Lower Incidence of End-Stage Renal Disease but Suboptimal Pre-Dialysis Renal Care in Schizophrenia: A 14-Year Nationwide Cohort Study

<div><p>Schizophrenia is closely associated with cardiovascular risk factors which are consequently attributable to the development of chronic kidney disease and end-stage renal disease (ESRD). However, no study has been conducted to examine ESRD-related epidemiology and quality of care before starting dialysis for patients with schizophrenia. By using nationwide health insurance databases, we identified 54,361 ESRD-free patients with schizophrenia and their age-/gender-matched subjects without schizophrenia for this retrospective cohort study (the schizophrenia cohort). We also identified a cohort of 1,244 adult dialysis patients with and without schizophrenia (1:3) to compare quality of renal care before dialysis and outcomes (the dialysis cohort). Cox proportional hazard models were used to estimate the hazard ratio (HR) for dialysis and death. Odds ratio (OR) derived from logistic regression models were used to delineate quality of pre-dialysis renal care. Compared to general population, patients with schizophrenia were less likely to develop ESRD (HR = 0.6; 95% CI 0.4–0.8), but had a higher risk for death (HR = 1.2; 95% CI, 1.1–1.3). Patients with schizophrenia at the pre-ESRD stage received suboptimal pre-dialysis renal care; for example, they were less likely to visit nephrologists (OR = 0.6; 95% CI, 0.4–0.8) and received fewer erythropoietin prescriptions (OR = 0.7; 95% CI, 0.6–0.9). But they had a higher risk of hospitalization in the first year after starting dialysis (OR = 1.4; 95% CI, 1.0–1.8, <i>P</i> < .05). Patients with schizophrenia undertaking dialysis had higher risk for mortality than the general ESRD patients. A closer collaboration between psychiatrists and nephrologists or internists to minimize the gaps in quality of general care is recommended.</p></div

All-cause mortality of the dialysis cohort stratified by different characteristics.

<p>^a Mortality: number per 1,000 person-years</p><p>^b Model is adjusted for age, gender, NHI registration location, income, CCI score, DM, nephrologists visit and year</p><p>CCI: Charlson Comorbidity Index, DM: diabetes mellitus, HR: hazard ratio, Nephrologist visit: in six months prior to dialysis initiation.</p

Demographics of study subjects in 2 different cohorts with and without schizophrenia.

<p>^a Age to be initially followed for schizophrenia cohort and age of initiating regular dialysis cohort</p><p>^b Conditions investigated six months prior to initiating regular dialysis</p><p>^c for patients continuously receiving dialysis for three months immediately after the index date</p><p>^d for patients on hemodialysis, and created vascular access at least 2 weeks before initiating regular dialysis</p><p>CCI: Charlson Comorbidity Index, DM: diabetes mellitus, EPO: erythropoietin, NHI: National Health Insurance.</p

Child’s daily use of mobile devices according to general characteristics of participants (n = 202).

Child’s daily use of mobile devices according to general characteristics of participants (n = 202).</p

Associations of child’s use of mobile devices and parent–child shared reading with the emotional and behavioral problems among children with mothers with a low depression level—results from multiple linear regression models.

Associations of child’s use of mobile devices and parent–child shared reading with the emotional and behavioral problems among children with mothers with a low depression level—results from multiple linear regression models.</p

Associations of general traits and maternal use of mobile devices with child’s exceeding the recommended use of mobile devices—results from multiple logistic regression models (n = 202).

Associations of general traits and maternal use of mobile devices with child’s exceeding the recommended use of mobile devices—results from multiple logistic regression models (n = 202).</p

Associations of child’s use of mobile devices and parent–child shared reading with the emotional and behavioral problems among children with mothers with a high depression level—results from multiple linear regression models.

Associations of child’s use of mobile devices and parent–child shared reading with the emotional and behavioral problems among children with mothers with a high depression level—results from multiple linear regression models.</p