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BACKGROUND/RATIONALE:
Antipsychotic medication is by far the most widely utilized treatment for schizophrenia in VA settings, and the VA has established guidelines for the appropriate use of these medications. The recent introduction of a new generation of antipsychotic medications has also offered great hope to persons with schizophrenia, but also may adversely affect health due to metabolic side effects. Improving all aspects of antipsychotic medication management is necessary to improve outcomes for persons with schizophrenia.
OBJECTIVE(S):
The goal of this project is to translate research findings about key aspects of antipsychotic treatment into routine care through a multi-component intervention. Mental Health QUERI's (MHQ) previous project for improving antipsychotic treatment demonstrated that a multi-component intervention improved use of guideline-recommended antipsychotic doses. This project will build on results and lessons learned from MHQ's previous translation project. The scope of translation will be expanded from an ongoing focus on reducing high antipsychotic doses to include two additional aspects of medication management that are directly linked to patient outcomes: 1) increasing monitoring for potentially serious side effects of newer antipsychotic medication,
and 2) increasing the appropriate use of clozapine for treatment-refractory patients.
METHODS:
The project is employing a multi-component intervention for improving antipsychotic prescribing while comparing the use of two different interpersonal marketing/influence strategies for translation. The primary objective is to compare the effectiveness of a team-based QI approach and a strategy using a clinical opinion leader augmented by an implementation coordinator to improve antipsychotic medication management. In addition, MHQ will determine the impact of a support and consultation program to promote clozapine prescribing. A total of ten VA Medical Centers from 4 different VA health care networks (VISNs) have been selected to participate on the basis of number of patients with schizophrenia, baseline performance on quality indicators, and organizational characteristics. Six of these sites will focus on side effect monitoring and antipsychotic dosing (two team-based QI, two clinical opinion leader, and two control), while two will receive the clozapine consultation program, with two matched control sites. Selected clinicians and staff (opinion leaders) will be identified and trained, and will implement the multi-component intervention consisting of educational materials and programs, information system tools, and performance monitoring and feedback. The intervention will take place for 6 months, and will be assessed with regard to improvement in side effect monitoring, high dose antipsychotic prescribing, and clozapine use. In addition, MHQ will assess impact of the intervention on patient outcomes at five of the sites.
FINDINGS/RESULTS:
Semi-structured qualitative interviews conducted with site participants for formative evaluation identified barriers at multiple levels that limit adherence to guidelines for antipsychotic medication management. Systems-level barriers included: (a) lack of mechanisms, structural resources or staff to ensure antipsychotic side effect monitoring is completed; (b) perceived limitations of an existing computerized clinical reminder for side effect monitoring; (c) lack of training on use of the clinical reminder; (d) difficulty interpreting and complying with VA policy on clozapine use; and (e) poor coordination with pharmacy. Provider-level barriers included: (a) lack of awareness of guideline recommendations; (b) low perceived need for quality improvement; and (c) general clinician resistance to change. Patient-level barriers included: (a) differential response to and toleration of high antipsychotic doses; and (b) patient compliance issues related to side effect monitoring. The project is ongoing, and tools and strategies designed to address these barriers are being tested.
IMPACT:
Implementation research is needed to demonstrate the two interventions' differential impact on medication management and outcomes, as well as to inform development of a national rollout strategy that is feasible, adaptable, exportable, and sustainable. Intermediate and long-term goals of this project focus on building and expanding MHQ's successful multi-component intervention while preparing for national implementation.
PUBLICATIONS:
None at this time.
DRA:
Health Services and Systems, Mental Illness
DRE:
Quality of Care
Keywords:
Schizophrenia, Translation
MeSH Terms:
none
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