How Good a Doctor…?Physical Health Care in a Forensic Setting

Dr. Alan Cohen FRCGP

Director of Primary Care, West London Mental Health TrustRetired Grumpy Old Git

Take Diabetes

More common in people with severe mental illness (SMI)

One of the major causes of premature death in this group

But no information on the quality of care provided to people with a SMI

There is a National Diabetes Audit that could address this omission

• Commissioned by HCIP and funded by NHSE, since 2004

• Takes data from inpatient care, and primary care

• Addresses four specific questions• Is everyone with diabetes diagnosed and recorded on a practice

register?

• What percentage receive the 9 key interventions recommended by NICE?

• What percentage achieved the 7 treatment targets recommended by NICE?

• What are the acute and long term complication rates?

The National Diabetes Audit

9 Key Interventions –process measures

HbA1c (mmol/mol)

Smoking

BMI

Blood Pressure (mmHg)

Serum Cholesterol (mmol/l)

Serum Creatinine

Urine Albumen

Foot Surveillance

Retinal screening*

7 Treatment Targets – outcome measures

HbA1c <58 mmol/mol

HbA1c <= 64 mmol/mol

HbA1c <= 75 mmol/mol

Blood Pressure (Systolic) <150mmHg

Blood Pressure (Systolic) <140 mmHg

Blood Pressure <=140/80

Serum Cholesterol < 5mmol/l

West London Mental Health Trust

0 – 9 years

10 – 19 years

20 – 29 years

30 – 39 years

40 – 49 years

50 – 59 years

60 – 69 years

70 – 79 years

80 – 89 years

90 – 99 years

Age Distribution at Broadmoor and at WLFS

Broadmoor Male (%) Broadmoor Female (%)

WLFS Male (%) WLFS Female (%)

Aim: to compare the standard of care delivered at Broadmoor and WLFS with the standards of the National Diabetic Audit

Primary Care team• GP• Nurse practitioner• Practice nurse, dietitian, health

care assistant, physiotherapist• Consultant diabetologist

Primary Care IT system

At each CPA• Physical health examination• Blood tests – in line with NICE

guidelines for both psychosis and diabetes

• ECG• Review of previous physical

health problems in the last six months

The Results - interventions

Broadmoor

• 195 all male beds

• 30 (15.4%) have Type 2 diabetes

• 26 (86.7%) received 8 recommended interventions

• 29 (96.6%) received 5 recommended interventions

• 20 (66%) patients agreed to have retinopathy screening

• 0 patients were recorded as smokers

WLFS

• 284 beds (61 female)

• 58 (20.4%) have Type 2 diabetes

• 48 (82.8%) received 8 recommended interventions

• 56 (96%) received 5 recommended interventions

• 36 (62%) patients agreed to have retinopathy screening

• 40 (68%) were recorded as smokers

The Results - outcomes

Broadmoor

• Mean HbA1c was 63.9mmol/mol

• 14 (46.7%) achieved good control of diabetes

• 5 (16%) achieved the composite of good diabetic control, ideal blood pressure and ideal cholesterol

• Insulin needed in 8 (27%) of patients

WLFS

• Mean HbA1c was 52.4mmol/mol

• 43 (74.1%) achieved good control of diabetes

• 27 (46.5%) achieved the composite of good diabetic control, ideal blood pressure and ideal cholesterol

• Insulin needed in 5 (8.6%) of patients

Differences between the units

• Mean HbA1c higher in Broadmoor (p = 0.05),• And therefore overall worse control, and overall a smaller proportion achieve

the composite score

• More likely to need insulin in Broadmoor (p = 0.05)

• Patients smoked at WLFS (68%) and none smoked at Broadmoor

• There was no statistical difference between any of the other treatment targets.

• Women at WLFS had a higher BMI than men at WLFS (p = 0.05)

Compared to National Data

• Comparisons are difficult because:• It is a general population and not a specific population of people in the

community with severe mental illness

• It is a population in the community and not a population held in long term mental health units

• Nationally 60% of people with diabetes accepted all 8 interventions

• Nationally treatment targets were higher across all indicators when compared to both mental health units.

So what?

• Both units were good at offering the interventions (84%) compared to the national average (60%)

• But despite offering the interventions, treatment target achievements were worse than the national figures, and worse at Broadmoor than at WLFS

• What could explain this?• Smoking?

• Antipsychotics?

Smoking

Smoking (nicotine) induces liver enzymes

Which increases the metabolism of anti-psychotic medication

So to achieve the same therapeutic effect in a smoker, a higher dose of medication is needed

When a smoker stops smoking, it is recommended that the dose of medication is reduced by about 25%, otherwise the drug level will increase to potentially toxic levels

68% of WLFS patients smoked

But they had better diabetic control…

Antipsychotic medication

No electronic data at WLMHT as to overall comparative use of antipsychotics

No information on relative diabetogenic effects of different antipsychotics, alone or in combination.

Some thoughts…

• Setting up the organisation of care was straightforward

• Getting the data was straightforward

• Interpreting the data was straightforward

But…

• Diabetes is more complex to manage in forensic settings

• The treatment target achievements were poor despite offering all the interventions recommended by NICE

• The role of smoking is ill-understood

• The role of antipsychotic medication is ill-understood

… and some questions

Are psychiatrists (or psychiatrists in training) the best people to offer diabetic care to a group that are more complex to treat than most other diabetics?

If not psychiatrists –then who (and how)?

Why don’t we have better information about medication use?

Why doesn’t the National Diabetic Audit include mental health trusts? Is this what is called “Parity of Esteem”?

In Summary

• We have the tools to deliver high quality physical health care

• When we start to do so, it raises clinical questions that are complex

• We do need some national leadership (politically and administratively) which is effective

But…

Thank you

Dr Alan Cohendoctoralancohen@me.com