Continuity of care for patients with a severe mental disorder: studies using Dutch health insurance registry data

Background Patients with severe mental disorder, like schizophrenia or bipolar disorders, need continuity of integrated healthcare to prevent crisis and hospitalization. Many of these patients discontinue their treatment, often experiencing adverse outcomes. The first objective of this study was to assess whether patients with schizophrenia or bipolar disorder receive continuity of psychiatric elective care. The second objective is to assess the relation between continuity of care with crisis and hospitalization. Methods Large registry-based retrospective cohorts of patients with schizophrenia or bipolar disorders were extracted from the registries of major Dutch healthinsurance companies over 2008-2014. The main research questions of six studies were: 1) Is the relation between continuity of care and hospitalization in the Netherlands changing from a period (2008-2011) with few financial barriers to receive psychiatric and somatic healthcare to a period (2012-2014) with a high rise in general co-payments, and a specific co-payment for psychiatric care in 2012 only? (studies 1-3) 2) What is the relation between route of administration of antipsychotic medication and time to discontinuation of psychiatric care? (study 4) 3) In patients treated for their disorder, can their previous psychiatric care predict discontinuity? Controlling for predictors of discontinuity, is there practice variation in continuity of care between providers of psychiatric care? (study 5-6) Major results 1) 60% of patients with schizophrenia or bipolar disorder receive continuity of care over 6 years 2) Continuity of care coincides with less crisis care, more elective care, more somatic care 3) The reduction in elective care over 2009-2014 is alarming 4) Somatic care increased 5) High co-payments coincide with less continuity of care and more crisis care 6) Crisis care was low under continuity of care and high in quarters with disorder specific medication only 7) High discontinuity in antipsychotic formulations: oral-weekly an alternative to depot formulation 8) Previous use of psychiatric care predicts continuity of care 9) Practice variation in continuity of care between providers did not significantly differ 10) Results over schizophrenia and bipolar disorder very similar but with some differences Conclusions Although patients with severe mental disorders, like schizophrenia or bipolar disorder, need continuity of care to prevent crisis and hospitalization, only 60% achieve continuity of care over 6 years. The reduction in elective care during the years 2009-2014 is alarming. Continuity of care coincides with less crisis or hospitalization, and more elective and somatic care. The use of crisis and hospitalization was highest in patients who only used medication for their psychiatric disorder without elective outpatient care; lowest among patients receiving continuity of care. Because crisis and hospitalization is expensive, there is a high potential for cost reduction when a shift to continuous care is achieved. The high rise in co-payments and extra co-payments for mental healthcare coincided with less continuity of care and more crisis and hospitalization. In patients with elective care, their previous use of psychiatric care predicts discontinuity of care. Practice variation between providers of psychiatric care, taking into account the predictive factors of previous care, was not significant. Only 20% of patients with schizophrenia showed continuity of using antipsychotic formulations (route of administration: oral-daily, oral-weekly, depot, or mixed) over one-year follow-up. There was a strong association between discontinuation of antipsychotic medication and the duration of recent antipsychotic use. Oral-weekly and depot formulations showed similar patterns and results. Oral-weekly can be an alternative for patients who do not want depot injections. Although we cannot establish causal relationships, these findings support professional guidelines for schizophrenia and bipolar disorder promoting continuity of care.