populations with a high adherence to the Med Diet.
Objective — To evaluate psychopathological symptoms, disabilities and family burden in schizophrenic patients and to analyse predictors of family burden and relatives' satisfaction. Design — Descriptive study of 203 patients with an ICD 10 — F2 diagnosis (schizophrenia and related disorders) in contact with the Desio Department of Mental Health on 31st December 1994. Setting — The Desio Department of Mental Health. Main outcome measures — The patients have been evaluated in three areas: disability (by ADC-DAS), psychiatric symptoms (by 24 items BPRS) and family burden (by Family Problems questionnaire). The outpatient, hospital and residential care contacts of the patients have been collected for six months by our service information system. For each area (DAS, BPRS and FP) a principal component analysis and a rotation of the significant components have been performed. Eleven factors, derived from three scales, have been retained as explanatory variables. Finally, a multiple regression analysis has been performed to assess the influence of explanatory variables on the set of response variables regarding family burden and relatives' satisfaction. Results — One third of patients suffer of moderate-severe positive symptoms, while negative symptoms are less frequent.
Aims — Evaluation of community residential facilities effectiveness in the Department of Mental Health of Desio (Milan). Method — Outcomes in symptoms, disability, family burden and quality of life were evaluated during one year through a longitudinal study, using a pre—test and post test design without control group. Results — Residential care is effective in reducing disability and symptoms, while it is not effective towards family burden. Quality of life is improved in some domains, but not in others (e.g. social and family relationships). Conclusions — Outcome assessment is feasible in residential facilities, following a multiaxial and multifactorial model. We need to clarify the goals of residential care, focussing on active components of the residential treatment.
Declaration of Interest
the research project was funded by Department of Health of Regione Lombardia (DGR n. 37596 del 24.7.1998).
Objective – The analysis aims to study the packages of care in the public Departments of Mental Health by diagnosis and service utilisation intensity. Design – Data on community, hospital and residential contacts were provided by the Regional Psychiatric Information System. The sample has been composed by 55518 patients residents in Lombardy and treated in public Departments of Mental Health. Setting – The public Departments of Mental Health in Lombardy. Main outcome measures – Fifteen packages of care were defined according to researchers' experience; the package “community care only” has been divided in five sub–packages; for every package the care weight has been attached. Results – Four packages of care (“community care only”, “hospital care plus community care”, “hospital care only” “community care plus day centre care”) represented 95% of the patients. Three quarter of the patients were treated only in the community setting, without hospital, residential and day centre contacts in the year. Heavier patients (patients with more than 5000 care weight) represent only 4%. Residential care is the heavier setting (36% of the total weight), while schizophrenia is the diagnosis with mayor impact on the community services (59% of the total weight). Of the patients treated only in the community setting one third receives only psychological and psychiatric visits, while two thirds integrated community care. Conclusions in community care the mixed packages represent the exception not the rule. More complex or heavier packages are addressed to severe mental illness patients.
Objective – The analysis aims to identify the main patterns of Psychiatric Services provided by Local Health Unities in Lombardy. Setting – Data were collected by regional psychiatric information system in Lombardy in 1992 and 1993, concerning resources and activity. Design – We developed Cluster Analysis based on previously selected indicators of facilities, staff and activity. Multivariate analisys was performed in order to eliminate redundancy of information. Results – Five clusters corresponding to different patterns of psychiatric services were identified. In the first cluster services are particularly concerned with admissions (in private hospital, as well); other community activities can be considered quite dull both in composition of teams and variety of therapy. In the unities of the second cluster we pointed out low rates of community activities (mainly inside and hardly diversified) and admissions as well. The third cluster is distingueshed by an intensive community activity (both in quantity and variety) and turning to private sector for admissions, maybe because of a lack of rehabilitative facilities. Unities belonging to the fourth cluster have got many structures and a lot of staff dedicated to the hospital activity and to a intense (but little diversified) community activity. In the fifth cluster psychiatric services have got many rehabilitative facilities and community staff are well diversified; the considerable (but little diversified) community activity is carried outside. Conclusions – The community psychiatric services in Lombardy are not homogeneous and it is possible to identify five different and well definied patterns. The cluster analisys is useful to follow up the model, using information system data.
Objective - Assessment of the «duration» of interventions in community services, or rather, of the time between subsequent contacts in community psychiatric services in Lombardy in 1990. The Authors relate the «duration» either to the different professional positions and to some variables, like resources and activities, obtained by the Regional Psychiatric Information System. Design - Descriptive analysis of data stored in the computerized database of the Regional Psychiatric Information System. The «duration» has been calculated on the basis of the ratio between working hours delivered by community services and the number of contacts provided in 1990. After trimming the observations, the «duration» has been related to other variables such as structure, staff and activities. Setting - 52 Regional Psychiatric Unit in Lombardy whose catchment area includes 99 Local Sanitary Districts (USSL) for a total population of 7.600.000 inhabitants. Results - A strong variability of «duration» has come out in differents USSL and for different professional competences. The «duration» is reduced by the increase of patients admitted to the Service, by the number of interventions and by the number of rooms available in the Unit. On the other hand, considering the working hours as a variable, the relation is not linear. Conclusion - Even though this index doesn't concern the quality of interventions, it can represent an useful starting point to evaluate community services. The «duration» seems to be an useful quantitative index to delineate the efficiency of services or rather the capability to provide interventions, saving resources or to deliver as many interventions as possible with such resources.
Objective – The study of the relation between treatment costs and disability of psychiatric patient groups. Design – Perspective assessment of costs and disability of 1371 adult psychiatric patients in charge at two Operative Psychiatric Units (OPU), followed during an average period of 9 months. Data are related to all OPU's psychiatric services, including ambulatory, full or half-residential and psychiatric departments of acute hospital services. Setting — OPUs of Magenta (MI) and Desio (MI). Methods – The disability level has been measured by Health of the Nation Outcome Scales (HoNOS) filled in at the inclusion of the patient in the study and every three—months on average thereafter. Besides other HoNOSs have been filled in both at admission and discharge from psychiatric departments of acute hospitals, Residential Centres of psychiatric Therapies and Rehabilitation and Guarded Communities. All patients have been grouped using the main psychiatric diagnosis (first digit ICD—10) and the maximum disability level shown in the whole period of the study. Direct costs of publicly financed psychiatric services have only been considered. Their attribution to each patient has been made applying standard costs or tariffs (diagnostic procedures) to the data perspectively collected by the regional Register and a purposely designed protocol. Results – Total cost of 1371 patients has been 9771.1 million lire with a cost per patient of 7127000 lire (sd 19499000) and a cost per «day in charge» of 27172 lire (sd 68358). The cost per day has been found unrelated with the length of observed time frame. At the inclusion the mean level of disability has been 4.26 points (sd 3.73) and 3.19 points (sd 3.26) at the end of the study. Its value, measured at maximum level shown by each problem in the whole period of study, has been 6.00 points (sd 4.64). Disability and treatment cost of each patient did result directly related (r = 0.626, p = 0.0001). All patients have been grouped in 12 classes with a significant (p = 0,0001) overall difference on both their disability level and treatment cost. Conclusion – All adult psychiatric patients could be grouped in disability related classes which sometimes have also a different treatment cost. A study on a greater number of patients is needed to confirm these results. It may also provide a more reliable basis for a new financing system of psychiatric services.
Objective — The analysis aims to study patterns of care of patients in contact with 5 Psychiatric Services in Lombardy. Four patterns have been identified :long term-high users, non long term-high users, long term-non high users, non long term- non high users. Design — Data were provided by the regional Psychiatric Information System. The cohort of patients have been composed by 5,670 patients included in 1994 one year prevalence. Setting — Five Psychiatric Services (Merate, Treviglio, Crema, Desio, Castano Primo) with a total population of 610,184 inhabitants aged over 14. Main utilised measures — Some sociodemographic and clinical variables have been taken into consideration for a descriptive analysis; a multinomial logistic regression model was used to identify the characteristics of patients associated with different patterns. Results — Long term-high users were 5.3%, i.e. a mean rate of 4.9/10,000 residents over 14, and absorbed 60% of resources; the absence of a partner was associated in regression analysis with this pattern. Non long term-high users were 1.2%, i.e. a mean rate of 1.1/10,000 residents over 14, and absorbed 7.8% of resources; age below 45, unemployment, absence of a partner, severe mental illness and first contact with Psychiatric Services in the period 1985-1989 were predictive variables. Long term-non high users were 23.4%, i.e. a mean rate of 21.6/10,000 residents over 14, and absorbed 18.1% of resources; age below 45, unemployment, living alone, absence of a partner, severe mental illness and first contact with Psychiatric Services before 1990 were predictive variables. Non long term-non high users were 70.1%, i.e. a mean rate of 64.8/10,000 residents over 14 and, and absorbed 18.1% of resources. Conclusions — Data show that on the whole the activity of Psychiatric Services is addressed to most serious patients, though considerable differences between Psychiatric Services utilisation may be found. This study highlights the importance of a regional Psychiatric Information System, that allows the monitoring in time and in the regional territory of patterns of care.
Objective - The analysis aims to study trends, during the period of 1983-1993, of the most relevant variables concerning equipment, staff and activity of the Lombardy Region Psychiatric Services. Setting - The study used data from all services, both hospital and community, that depend on Psychiatric Units. Data regarding Psychiatric Hospitals were not included. Design - Data were provided by the Regional Psychiatric Information System, which since 1983 has regularly collected information on equipment, staff and services supplied by the Regional Psychiatric Unit. A graphic analysis with a description of trends and the interrelation of the time series has been carried out. Main outcome measures - The analysis uses two types of variables: resources and services variables related to other community psychiatric facilities. Indexes or rates are computed to study the relations between the two sets of variables. Results - We verified a remarkable upward trend in the level of activity (both hospital and community) not entirely explained by the increase in resources. In fact, the growth of psychiatric services is linked with higher productivity and a growing demand as well. We have also seen that the growth of community activity has been stronger than that concerning hospital variables. Thus, as far as we can assess from data (not including the private sector), the use of hospitalization in psychiatric activity has decreased in the last decade. Conclusions - The analysis highlights the importance of an Information System to describe changes in service organizations and to provide data for specific studies, such as outcome studies.
Aims — To describe the mental health system in Albania. Methods — Data were gathered in 2003 and in 2004 using a new WHO instrument, World Health Organization Assessment Instrument for Mental health Systems (WHO-AIMS), designed for collecting essential information on the mental health system of low and middle income countries. It consists of 6 domains, 28 facets and 156 items. Results — The information collected through WHO AIMS covered the key aspects of mental health system in Albania: the mental health policy and the legislative framework, the network of mental health services and the characteristics of the users, the role of the primary health care, the human resources, the public education and the links with other governmental sectors, monitoring and research. Conclusions — The data collection through WHO AIMS represented a needed step for a better in-depth knowledge of the system and for implementing actions to strengthen the system. Examples of planned actions were the improvement of the mental health component in primary care, a clear shift of resources from mental hospitals to community facilities, an increase of the outpatient care and an expansion of the mental health information system.
Aims – The treatment of schizophrenic disorders is the most important challenge for community care. The analysis focuses on packages of care provided to 23.602 patients with a ICD-10 diagnosis of schizophrenic disorder and treated in 2001 by the Departments of Mental Health in Lombardy, Italy. Methods – Packages of care refer to a mix of treatments provided to each patient during the year by different settings. Direct costs of the packages were calculated. Linear Discriminant Analysis has been used to link socio-demographic and diagnostic sub-groups of the patients to packages of care. Results – People with schizophrenic disorders received relatively few care packages: only four packages involved more than 5%. Two thirds of the patients received only care provided by Community Mental Health Centres. In the other two packages with a percentage over 5%, the activity was provided by CMHCs, jointly with General Hospitals or Day Care Facilities. Complex care packages were rare (only 6%). As well as the intensity, also the variety of care provided by CMHCs increased with the complexity of care packages. In Lombardy more than half of the resources were spent for schizophrenia. The range of the costs per package was very wide. LDA failed to link characteristics of the patients to packages of care. Conclusions – Care packages are useful tools to understand better how mental health system works, how resources have been spent and to point out problems in the quality of care.
Aims – The aims of the SIEP-DIRECT'S Project (DIscrepancy betweenRoutine practice andEvidence in psychiatricCommunityTreatments onSchizophrenia) are: 1) To evaluate the appropriateness of the NICE guidelines for schizophrenia in Italian Departments of Mental Health; 2) to develop and to test a set of SIEP indicators, based on the NICE recommendations, useful to evaluate their real application in mental health services. Methods – Based on the NICE recommendations, 103 indicators have been developed, some of them qualitative and the rest quantitative. These indicators investigate five different areas: 14 indicators concern the common elements in all phases of mental health care; 11 the treatment of first episode; 24 the crisis treatment; 41 the recovery promotion; 13 the urgency, including management of violent behaviours and fast soothing. After a pilot study conducted in 2 community mental health services, the indicators were tested in 19 Italian Departments of Mental Health, to obtain a self-evaluation of the quality of care and to verify the application of NICE recommendations in the clinical routine of these Services. Data for the self-evaluation have been obtained from the DSM'ls psychiatric informative system and from the Direction of the local health authorities or of the DSM. Moreover, for some indicators, information has been gathered from the clinical records, and by means of questionnaires administered to a sample of patients and relatives. Finally, “multidisciplinary” (i.e. involving different types of professionals) or “specialized” (i.e. involving only psychiatrists) focus groups have assessed the degree of similarity between practice and recommendation for 33 indicators. Finally, the focus group methodology has been applied in all services with the aim to judge the appropriateness of each NICE recommendation in the context of the Italian Departments of Mental Health. Results and Conclusions – Most NICE recommendations have been considered useful and appropriated to measure quality of care in the context of the Italian services. The SIEP indicators have been easily used by the services participating in the DIRECT's Project. The self-evaluation process has provided several data of great relevance to improve the quality of care for schizophrenia and implement clinical guidelines in Italy.
Aims – To highlight the major discrepancies that emerged between evidence and routine practice in the framework of the SIEP-DIRECT's Project (DIscrepancy between Routine practice and Evidence in psychiatric Community Treatments on Schizophrenia ). The Project was conducted in 19 Italian mental health services (MHS), with the aims of: a) evaluating the appropriateness of the NICE Guidelines for Schizophrenia in the Italian context, b) developing and testing a set of 103 indicators that operationalised preferred clinical practice requirements according to the NICE Guidelines, and c) evaluating their actual application in Italian MHSs. Methods – The indicators investigated five different areas: common elements in all phases of schizophrenia; first episode treatment; crisis treatment; promoting recovery; the aggressive behaviour management. Results – The NICE recommendations examined were judged in most instances to be appropriate to the Italian MHS context, and the indicators fairly easy to use. The more severe and frequently encountered evidence-practice discrepancies were: lack of written material, guidelines, and information to be systematically provided to users; lack of intervention monitoring and evaluation; difficulty in implementingspecific and structured forms of intervention; difficulty in considering patients' family members as figures requiring targeted support themselves and who should also be regularly involved in the patient care process. Conclusions – The key actions to be undertaken to favour implementation of evidence-based routine practices are: focussing on mental illness onset and family support/involvement in care; planning training activities aimed at achieving specific treatment goals; encouraging MHS participation in evaluation activities; identifying thresholds for guideline application and promoting specific guideline implementation actions; and activating decision making and resource allocationprocesses that rely more strictly on evidence and epidemiological assessment. These considerations are of value for rethinking the model of community psychiatry in Italy as well as in other countries.
Aims – To evaluate the quality of psychiatric care during the acute psychotic episode and the early post-acute period. Methods – Data concerning 24 indicators, drawn from NICE recommendations, were collected in 19 Departments of Mental Health, in the frame of the SIEP-DIRECT's Project to evaluate the implementation of NICE recommendations in Italian Mental Health Services. Results – The treatment of the acute episode in the Italian Mental Health Services is not based only on admissions in Psychiatric Ward in General Hospitals, but also on intensive home based care. The utilization of day hospital facilities for treating acute episodes is less frequent, as the presence of home based follow up after discharge. About of Departments of Mental Health did not have clinical guidelines concerning the pharmacological treatment in this area. However usually the standard practices followed NICE recommendations in terms of prescribed dosages, monitoring side effects and rationale for shifting to atypical antipsychotic drugs. Antipsychotic drugs, atypical or conventional, were frequently prescribed concurrently, while utilization of atypical antipsychotic drugs was increasing. Conclusions – The results show critical points concerning on one hand the scarce diffusion of clinical guidelines, on other hand the connection between standard practices, clinical guidelines and marketing of atypical antipsychotic drugs. It should be reinforced the role of the community and particularly at service level the capacity of community mental health teams to treat the acute patients.
Aims – This paper aims at presenting the most significant results emerging from the work carried out by the focus groups of the multi-centre Project SIEP-DIRECT's. The Project is aimed at assessing the existing discrepancies between the evidence-based NICE guidelines for schizophrenia and the usual practices of care given by Italian mental health services. Each focus group was requested to give an evaluation on: a) appropriateness of the English NICE guidelines in the context of the Italian mental health services; b) clarity and usefulness of the 103 indicators developed on the basis of the NICE recommendations to measure their level of application within the services. Methods - In each of the 19 mental health departments or psychiatric services participating in the Project there were organized “multidisciplinary” focus groups and “specialistic” focus groups. The former included, amongst others, professional operators of the mental health services, patients, their relatives, representatives of patient organizations and general practitioners. They examined the recommendations and indicators upon which the participants could express their opinion or judgment based on their knowledge, experience or information in their possession. The latter group, composed only of psychiatrists, examined the recommendations and indicators relative to pharmacological treatments that regarded the specific competences of their professional category. Results – Most NICE recommendations seemed appropriate to the working context of the Italian services. However, some perplexity emerged as regards specific organizational models of the services, such as the specific services for psychotic onsets or the assertive outreach teams, which were believed not to be strictly pertinent to the traditional organization of mental health care in our Country. There were also some criticisms regarding the cognitive-behavioural treatments which the NICE Guidelines recommend as the principle psychotherapeutic option for patients with schizophrenia, since in many Italian services, when the use of psychological interventions are needed, the tendency is to prefer interventions based on psychodynamic theories. The SIEP indicators were generally held to be clear and acceptable. Conclusions – In the view of the focus groups, the NICE guidelines are on the whole useful and suitable for orientating the services in the choice of more efficacious practices in the treatment of patients with schizophrenia. Moreover, the results obtained legitimate the use of the set of SIEP indicators for the evaluation of good practices and the quality of care offered by Italian services. Finally, the use of focus groups delines to a different context as well as the verification of the comprehensibility and applicability of SIEP indicators.
Aims – To evaluate the quality of psychiatric care in Italian community-based services and the discrepancy between real practices and NICE recommendations for the treatment of schizophrenia concerning the elements common to all phases of care and the first episode of psychosis. Methods – Data concerning 14 indicators on common aspects of care in all phases and 11 indicators concerning psychosis onset, drawn from NICE Recommendations, were collected in 19 Departments of Mental Health. Results – An optimistic attitude seems to prevail in the staff in all phases of care, while remarkable discrepancies between service practice and recommendations have been found in relation to systematic assessment, availability of informative leaflets and support to relatives. Concerning the treatment of first episode, a lack of specific services and differentiated activities, and paucity of practices based on specific guidelines has been detected. However, Italian community based services proved to have a good capacity to provide help quickly to those seeking help for a psychotic onset, to maintain regular contact with them in the subsequent year, and provide pharmacological treatment reasonably in line with the scientific evidence. Instead, little specific support is provided to the relatives. Conclusions – The results show critical points concerning capacity of assessment and treatment standardization, in all aspects of care and specifically in the treatment for the first episode. Differentiation of activities specifically dedicated to the patients at their first episode should be promoted as well as strategies to support relatives in a more specific way.