Comorbid Diabetes and Severe Mental Illness: Outcomes in an Integrated Health Care Delivery System
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Department of Psychiatry, Weill Institute of Neurosciences, University of California, San Francisco, San Francisco, CA, USA; 2UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA; 3UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA; 4Thriving Mind South Florida and Washington University School of Medicine, St Louis, CA, USA; 5Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA; 6Department of Psychiatry, Columbia University, New York City, NY, USA; 7Kaiser Permanente Northern California Division of Research, Oakland, CA, USA.
BACKGROUND: Diabetes prevalence is twice as high among people with severe mental illness (SMI) when compared to the general population. Despite high prevalence, care outcomes are not well understood. OBJECTIVE: To compare diabetes health outcomes received by people with and without comorbid SMI, and to understand demographic factors associated with poor diabetes control among those with SMI. DESIGN: Retrospective cohort study PARTICIPANTS: 269,243 adults with diabetes MAIN MEASURES: Primary outcomes included optimal glycemic control (A1c < 7) or poor diabetes control (A1c > 9) in 2014. Secondary outcomes included control of other cardiometabolic risk factors (hypertension, dyslipidemia, smoking) and recommended diabetes monitoring. KEY RESULTS: Among this cohort, people with SMI (N = 4,399), compared to those without SMI (N = 264,844), were more likely to have optimal glycemic control, adjusting for various covariates (adjusted relative risk (aRR) 1.25, 95% CI 1.21–1.28, p < .001) and less likely to have poor control (aRR 0.92, 95% CI 0.87–0.98, p = 0.012). Better blood pressure and lipid control was more prevalent among people with SMI when compared to those without SMI (aRR 1.03; 95% CI 1.02–1.05, p < .001; aRR 1.02; 95% CI 1.00–1.05, p = 0.044, respectively). No differences were observed in recommended A1c or LDL testing, but people with SMI were more likely to have blood pressure checked (aRR 1.02, 95% CI 1.02–1.03, p < .001) and less likely to receive retinopathy screening (aRR 0.80, 95% CI 0.71–0.91, p < .001) than those without SMI. Among people with diabetes and comorbid SMI, younger adults and Hispanics were more likely to have poor diabetes control. CONCLUSIONS: Adults with diabetes and comorbid SMI had better cardiometabolic control than people with diabetes who did not have SMI, despite lower rates of retinopathy screening. Among those with comorbid SMI,
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11606-019-05489-3) contains supplementary material, which is available to authorized users. Received October 30, 2018 Revised May 2, 2019 Accepted September 25, 2019
younger adults and Hispanics were more vulnerable to poor A1c control. KEY WORDS: diabetes; severe mental illness; healthcare delivery system; health outcomes. J Gen Intern Med DOI: 10.1007/s11606-019-
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