The quality of clinical pathways delivered to patients with severe mental disorders. A multi-regional italian investigation based on healthcare utilization databases. The QUADIM project

Improving the quality of care is a leading priority for national health systems, consistent with the aim of improving population health, while maintaining the sustainability of the whole health system, especially for the mental health system, since it is composed by a complex network of community mental health teams of professionals and a wide range of community-based treatment, rehabilitation, day-care and residential care facilities. The quality of routine mental healthcare is still far from optimal, worldwide and in Italy, because it is not always delivered in accordance with evidence-based mental health standards and it can vary greatly among providers. Indeed, the construct of process indicators in the field of mental health is often not completely consistent with recommendations in evidence-based guidelines, where existing. To date, only few studies have analyzed this issue in Italy, despite the quality of mental health care has become a frequent subject of international evaluations. Given these premises, the QUADIM Project (“Clinical pathways in patients with severe mental disorders in Italy”), an Italian multi-regional project funded in 2016 by the Italian Health Ministry, was conducted with the aim to assess the quality of healthcare pathways provided to patients with serious mental illnesses (SMI) assisted by regional Departments of Mental Health (DMHs) in a real-world setting, using a set of process indicators developed by a panel of experts starting from a document approved by the italian Unified State-Regions Conference (2014). The main aim of this thesis was the conduction and the management of this project, which constituted my thesis project during the PhD. For each of the four SMI investigated (i.e., schizophrenic, depressive, bipolar and personality disorders), from the regional Healthcare Utilization (HCU) databases were identified the cohorts of adult patients affected by this specific mental disorder and taken in care by regional DMHs during the years 2015-2016. The adherence of these patients to the defined process indicators was evaluated during the first 12 months of follow-up, assessing strengths and weaknesses of the four regional mental health systems. As far as the process indicators were designed and developed taking inspiration from clinical recommendations that should be followed for improving the quality of mental healthcare, and by considering that a better process profile, as measured by these indicators, not necessarily lead to better outcomes, a secondary aim of the QUADIM project was the conduction of a validation study for evaluating their relationship with measurable clinical outcomes. Thus, among patients affected by an incident schizophrenic spectrum disorder, case-crossover study was conducted in order to validate some process indicators, relating them, as a proxy of the quality of delivered care, with some clinical outcomes, such as admission to hospital psychiatric wards (GHPWs). The layout of the thesis has been divided into different sections. I will proceed in the first instance by giving an overview of the QUADIM project and the methods used to identify the cohorts of patients affected by SMI, to design and develop the process indicators and to conduct the validation study among patients with incident schizophrenic spectrum disorder; proceeding with a detailed description of the results and reporting the main findings of the validation study. Finally, the implications of monitoring the process of care of patients with incident schizophrenic disorder and, more in general, of the proposed approach, were discussed.