Population-based prevalence of smoking in psychiatric inpatients: a focus on acute suicide risk and major diagnostic groups

Objective

The aim of the study was to define the extent of current and lifetime smoking by diagnostic groups and suicide risk as reason for admission in a geographically defined psychiatric inpatient cohort.

Design

The study used a population-based retrospective chart review.

Methods

Smoking status and discharge diagnoses for Olmsted County, Minnesota, inpatients aged 18 to 65 admitted for psychiatric hospitalization in 2004 and 2005 were abstracted from the electronic medical record. Diagnostic groups were compared to each other using χ² tests and Fisher exact test to analyze smoking status within the inpatient sample with significance defined as P ≤ .05.

Results

Eighty percent (80.41) of our sample of 776 patients was hospitalized due to acute suicide risk. Discharge diagnostic group composition included affective disorders (80.3%), substance abuse disorders (36.1%), anxiety disorders (19%), psychotic disorders (16.4%), and personality disorders (10.3%). Of the sample, 72.2% had at least one comorbid disorder. Of the 776 patients, 356 (45.9%) were current smokers. Substance abuse and psychotic disorder diagnoses were significantly correlated with current smoking status (<.0001, .02) with 77.1% and 55.9%, respectively, being current smokers compared to other psychiatric inpatient groups. All diagnostic groups smoked at higher rates and had less success stopping than the US general population.

Conclusion

Our findings clearly demonstrate stratification of current smoking and quit rates in psychiatric inpatient' diagnostic groups vs the US general population and Minnesota. Further research into the association between suicide risk, smoking, and mortality in the seriously mentally ill is necessary. Recognizing and addressing smoking in psychiatric patients in both hospital and outpatient settings is critical to addressing survival differences compared to the general population.     

Dropouts in a long-term follow-up study involving voluntary counseling and HIV testing: experience from a cohort of police officers in Dar Es Salaam,Tanzania

BACKGROUND: Results of most population-based studies primarily are derived from people who responded positively and thereby continued to participate in such studies. It is, however, equally important to know the characteristics of study subjects who drop out to learn the reasons that kept them from continuing to participate in the study, especially because they had initially agreed to participate in such a study. In studies with long-term follow-up, reasons for nonresponse may provide invaluable information that may be gathered through continued contact with study subjects who have withdrawn from the study. OBJECTIVES: To determine characteristics of study participants who withdrew from an ongoing study of police officers, which involved counseling and HIV testing, and to determine reasons for their discontinued participation. METHODS: Demographic characteristics of a cohort of police officers who had been participating in a study to determine their suitability for HIV vaccine trials were analyzed. Characteristics of those who did not return for the second survey of appointments for HIV testing were compared with those who continued their participation. A randomly selected sample of 132 police officers who did not participate in the second survey of HIV testing were asked why they did not return. Answers were obtained from 84 people who had discontinued their participation. RESULTS: Of eligible police officers, 2087 (72.1%) responded to the call for follow-up appointments, whereas 807 (27.9%) did not return. Those who did not return to participate in the second survey had significantly higher rates of HIV seropositivity (17.2%) than those who did return (13.5%) (p <.05). The rate of return in unmarried participants was worse (p <.05) than the rate among married participants. Rates of sexual contacts with partners other than their spouses and levels of alcohol consumption did not differ between the two groups. Reasons for dropping out of the study included fear of knowing results of HIV testing in 54.6%, lack of time to continue in 34.5%, and fears about job security in 3.6%. CONCLUSION: Fears of finding out that one might be seropositive need to be answered at recruitment, and practical arrangements must be made to facilitate further follow-up. A bias for lower incidence might be introduced in vaccine trials if participants thought to be at highest risk for HIV infection discontinue participation.     

Barriers to Care and Comorbidities Along the U.S.-Mexico Border

Objective

While limited access to care is associated with adverse health conditions, little research has investigated the association between barriers to care and having multiple health conditions (comorbidities). We compared the financial, structural, and cognitive barriers to care between Mexican-American border residents with and without comorbidities.

Methods

We conducted a stratified, two-stage, randomized, cross-sectional health survey in 2009–2010 among 1,002 Mexican-American households. Measures included demographic characteristics; financial, structural, and cognitive barriers to health care; and prevalence of health conditions.

Results

Comorbidities, most frequently cardiovascular and metabolic conditions, were reported by 37.7% of participants. Controlling for demographics, income, and health insurance, six financial barriers, including direct measures of inability to pay for medical costs, were associated with having comorbidities (odds ratios [ORs] ranged from 1.7 to 4.1, p<0.05). The structural barrier of transportation (OR=3.65, 95% confidence interval [CI] 1.91, 6.97, p<0.001) was also associated with higher odds of comorbidities, as were cognitive barriers of difficulty understanding medical information (OR=1.71, 95% CI 1.10, 2.66, p=0.017), being confused about arrangements (OR=1.82, 95% CI 1.04, 3.21, p=0.037), and not being treated with respect in medical settings (OR=1.63, 95% CI 1.05, 2.53, p=0.028). When restricting analyses to participants with at least one health condition (comparing one condition vs. having ≥2 comorbid conditions), associations were maintained for financial and transportation barriers but not for cognitive barriers.

Conclusion

A substantial proportion of adults reported comorbidities. Given the greater burden of barriers to medical care among people with comorbidities, interventions addressing these barriers present an important avenue for research and practice among Mexican-American border residents.Limited access to health care has been associated with a wide range of adverse health consequences including premature mortality^1,2 and increased risk for many common chronic conditions.^3–5 Despite prior research documenting associations between sustained lack of access and many health conditions independently,^6,7 very little research has described whether people with more than one health condition (i.e., comorbidities) experience greater barriers to obtaining health care.Prior research based on information from the Medical Expenditure Panel Survey has further indicated that people with multiple chronic conditions incur far greater health-care costs (up to seven times as many) as patients with only one chronic condition.⁸ It is essential, therefore, to understand the barriers to care that are disproportionately faced by people with comorbidities who need ongoing care, particularly among populations at high risk for developing comorbidities.Populations at high risk for having multiple health conditions include most minority populations in the U.S. and, in particular, Hispanic people, the largest and most rapidly growing minority group in the U.S.⁹ For example, the largest subgroup of Hispanic people, Mexican-Americans, has been found to have the highest incidence (an estimated 33.2%) of metabolic syndrome,¹⁰ a cluster of risk factors placing people at higher risk for heart disease, type 2 diabetes, and stroke.¹¹ Although there is substantial variability among Hispanic subgroups, based on information from the National Health Interview Survey, Mexican-American populations have the poorest access to care and the lowest use of health services of all Hispanic subgroups.^12,13 An estimated 32% of Hispanic people in the U.S. do not have health insurance compared with 15% of non-Hispanic white people.¹⁴ Besides economic limitations, Hispanic populations often face additional barriers to accessing health services. Factors that have been reported to impede Hispanic populations from obtaining medical care include, but are not limited to, language and literacy barriers,^15–17 lack of transportation and geographic inaccessibility,^15,17 the perception of being treated without respect in medical settings, and the perception that they would have received better quality care if they belonged to a difference racial/ethnic group.¹⁸A valuable guiding framework for the current study that provides a comprehensive overview of modifiable factors associated with access to health care is the recently developed Health Care Access Barriers model, an evidence-based analytical framework developed by Carillo and colleagues.¹⁹ This model describes the assessment of three categories of barriers to health care (financial, structural, and cognitive) that have been shown to be associated with poor health outcomes.Given the limited access to health care and high risk for comorbidities, gaining insight into which financial, structural, and cognitive barriers to care are associated with comorbidities among Mexican-Americans can provide valuable information for preventive efforts. Therefore, based on information from a randomized household survey conducted in a large city along the U.S.-Mexico border, the primary aim of the current study was to compare barriers to health care of participants with and without comorbidities. We hypothesized that people reporting comorbidities would be disproportionately affected by financial, cognitive, and structural barriers to care.