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Cardiovascular Disease Mortality of Medicaid Clients with Severe Mental Illness and a Co-occurring Substance Use Disorder

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Abstract

Increasing attention focuses on cardiovascular disease (CVD) among persons with SMI. We examined, among persons with SMI, whether co-occurring substance use disorder (SUD) elevates the risk of CVD death. We linked 2002–2007 Medicaid claims data on 121,817 persons with SMI to cause and date of death information. We applied a proportional hazards model that controls for co-morbidity at baseline, atypical antipsychotic prescription medications, age, gender and race/ethnicity. Results among persons with co-occurring SUD indicate a 24 % increased risk of CVD death (hazard ratio 1.24; 95 % confidence interval 1.17–1.33). We encourage further coordination of services for this population.

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Authors and Affiliations

  1. Program in Public Health, University of California, Irvine, 635 E. Peltason Drive, Irvine, CA, 92697-3957, USA

    Tim A. Bruckner

  2. Department of Health Policy and Management, Oregon State University, Corvallis, OR, USA

    Jangho Yoon

  3. School of Pharmacy, University of California, San Francisco, San Francisco, CA, USA

    Marco Gonzales

Authors
  1. Tim A. Bruckner
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  2. Jangho Yoon
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  3. Marco Gonzales
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Corresponding author

Correspondence to Tim A. Bruckner.

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Conflict of Interest

Tim Bruckner, Jangho Yoon, and Marco Gonzales declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Given that we analyzed previously collected data, none of the Authors made contact with any of the human participants. The State of California, Committee for the Protection of Human Subjects, CA-DHCS, and the University of California, Irvine approved the use of this dataset for this study (Protocol Numbers 08-12-57, 12-10-0813, and 2010-7472, respectively).

Appendix: Sensitivity Analysis of Confounding due to Smoking

Appendix: Sensitivity Analysis of Confounding due to Smoking

California collects Medi-Cal claims information chiefly for accounting purposes and processing of reimbursements to providers. Health data on smoking prevalence among persons with SMI are often missing. Such missing data may therefore underestimate the “true” prevalence of smoking in our population. Lack of information on smoking may bias the estimate of the relation between SUD and CVD mortality among persons with SMI.

To address potential confounding bias due to smoking, we used the “confounding risk ratio” approach recommended by Breslow and Day (1980) and implemented previously by researchers that examined persons with SMI (Ray et al. 2009). This approach estimates the extent to which an unmeasured confounder could affect results. The confounding risk ratio equation appears below:

$$\omega = \frac{{(RR_{c} Q_{1} + (1 - Q_{1} )}}{{RR_{c} Q_{0} + (1 - Q_{0} )}}$$
(1)

where RRc is the risk ratio for confounder, Q 1 the confounder prevalence among user group, and Q 0 the confounder prevalence among nonuser group.

We estimated each of these values based on previous literature. In the equation above, RRc reflects the relative risk of CVD death due to smoking. Several reports find that smokers show a twofold elevated risk of CVD death as compared with non-smokers. Q 1 represents persons with both SMI and SUD. The maximum estimated prevalence of smoking among this group is 70 % (Kalman et al. 2005). Among Q 0, the persons with SMI but no SUD, the maximum estimated prevalence of smoking is 58 % (Lasser et al. 2000). Substitution of these values into the equation yields the following result:

$$\omega = \frac{(2.0(0.70) + (1 - 0.70))}{2.0(0.58) + (1 - 0.58)} = 1.075.$$

The confounding risk ratio of 1.075 suggests that the observed estimate between SUD and CVD death exceeds the relative hazard by 7.5 % as compared to what would be calculated had we fully controlled for smoking. We refer the reader to the main text which describes why this value likely overestimates actual confounding by smoking.

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Bruckner, T.A., Yoon, J. & Gonzales, M. Cardiovascular Disease Mortality of Medicaid Clients with Severe Mental Illness and a Co-occurring Substance Use Disorder. Adm Policy Ment Health 44, 284–292 (2017). https://doi.org/10.1007/s10488-016-0722-9

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