BACKGROUND/RATIONALE:
Veterans with severe mental illness (SMI) --schizophrenia, bipolar disorder, post-traumatic stress disorder, and major depression, have high comorbidity burden and may undergo major surgery at higher rates than veterans without SMI. SMI are common in the VA with devastating impact on health. Yet our systematic literature review (1966-2007) identified only 12 studies reporting perioperative clinical outcomes for SMI patients. The meager evidence base highlighted an important gap in knowledge regarding patients with SMI.

OBJECTIVE(S):
(1) Compare surgery rates among VA patients by SMI status (schizophrenia, bipolar disorder, PTSD, Major depressive disorder [MDD], no mental illness). (2) Model 30-day, 90-day, and 1-year postoperative mortality and survival by SMI status. (3) Assess 30-day, 90-day, and 1-year postoperative complications (e.g., heart attack, venous thromboembolism, ICU admission, pneumonia, respiratory failure, sepsis, wound infection) by SMI status.

METHODS:
Surgical Treatment Outcomes for Patients with Psychiatric Disorders (STOPP) used archival VA data on patients treated during FY2006-FY2009. Incorporation of Veterans Affairs Surgical Quality Improvement Program (VASQIP) data was attempted to permit in-depth analyses for the overlap sample, but the application for VASQIP data after several iterations never achieved approval as we were unable to meet VASQIP prerequisites. We calculated rates of surgery, postoperative mortality and survival, and postoperative complications. Multivariable analyses assessed the impact of SMI on outcomes, adjusting for demographic and clinical covariates. Exploratory work using Relative Value Units (RVUs) was unfeasible in most cases (90%) because they were defined by ICD9A procedure codes rather than CPT codes and mapping to CPT's lacked sufficient precision.

FINDINGS/RESULTS:
The surgery cohort, using definitions developed in the VISN 17-funded FY2005 pilot study that preceded this merit award and augmented by new codes recorded in FY2006-2009 data, comprised 388,518 individuals including 4% day-of-surgery-admissions (DOSA), 90% pre-admitted, and 6% with both events on the same date. These proportions reflect each patient's first qualifying surgery during FY2006-2009. Patients had up to 17 major operations in one year.

The rate of major surgery among patients without SMI was 5.4% vs 6.4% among SMI patients. Severe mental illness was diagnosed preoperatively for 14% of the surgery cohort, slightly more prevalent than among non-surgery patients (12%).

The cohort of surgery patients was 4% female, 19% black, 78% white, 2% other race, and 6% of patients were Hispanic. Among surgery patients, 40% were VA-eligible via low income (VA Priority 5) compared to 32% of non-surgery patients. Comorbidity burden averaged 2.6 (SD 2.5) per Charlson score, 4.3 (SD 2.3) chronic conditions per Selim. There were more women in the SMI-surgery groups (6%-13%) compared to non-SMI surgery patients (4%).

Common operations were coronary artery bypass graft (CABG; performed on 4.5% of major surgery patients; 17,657), vascular operations (129,340 patients; 33%), musculoskeletal operations especially of hip or knee (36,850 patients; 10%) and digestive system procedures (38,889 patients; 10%). Rates of CABG and vascular operations were lower among patients with SMI especially those with schizophrenia (2%; P<.05). On the other hand, patients with schizophrenia were more likely to have operations to the skin and digestive system, below-the-knee amputations and other amputations (e.g., partial foot removal).

Readmission within 30 days of discharge following surgery varied by schizophrenia vs non-SMI, e.g., vascular operations (18% vs. 15%), CABG (22% vs. 11%), and hip/knee procedures (13% vs. 6%; P<.0001 for all).

In a sub-analysis of 113,726 depressed patients, 7,373 patients (6.5%) experienced one or more of four common inpatient surgeries (1,441 hip/knee, 1,550 digestive, 641 CABG, and 4,311 vascular procedures). Depressed Hispanic patients were less likely to receive hip/knee (OR=0.7), CABG (OR=0.3) or vascular operations (OR=0.7) but equally likely as white or black patients to receive digestive system procedures. Black patients had modestly decreased relative odds of vascular surgery. No differences in postoperative mortality for these common inpatient surgeries were found.

In a sub-analysis of 89,995 patients having major surgery in FY2006, African-Americans (18%; 16,252) were at increased risk of suicidal behavior/ideation (HR=1.2; 95% CI 1.1-1.3) while Hispanics were not (HR=1.1; 95% CI 0.9-1.3). Other risk factors included preoperative SMI, pain, and postoperative complications and new-onset depression. The postoperative period may be a time of heightened risk for suicidality amongst VA's minority patients.

In in-depth explorations of risk factors, QT-prolongation was much more common among SMI than non-SMI patients (Stock et al in press), and parental status at demobilization correlated with PTSD diagnosis/treatment (in development).

IMPACT:
STOPP produced new knowledge in the area of surgical intervention and SMI. Given the high prevalence of cardiovascular disease in patients with SMI, higher rates of surgical intervention among these patients were expected. Yet operations to treat vascular disease and coronary artery blockage were relatively less common among patients with SMI than without. Surgery patients were highly disabled, obese and unmarried. Thus perioperative teams are dealing with considerably disadvantaged patients, a sizable, high-risk subgroup requiring attentive follow-up to ensure good wound management and timely postoperative symptom reporting, activities some patients with SMI will find unmanageable. To reduce postoperative readmission with its attendant costs and increased risk of pain and death, innovative programs tailored to patients with severe mental illness may need to be developed and evaluated.

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External Links for this Project

NIH Reporter

Grant Number: I01HX000296-01
Link: https://reporter.nih.gov/project-details/7870541

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PUBLICATIONS:

Journal Articles

1. Janke-Stedronsky SR, Greenawalt DS, Stock EM, Tsan JY, MacCarthy AA, MacCarthy DJ, Copeland LA. Association of parental status and diagnosis of posttraumatic stress disorder among veterans of Operations Iraqi and Enduring Freedom. Psychological trauma : theory, research, practice and policy. 2016 Jan 1; 8(1):72-9. [view]
2. Copeland LA, Zeber JE, Pugh MJ, Phillips KL, Lawrence VA. Ethnicity and Race Variations in Receipt of Surgery among Veterans with and without Depression. Depression research and treatment. 2011 Oct 12; 2011:370962. [view]
3. Tsan JY, Stock EM, Greenawalt DS, Zeber JE, Copeland LA. Mental health treatment after major surgery among Vietnam-era Veterans with posttraumatic stress disorder. Journal of Health Psychology. 2016 Jul 1; 21(7):1249-60. [view]
4. Case DJ, Copeland LA, Stock EM, Herrera HR, Pfanner TP. Pneumococcal vaccination rates in VHA patients with inflammatory bowel disease. Medicine. 2015 Feb 1; 94(6):e417. [view]
5. Evans LD, Stock EM, Zeber JE, Morissette SB, MacCarthy AA, Sako EY, Lappin J, Lawrence VA, MacCarthy DJ, Copeland LA. Posttransplantation Outcomes in Veterans With Serious Mental Illness. Transplantation. 2015 Aug 1; 99(8):e57-65. [view]
6. Copeland LA, Zeber JE, Sako EY, Mortensen EM, Pugh MJ, Wang CP, Restrepo MI, Flynn J, MacCarthy AA, Lawrence VA. Serious mental illnesses associated with receipt of surgery in retrospective analysis of patients in the Veterans Health Administration. BMC surgery. 2015 Jun 18; 15:74. [view]

Journal Other

1. Zeber JE, Copeland LA, Lawrence VA, Pugh MJ, Restrepo MI. Surgical Rates of common procedures in Veterans with Schizophrenia and Other Mental Illness. [Abstract]. Schizophrenia Bulletin. 2011 Mar 1; 37(S1):101-101. [view]

Conference Presentations

1. Copeland LA, Zeber JE, Sako EY, Flynn J, MacCarthy A, MacCarthy D, Lawrence VA. Epidemiology of Three Common Surgeries in Veterans with Schizophrenia. Poster session presented at: International Congress on Schizophrenia Research; 2011 Apr 3; Colorado Springs, CO. [view]
2. Zeber JE, Copeland LA, Pugh MJ, Mortensen EM, Restrepo MI, Lawrence VA. Surgical Rates of Common Procedures in Veterans with Serious Mental Illness. Poster session presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 28; Little Rock, AR. [view]

DRA: Mental, Cognitive and Behavioral Disorders
DRE: Prognosis
Keywords: none
MeSH Terms: none