Background One critical barrier to the uptake of mental health programmes is the so-called physical healthcare gap, a concern raised by the unattended physical comorbidity and early mortality of persons with severe mental illness. Aims To evaluate the extension of physical healthcare gap among persons with severe mental illness under chronic drug therapies. Method A population-based cohort study was carried out, using Lombardy healthcare utilisation databases. Prevalent patients treated with blood pressure-, lipid- or glucose-lowering agents were identified in January 2017. Among these, those who were receiving care for depression, schizophrenia, bipolar disorder or personality disorder formed the study cohort. A reference cohort was randomly selected from prevalent patients treated with chronic therapies without signs of severe mental disorders, to be matched with study cohort members for gender, age and number of previous contacts with the National Health System. One-year adherence to healthcare was measured through the proportion of days covered (drug adherence), and exposure to selected recommendations (clinical control adherence). Results The 55 162 patients with severe mental illness were less likely to have high adherence to blood pressure-lowering, lipid-lowering or antidiabetic agents than the reference cohort by −24% (95% CI −26 to −22%), −10% (95% CI −14 to −6%) and −25% (95% CI −29 to −21%), respectively. The 9250 patients with diabetes and severe mental illness had −18% (95% CI −22% to −13%) reduced likelihood to meet recommendations for the clinical management of diabetes, compared with the reference cohort. Conclusions Adherence to chronic drug therapies was sensibly worse among patients living with mental illness than those without signs of mental disorders.

Objective:Aim of the study was to evaluate the protective effect of antidiabetic drugs in a large cohort of unselected elderly diabetic patients differing for their clinical status and life expectancy. The evaluation focused, in particular, on a group of patients with a very low survival rate because frail patients are usually excluded from intervention trials, limiting evidence on treatment effectiveness. The protective effect of drug therapy, quantified by the reduction in all-cause mortality with increased adherence to antidiabetic agent therapy, was studied by stratifying patients according to their life expectancy.Design and method:The Lombardy (Italy) residents, aged > 65 years, who received > 2 consecutive prescriptions of antidiabetic agents during 2012 were identified and the date of the third prescription was defined as the index date. A case-control study was nested into the cohort of antidiabetic drug users. Death from any cause was the outcome of interest, and cases were cohort members who died during follow-up (up to 2018). For each case, a control was selected and matched for age, gender, and clinical profile. Conditional logistic regression was used to model the risk of outcome associated with four categories of adherence to antidiabetic drugs. Adherence to drug therapy was measured by considering the proportion of days of the follow-up covered by the drugs. The analysis was stratified according to four categories of the clinical profile (good, intermediate, poor, and very poor) differing for life expectancies, as evaluated by a multisource comorbidity score able to accurately predict the risk of death.Results:Among the 276,336 patients in treatment with antidiabetic agents during 2012, 188,983 met the inclusion criteria and generated 49,219 deaths during follow-up, 49,201 of whom were matched to a control. The 6-year survival decreased from 85% to 52% from the group of patients with good to the group of patients with a very poor clinical status.Adherence to treatment was associated with a progressive decrease in the risk of mortality in all categories of clinical status. The reduction from lowest to highest adherence level was 36% (95% CI, 25–46%), 50% (44–56%), 38% (33–42%) and 26% (17–34%) from good to very poor clinical status (Figure).Conclusions:In a real-life context, adherence to antidiabetic drugs is associated with a reduction in the risk of mortality regardless of the clinical status of the patients. However, in more frail patients, the benefit of treatment is less than in patients in good clinical condition.

Background To evaluate the protective effect of oral antidiabetic drugs in a large cohort of elderly patients with type 2 diabetes differing for age, clinical status, and life expectancy, including patients with multiple comorbidities and short survival. Methods A nested case–control study was carried out by including the cohort of 188,983 patients from Lombardy (Italy), aged ≥ 65 years, who received ≥ 3 consecutive prescriptions of antidiabetic agents (mostly metformin and other older conventional agents) during 2012. Cases were the 49,201 patients who died for any cause during follow-up (up to 2018). A control was randomly selected for each case. Adherence to drug therapy was measured by considering the proportion of days of the follow-up covered by the drug prescriptions. Conditional logistic regression was used to model the risk of outcome associated with adherence to antidiabetic drugs. The analysis was stratified according to four categories of the clinical status (good, intermediate, poor, and very poor) differing for life expectancy. Results There was a steep increase in comorbidities and a marked reduction of the 6-year survival from the very good to the very poor (or frail) clinical category. Progressive increase in adherence to treatment was associated with a progressive decrease in the risk of all-cause mortality in all clinical categories and at all ages (65–74, 75–84 and ≥ 85 years) except for the frail patient subgroup aged ≥ 85 years. The mortality reduction from lowest to highest adherence level showed a tendency to be lower in frail patients compared to the other categories. Similar although less consistent results were obtained for cardiovascular mortality. Conclusions In elderly diabetic patients, increased adherence to antidiabetic drugs is associated with a reduction in the risk of mortality regardless of the patients’ clinical status and age, with the exception of very old patients (age ≥ 85 years) in the very poor or frail clinical category. However, in the frail patient category the benefit of treatment appears to be less than in patients in good clinical conditions.