How does a history of psychiatric hospital care influence access to coronary care: a cohort study

OBJECTIVES: Equity in physical health of patients with severe mental disorders is a major public health concern. The aim of this cohort study was to examine equity in access to coronary care among persons with a history of severe mental disorder in 1998–2009. DESIGN: Nationwide register linkage cohort study. SETTING: Hospital care in the Finnish healthcare system. POPULATION: The study population consisted of all residents in Finland aged 40 years or older. All hospital discharges in 1998–2009 with a diagnosis of coronary heart disease or severe mental disorder were obtained from the Care Register. PRIMARY OUTCOME MEASURES: Data on deaths, hospitalisations and coronary revascularisations were linked to the data set using unique personal identifiers. RESULTS: Patients with severe mental disorders had increased likelihood of hospital care due to coronary heart disease (RR between 1.22, 95% CI 1.18 to 1.25 and 1.93, 1.84 to 2.03 in different age groups) and in 40–49-year-olds also increased likelihood of revascularisation (1.26, 1.16 to 1.38) compared with persons without mental disorders. Access to revascularisation was poorer among older persons with severe mental disorders in relation to need suggested by increased coronary mortality. In spite of excess coronary mortality (ranging from 0.95, 0.89 to 1.01 to 3.16, 2.82 to 3.54), worst off were people with a history of psychosis, who did not have increased use of hospital care and had lower likelihood of receiving revascularisations (ranging from 0.44, 0.37 to 0.51 to 0.74, 0.59 to 0.93) compared with persons without mental disorders. CONCLUSIONS: Selective mechanisms seem to be at work in access to care and revascularisations among people with severe mental disorders. Healthcare professionals need to be aware of the need for targeted measures to address challenges in provision of somatic care among people with severe mental health problems, especially among people with psychoses and old people.