BACKGROUND/RATIONALE:
Research has suggested that guideline-concordant antipsychotic dosing and use of newer antipsychotics improve symptom outcomes for patients with schizophrenia. Mental Health QUERI (MHQ) has found that antipsychotic prescribing often deviates from VHA guideline recommendations. This demonstration project employed a multi-component intervention to improve medication management in schizophrenia.
OBJECTIVE(S):
This study tested the effectiveness of a translation intervention to increase: 1) the proportion of patients who receive guideline-concordant antipsychotic doses, and 2) the proportion of inpatients switched from conventional to newer antipsychotics.
METHODS:
Eight VA facilities in one network were matched in pairs with regard to baseline prescribing patterns, number of patients with schizophrenia and number of mental health providers. One randomly-selected site in each pair received the multi-component translation intervention. All sites received a package of educational and clinical tools-- pocket cards, guidelines fact sheets, and patient activation materials. Translation sites participated in a 12-month program of evidence-based behavioral-change strategies, including facilitation by MHQ staff; site visits and focus groups for educational and motivational purposes; recruitment and training of opinion leaders; implementation of clinical reminders; and monthly feedback of performance measures derived from pharmacy and utilization data supplemented by medical record review.
FINDINGS/RESULTS:
At baseline, 9.0% of 4,482 patients with schizophrenia were prescribed higher-than-recommended doses of oral antipsychotics. One intervention site substantially decreased use of very high antipsychotic doses (greater than 125% of the upper bound of the recommended range), while results at other sites were mixed. The proportion of inpatients with schizophrenia who were switched from conventional to newer agents decreased, with no significant differences between translation and comparison sites. The extent of project activities at translation sites, including contact of opinion leaders with MHQ staff and provider education, correlated with improvement in antipsychotic dosing. In summary, the multi-component intervention was not consistently effective at reducing the proportion of patients receiving high antipsychotic doses. However, estimated annualized antipsychotic costs decreased 9.3% at intervention sites, in comparison to a 0.4% reduction at the comparison sites. Organizational/site characteristics may explain the variability of the intervention’s effects among sites.
IMPACT:
The intervention has been modified based on quantitative and qualitative findings, and is being tested in a subsequent project. Increased adherence to medication management recommendations of VHA schizophrenia guidelines will result in reduced practice variation and improved patient outcomes. Intervention components have been disseminated nationally.
PUBLICATIONS:
Journal Articles
- Curran GM, Thrush CR, Smith JL, Owen RR, Ritchie M, Chadwick D. Implementing research findings into practice using clinical opinion leaders: barriers and lessons learned. Joint Commission Journal on Quality and Patient Safety. 2005; 31(12): 700-7.
- Owen RR, Thrush CR, Cannon D, Sloan KL, Curran G, Hudson T, Austen M, Ritchie M. Use of electronic medical record data for quality improvement in schizophrenia treatment. Journal of The American Medical Informatics Association : JAMIA. 2004; 11(5): 351-7.
- Hudson TJ, Sullivan G, Feng W, Owen RR, Thrush CR. Economic evaluations of novel antipsychotic medications: a literature review. Schizophrenia Research. 2003; 60(2-3): 199-218.
