Intervention Fails to Boost Metabolic Monitoring Rates

Deborah Brauser

May 25, 2012

May 25, 2012 (Philadelphia, Pennsylvania) — Rates of metabolic monitoring of patients taking antipsychotic medications remains subpar — leading to the need for much better implementation tools and reminders for clinicians, new research suggests.

Despite treatment guidelines, a study of adult patients enrolled in a primary care/community health network who were prescribed a second-generation antipsychotic (SGA) showed that only 30% to 40% underwent complete baseline measurement of metabolic parameters. These overall rates were not significantly different between psychiatric care providers and other medical providers.

Even after the implementation of a new education program that included electronic monitoring record (EMR) prompts at time of prescribing and at follow-up visits, monitoring rates did not increase significantly.

"Physician awareness of this problem is not the only barrier. And education alone is not enough to increase the rates of checking," lead author Ronit K. Dedesma, MD, consultation-liaison psychiatrist at Cambridge Health Alliance in Massachusetts and an instructor at Harvard Medical School, told Medscape Medical News here at the American Psychiatric Association's (APA's) 2012 Annual Meeting.

"For example, many of our psychiatrists don't have a blood pressure cuff or scale in their offices. Also, getting patients to get their blood drawn is enormously difficult, appointments are short, and it's hard to address many things in a single doctor's visit," she added.

Dr. Dedesma said that she would encourage individual clinicians to consider and address the challenges of checking metabolic parameters.

"I would tell others to think about systems changes in their own environment that can help make getting these things done a little bit easier, including possibly getting access to a medical assistant," she said.

System-Wide Monitoring Program

It is well known that SGAs, also known as atypical antipsychotics, cause metabolic changes, including weight gain and disturbances of glucose and lipid metabolism.

In 2003, the US Food and Drug Administration began to require that SGA manufacturers place warning labels on SGAs outlining these risk and send letters to neuropsychiatric healthcare professionals.

Soon after, the American Diabetes Association and the APA jointly published a statement specifying a monitoring protocol for patients receiving atypical antipsychotics.

The statement recommends that patients on these medications undergo assessment of metabolic parameters, including weight, waist circumference, blood pressure, and blood glucose and cholesterol levels, at treatment initiation and subsequently at regular intervals.

"The idea is that if patients are checked for these things early and regularly, problems can be detected and changes can be implemented sooner so that medical complications down the road don't happen."

Still, as reported at the time by Medscape Medical News, a study published in 2010 in the Archives of General Psychiatry of a 3-state population of Medicaid recipients showed that fewer than one third of those treated with SGAs underwent blood glucose or lipid testing.

For the current study, the investigators sought to assess the metabolic monitoring rates of patients newly placed on antipsychotic medications at Cambridge Health Alliance after the implementation of a new system-wide monitoring program.

The program included educational sessions and grand rounds presentations about the morbidity associated with SGAs, along with newly developed recommended guidelines for all members of the Alliance's departments of psychiatry, family practice, and internal medicine.

Then, at the time of prescribing, clinicians were automatically prompted through the EMR about the monitoring guidelines. In addition, "EMR tools using EPIC software, such as smart phrases and flowsheets," were developed to promote metabolic monitoring at recommended intervals.

EMR data were assessed for the 798 adult outpatients who began taking SGAs during 2010 (preintervention) and the 247 who began taking SGAs in 2011 (postintervention).

The investigators evaluated metabolic monitoring rates at baseline (when the patient was first prescribed an SGA) and at a 12-week follow-up. Waist circumference rates were not able to be monitored because of issues with the study software.

Little Change

Results showed that 64% of the SGA prescriptions were written by psychiatrists in 2010, 26% were by family care providers (PCPs), and 10% were written by both a psychiatrist and a PCP.

In 2011, after the educational intervention had been implemented, these percentage rates changed to 59%, 38%, and 3%, respectively.

Overall, 26% of the prescriptions were written for unlisted diagnoses, 23% were for "other" disorders (including insomnia or pain), 19% were for bipolar disorder, 15% were for psychosis, 11% were for anxiety disorders, and 4% were for substance use disorders.

Preintervention, the PCPs measured weight at a rate of 67% at baseline and at a rate of 73% at the 12-week follow-up. They also checked blood pressure at rates of 83% to 87% at baseline and at 77% at follow-up. Glucose and lipid levels were checked at rates of approximately 45% and 22%, respectively, "at all time-points pre- and postintervention."

Weight and blood pressure check rates remained relatively the same postintervention.

For the psychiatrists at preintervention, weight was checked at a rate of 32% at baseline and 65% at follow-up, and blood pressure was checked at a rate of 58% at baseline and 70% at follow-up. These rates stayed relatively the same postintervention.

Also postintervention, the psychiatrists checked glucose at rates of 33% at baseline and at 43% at follow-up, and they checked lipids at 11% at baseline and at 19% at follow-up.

"Our initial efforts don't seem to have made much of a difference at all. However, the psychiatrists did significantly better at the 12-week follow-up than they did when they first started communication," said Dr. Dedesma.

"This makes a lot of sense because when you see a patient and assess that they need an antipsychotic for their disorder, you're doing a lot of psycho-education and talking about the potential side effects of the medication. That visit always runs over, so weight checks, etc, often get delayed until the next visits."

On the other hand, the monitoring rates for PCPs "tended to be no different" in terms of baseline vs 12-week follow-up.

"Ideally, the number of patients on antipsychotic medication who get checked for the metabolic parameters at recommended intervals would be 100%. But for a number of reasons, we're not there yet," said Dr. Dedesma.

She reported that her team is continuing their educational efforts and working on more EMR tools to remind physicians "when a patient is due to be checked."

"In addition, we're discussing systems-based changes that we can implement to increase the rates of adherence to the monitoring recommendations. We hope that this will ultimately result in better patient health," she said.

Great Potential

Jeffrey Borenstein, MD, medical director of Holliswood Hospital in New York City and chair of the APA Council on Communications, told Medscape Medical News that the use of EMR "offers an opportunity to really improve patient care."

"Putting systems in place through electronic medical records can really make a difference," said Dr. Borenstein, who was not involved with this study.

"I see this as having great potential for us as a field."

Dr. Dedesma and Dr. Borenstein have disclosed no relevant financial relationships.

The American Psychiatric Association's 2012 Annual Meeting. Abstract Poster #NR7-33. Presented May 7, 2012.