标题：Reduced Mortality Among Department of Veterans Affairs Patients With Schizophrenia or Bipolar Disorder Lost to Follow-up and Engaged in Active Outreach to Return for Care
摘要：Objectives. We determined whether contacting Department of Veterans Affairs (VA) patients with schizophrenia or bipolar disorders (serious mental illness [SMI]) who had dropped out of care for prolonged periods resulted in reengagement with VA services and decreased mortality. Methods . We developed a list of patients with SMI who were last treated in fiscal years 2005 to 2006, and were lost to follow-up care for at least 1 year. VA medical centers used our list to contact patients and schedule appointments. Additional VA administrative data on patient utilization and mortality through May 2009 were analyzed. Results. About 72% (2375 of 3306) of the patients who VA staff attempted to contact returned for VA care. The mortality rate of returning patients was significantly lower than that for patients not returning (0.5% vs 3.9%; adjusted odds ratio = 5.8; P < .001), after demographic and clinical factors were controlled. Conclusions. The mortality rate for returning patients with SMI was almost 6 times less than for those who did not return for medical care. Proactive outreach might result in patients returning to care and should be implemented to reengage this vulnerable group. Serious mental illness (SMI), including patients with schizophrenia and bipolar disorder, is associated with substantial functional impairment, morbidity, and premature mortality. 1,2 In a given year, Veterans Affairs (VA) treats more than 230 000 patients for SMI. 3 VA patients with SMI die on average 13 to 18 years younger than the US general population, 1 and this mortality gap exceeds 20 years in non-VA populations. 2 A key driver of premature mortality among VA and non-VA patients with mental disorders is medical comorbidity, and cardiovascular disease is the number 1 cause of death. 4 Persons with SMI have standard mortality ratios that are about 2.5 times greater than those of the general population. 2 Improving access to medical care and the continuity of that care to reduce the risk of premature mortality among patients with SMI are important goals within VA and non-VA health care systems. 4,6,7 In a recent VA health services study, researchers reported that VA patients with schizophrenia with little care in the previous year were more likely to die than those without schizophrenia, suggesting that treatment dropouts in this group might be a significant risk factor in mortality and that efforts should be made to provide them treatment. 8 Similarly, patients with bipolar disorders as well as schizophrenia who were burdened by comorbid medical conditions might be prescribed medications that require regular monitoring (e.g., second-generation antipsychotics and mood stabilizers). 5 Improving access to care for VA patients with schizophrenia or bipolar disorder has been a consistent priority goal, as stated in the Veteran Health Administration’s (VHA) Uniform Mental Health Services Handbook and with Congress under the 1996 Public Law (104-262). Since the early 1990s, VA has modified its care-delivery system by moving from an inpatient to an outpatient model. Between 1993 and 2009, overall hospital admissions declined 33%, whereas the number of outpatient visits tripled. 9,10 Greater reliance has therefore been placed on community-based programs and ambulatory case management for veterans in general. Although veterans with SMI face substantial functional limitation and increased risk of hospitalization, there has been no national effort to date to facilitate reengagement among veterans with SMI who drop out of VA care. In December 2010, the VHA’s Office of the Medical Inspector (OMI) completed a landmark quality improvement project whose objectives were to identify and contact veterans with SMI who dropped out of care for a minimum of 1 year, and to offer them VA medical services. We described this project and presented the results on patient reengagement. We also compared mortality rates of patients returning to VA care after prolonged absences with mortality rates of patients who did not return.
