Linchpin to Success: Engaging Staff in Implementation of Long-Acting Injectable Medications

Transcription

1 Linchpin to Success: Engaging Staff in Implementation of Long-Acting Injectable Medications The Care Transitions Network National Council for Behavioral Health Montefiore Medical Center Northwell Health New York State Office of Mental Health Netsmart Technologies

2 Please welcome John M. Kane, MD: Vice President for Behavioral Health Services of the North Shore - Long Island Jewish Health System and Chairman of Psychiatry at The Zucker Hillside Hospital. He is Professor of Psychiatry, Neurology and Neuroscience and holds the Dr. E. Richard Feinberg Chair in Schizophrenia Research at the Albert Einstein College of Medicine.

3 Objectives Key to the success of any new practice is the engagement and support of staff who are responsible for its day-to-day implementation. In this Part 2 of the LAI webinar series, we explore strategies for working with prescribers, therapists, and administrative staff to understand the relevance of LAI medications, address common questions and potential barriers and motivate change.

4 Why staff attitudes are important to address Weiden and colleagues (2014) recorded and analyzed conversations about offering LAI treatment between psychiatrists at community mental health centers and their patients with schizophrenia Psychiatrists commonly Prioritized discussion of risks over benefits Did not provide a strong patient-specific rationale for LAIs Were tentative in the offer of LAIs Identified the offer of LAIs as an imposition to the patient J Clin Psychiatry Jun;76(6):684-90

5 Relevance of LAIs Roughly half of patients with schizophrenia do not adhere to their prescribed medication regimen. The yearly cost of re-hospitalization in this population due to non-adherence in 1993 is estimated at $800 million. Depot medications offer an advantage in early recognition of noncompliance. If 50% of this population is not adherent, it would seem logical that 50% of antipsychotic prescriptions would be for depot medications. The paradox is that depot antipsychotics play a relatively minor role in treatment of schizophrenia. American clinicians use these medications less compared to physicians abroad. Shi L, Ascher-Svanum H, Zhu B, et al. Characteristics and use patterns of patients taking first-generation depot antipsychotics or oral antipsychotics for schizophrenia. Psychiatr Serv 2007; 58 (4): Glazer, WM (2007) The depot paradox. Behav Healthc 27:44-46

6 Guidelines

7 Multiple schizophrenia guidelines recognize LAIs as a treatment option But usually when non-adherence with oral medication has led to relapse, for example: APA (2004): Consider an LAI when non-adherence has led to recurrent relapses RANZCP (2005): Despite psychosocial adherence interventions a patient repeatedly fails to adhere to necessary medication and relapses frequently PORT: Frequent relapses on oral medication or a history of poor adherence with oral medication APA=American Psychiatric Association; PORT=Patient Outcomes Research Team; RANZCP=Royal Australian and New Zealand College of Psychiatrists Lehman AF, et al. Am J Psych. 2004;161(Suppl 2):1-56.

8 Some guidelines take a broader view of LAI use NICE (2014): Consider LAI for people with schizophrenia: Who would prefer such a treatment after an acute episode Where avoiding covert non-adherence (either intentional or unintentional) to antipsychotic medication is a clinical priority NICE=National Institute for Health and Care Excellence NICE Schizophrenia full guidelines (update), March 2014; Lehman AF, et al. Am J Psych. 2004;161(Suppl 2):1-56. LAIs are an important treatment option for many patients

9 Potential barriers: Why are many psychiatrists reluctant to use LAIs?

10 Psychiatrists, % Psychiatrists cite multiple reasons for not prescribing LAI atypical antipsychotics % 80% 75% 71% 68% 58% % Sufficient Adherence to Oral Patient Refusal Antipsychotic Not Available as LAI Costs of Drug Not Appropriate Option After Relapse Poorer Control of Effect Compared to Oral Drug High EPS Risk With LAI EPS=extrapyramidal symptom; LAI=long-acting injectable. Heres S et al. J Clin Psychiatry. 2006;67(12):

11 Other reasons for reluctance to offer LAIs Clinicians lack of knowledge of LAIs Especially dose and pharmacokinetics Lack of experience with LAIs among younger staff Misconceptions (e.g., higher side effect burden with LAIs vs oral antipsychotics) Clinicians attitudes regarding of LAIs Overestimate their patients medication adherence Believe LAI is less acceptable to patients than oral antipsychotics Concerns over stigma and coercion FGA=first-generation antipsychotic; OAPs=oral antipsychotics Heres S, et al. Int Clin Psychopharmacol. 2007;22(5): ; Patel MX, et al. Psychol Med. 2003;33(1):83-89.

12 Clinicians attitudes regarding LAIs Some psychiatrists regard LAIs as inappropriate for first-episode patients 34% UK (Patel et al 2010) 71% Germany (Heres et al 2006)

13 Patients views more positive Patients favor their current formulation 1 Overall 18% 40% report preferring LAI to oral Higher rates if restricted to patients prescribed LAIs Most patients with schizophrenia report not receiving information about LAIs 2 Includes early intervention patients 3 1. Walburn et al, 2001; 2. Jaeger and Rossler, 2010; 3. Das A, et al Therapeutic Advances Psychopharmacology Clinicians beliefs may act as a prescribing barrier to the use of LAIs in early schizophrenia

14 Most psychiatrists have to judge an LAI as clearly superior to OAP regarding relapse prevention before recommending IT OAP=oral antipsychotic; RCTs=randomized controlled trials. Hamann J, et al. Eur Neuropsychopharmacol. 2010;20:

15 Psychiatric nurses attitudes Interprofessional group differences exist which may undermine the treatment process. Community psychiatric nurses believed depot medications are Old fashioned 34% Stigmatizing 44% Compromised patient autonomy 28% Are coercive 42% Familiarity with depots and knowledge of side effects were positively associated with favorable attitudes. Patel, MX et al. Antipsychotic depot medication and attitudes of community psychiatric nurses. Journal of Psychiatric and Mental Health Nursing, 2005, 12,

16 Psychiatrist and psychiatric nurses perceptions of LAI antipsychotics Perception Nurses Psychiatrists P % (N=96) % (N=103) Stigmatizing Old-fashioned Less acceptable to pts Coercive <.001 Compromise autonomy <.001 More bothersome UK community mental health professionals Patel MX, et al. Psychol Med. 2003; Patel MX, et al. J Psych Ment Health Nursing. 2005

17 Logistical concerns Wilbur et al. found that most (86%) of nurses surveyed had favorable attitudes to administering depots but rated this as a task of low importance. In other queries, some felt depot administration did not utilize their skills and could be done by other nurses. (Bennet et al. 1995). It has been suggested that discontent from nursing staff regarding depot administration is related to a low level of involvement with treatment planning. (Svedberg et al. 2000). Bennett J, et al. (1995) Assessing the side-effects of antipsychotic drugs: a survey of CPN practice. Journal of Psychiatric and Mental Health Nursing 2, Walburn J. et al. (2001) Systematic review of patient and nurse attitudes to depot antipsychotic medication. British Journal of Psychiatry 179, Patel, MX et al. Antipsychotic depot medication and attitudes of community psychiatric nurses. Journal of Psychiatric and Mental Health Nursing, 2005, 12, Svedberg B. et al. (2000) The mortality of treating patients with depot neuroleptics: the experience of community psychiatric nurses. Nursing Ethics 7,

18 Other barriers to LAI use Service barriers Lack of community nurses to administer LAI Lack of reimbursement Financial barriers Higher acquisition cost of LAI Failure to consider total illness costs Heres S, et al. Int Clin Psychopharmacol. 2007;22(5): ; Patel MX, et al. Psychol Med. 2003;33(1):83-89

19 Education on LAIs is critical Clinicians and ancillary staff, as well as patients and their families, need education about the potential benefits of LAI agents. Clinicians and the extended care team should be able to expect and address any issues that patients may have about LAI antipsychotics. The first step in this educational process is to acknowledge concerns of using LAI antipsychotics from the point of view of patients and their families as well as of healthcare professionals. Following this overview of pros and cons, detailed education about LAI therapy and its most appropriate uses should be tailored to the healthcare team. Then, these team members can identify patients for whom LAI antipsychotics may improve outcomes and educate those patients and their families about this treatment option. Correll CU. J Clin Psychiatry. 2014;75(9):e25.

20 Healthcare professionals concerns Healthcare providers may lack appreciation of patients true non-adherence rates so they attribute relapses to chronic disease rather than to inconsistent medication adherence. Members of the healthcare team may also have reservations about using LAI antipsychotics. Typically, LAI drugs are used as a last resort for patients who have had multiple hospitalizations. Trials of LAI versus oral antipsychotics have produced mixed outcomes. Many providers lack training and experience with LAI agents. Inflexible dosing Organizational barriers, such as lack of healthcare team buy-in and insufficient financial or staff resources, may also hinder the use of LAI antipsychotics. Kane JM, et al. J Clin Epidemiol. 2013;66(suppl 8):S37-S41; Kane JM, et al. World Psychiatry. 2013;12(3): ; Kaplan G, et al. J Patient Pref Adher. 2013;7: ; Jaeger M, Rossler W. Psychiatry Res. 2010;175(1-2):58-62.

21 Response to healthcare professionals concerns LAIs offer continuous medication delivery, which can help promote adherence, reduce symptoms, and improve functioning. Healthcare team will know if the patient has missed an appointment and can mobilize the family to help intervene and get patients back into treatment in a timely manner. When a LAI agent is stopped, the blood levels do not drop precipitously. With LAI formulations, the staff will not be guessing about treatment efficacy. If patients receive the injection and do not experience an adequate improvement, then the medication needs to be changed. Zhornitsky S, Stip E. Schizophr Res Treatment. 2012;2012:407171

22 Patients and family concerns More frequent appointments Fear of injection site pain Worry that the conversion from an oral to an LAI medication might be difficult They will be unable to stop the medication when a severe side effect occurs Perceived stigma of LAI antipsychotics (e.g., I need an injection therefore I am sicker ) May be deterred by real or perceived increase in medication costs

23 Response to patients and family concerns Clinicians need to be able to point out that the benefits can outweigh these concerns. Injection appointment may strengthen the therapeutic alliance and decrease relapse and rehospitalization rates. Physicians should describe the process for transitioning to an LAI medication and be sure to stress that injection site pain in general is mild and transient. Although injected medication cannot be stopped like an oral agent can, the continuous antipsychotic coverage should be a major benefit rather than a drawback, and most relevant side effects can be managed even in the continued presence of the antipsychotic. Patients may have fewer side effects than with an oral Less stress over the need to remember to take an oral medication regularly. Family members will be relieved of the need to constantly check on patients adherence. Cost questions should be addressed with team members who handle insurance coverage. Atkins S, et al. BMC Psychiatry. 2014;14(1):7; Weiden PJ, et al. Psychiatr Serv. 2004;55(8): ; Zhornitsky S, Stip E. Schizophr Res Treatment. 2012;2012:

24 Patients are willing to accept LAI antipsychotic therapy when properly informed In a survey of psychiatrists: Patient refusal was cited as a primary reason for not prescribing LAI antipsychotics 1 In a survey of patients without LAI antipsychotic experience: 79% cited having never been informed about the option by their psychiatrist 2 75% of psychiatrists felt that they informed the patient, but only 33% of patients felt informed 2 In a survey of patients with >3 months of LAI antipsychotic experience: Injectable antipsychotics were the preferred formulation 3 70% of patients felt better supported in their illness by virtue of regular contact with the doctor or nurse who administered their injection 3 In another study, 77% of FEP pts offered LAI risperidone accepted it 4 LAI = Long acting injectible FEP = Federal Employee Program Heres S. et al. J Clin Psychiatry. 2006;67(12): Jaeger M, Rossler W. Psychiatry Res. 2010;175(1-2): Caroli F et al. Patient Prefer Adherence. 2011;5: Weiden P, et al. J Clin Psychiatry. 2012;73(9):

25 Administrator concerns based upon early results of a survey of administrators in New York Many do not have a prescriber background so they do not have the ability to evaluate medication decisions The CTN provides education about the potential benefits of LAIs Having an active LAI program will change the nature of the facility s patient population and the facility will get referrals of patients with adherence problems Patients who accept referral to a facility because the facility will provide LAIs have already made a decision to enhance their adherence to medication treatment Facilities with LAI programs help to counter stigma against patients who prefer LAI treatment

26 Administrator concerns based upon early results of a survey of administrators in New York Logistical issues Recruiting someone to administer the injections Training staff Obtaining the medications Storage of medications and needles Financial aspects Approvals for the medications Co-pays For help with logistics, please view the 3 rd webinar in this series that is devoted to workflows and other logistical issues concerning LAIs.

27 A key element for all clinic staff The healthcare field is moving towards value based reimbursement If clinics are going to be prepared for that, reducing rates of relapse and hospitalization is key Use of LAIs can be an important component of strategies to reduce rates of relapse and hospitalization

28 Solutions to motivate change

29 Solutions to motivate change Administrators need to support clinical environments that promote clinicians' ability to monitor non-adherent behavior in patients Education. Clinicians need the education and the time to work with nonadherent patients. Prescribers, especially younger ones, need to receive adequate training, specifically in the use of depot formulations Teamwork. Clinicians working in multidisciplinary teams need to understand the division of labor and the responsibilities for implementing specific tactics to decrease patients' non-adherent behavior We must destigmatize depot formulations Glazer, WM (2007) The depot paradox. Behav Healthc 27:44-46

30 Solutions to motivate change Training/refresher courses about depots should highlight systematic treatment decision-making and side effect monitoring which may improve professionals attitudes and knowledge about and clinical monitoring of depots. There is not literature about other health professionals attitudes (LCSWs, MHCs, psychologists) but these professionals are often actively engaged with patient care and may have greater contact with patients and families. Exploring attitudes of these staff members and including them in psychoeducation would be helpful. Patel, MX et al. Antipsychotic depot medication and attitudes of community psychiatric nurses. Journal of Psychiatric and Mental Health Nursing, 2005, 12,

31 References Weiden, P. et al. The challenge of Offering Long-Acting Antipsychotic Therapies: A Preliminary Discourse Analysis of Psychiatrist Recommendations for Injectable Therapy to Patients With Schizophrenia. J Clin Psychiatry 76:6, June Samalin, L. et al. Clinicians Attitudes Toward the Use of Long-Acting Injectable Antipsychotics. The Journal of Nervous and Mental Disease. Volume 201, Number 7, July Rossi, G. et al. Long-Acting antipsychotic drugs for the treatment of schizophrenia: use in daily practice from naturalistic observations. BMC Psychiatry 2012, 12:122. Patel, MX. et al. Psychiatrists use, knowledge and attitudes to first- and second-generation antipsychotic long-acting injections: comparisons over 5 years. J Psychopharmacol (2009) Llorca, PM. et al. Guidelines for the use and management of long-acting injectable antipsychotics in serious mental illness. BMC Psychiatry 2013, 13:340. Geerts, P. et al. Attitudes towards the administration of long-acting antipsychotics: a survey of physicians and nurses. BMC Psychiatry 2013, 13:58.

32 References Besenius, C. et al. Health professionals attitudes to depot injection antipsychotic medication: a systematic review. Journal of Psychiatric and Mental Health Nursing, 2010, 17, systematic review. Journal of Psychiatric and Mental Health Nursing, 2010, 17, Hamann, J. et al. Checking the plausibility of psychiatrists arguments for not prescribing depot medication. European Neuropsychopharmacology (2014) 24, Heres, S. et al. Psychiatrists attitudes to antipsychotic depot treatment in patients with first-episode schizophrenia. European Psychiatry 26 (2011) Jaeger, M and Rsooler, W. Attitudes towards long-acting depot antipsychotics: A survey of patients, relatives, and psychiatrists. Psychiatry Research 175 (2010) Kaplan, G. et al. Impact of long-acting injectable antipsychotics on medication adherence and clinical, functional, and economic outcomes of schizophrenia. Patient Preference and Adherence. 2013:

33 References Patel, MX et al. Antipsychotic depot medication and attitudes of community psychiatric nurses. Journal of Psychiatric and Mental Health Nursing, 2005, 12, Walburn J. et al. (2001) Systematic review of patient and nurse attitudes to depot antipsychotic medication. British Journal of Psychiatry 179, Bennett J, et al. (1995) Assessing the side-effects of antipsychotic drugs: a survey of CPN practice. Journal of Psychiatric and Mental Health Nursing 2, Svedberg B. et al. (2000) The mortality of treating patients with depot neuroleptics: the experience of community psychiatric nurses. Nursing Ethics 7, Zhornitsky S, Stip E. Oral versus long-acting injectable antipsychotics in the treatment of schizophrenia and special populations at risk for nonadherence: a systematic review. Schizoph Res Treatment. 2012; 2012:

34 References Kim, B. et al. Long-Acting Injectable Antipsychotics for First-Episode Schizophrenia: The Pros and Cons. Schizophrenia Research and Treatment. Volume 2012, Article ID Kane, J. et al. Guidelines, for depot antipsychotic treatment in schizophrenia. European Neuropsychopharmacology 8 (1998) Kane, J and Garcia-Ribera, C. Clinical guideline recommendations for antipsychotic longacting injections. BJP 2009, 195:S63-S67. Glazer, WM (2007) The depot paradox. Behav Healthc 27:44-46 Shi L, Ascher-Svanum H, Zhu B, et al. Characteristics and use patterns of patients taking first-generation depot antipsychotics or oral antipsychotics for schizophrenia. Psychiatr Serv 2007; 58 (4):

35 Thank you! For Questions Please The project described was supported by Funding Opportunity Number CMS-1L from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. Disclaimer: The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.