APNA 27th Annual Conference Session 2036: October 10, 2013

Transcription

1 Leigh Powers DNP, MSN, MS, BS, APRN, PMHNP BC APNA Annual Conference October 10, 2013 *The speaker has no conflicts of interest to disclose Compare quality of care through measurement of adherence to a practice guideline when prescribing atypical antipsychotics to published measures. Clearly identify the guidelines for monitoring side effects when prescribing second generation antipsychotics. Identify implications for future implementation of evidence based practice for improved patient outcomes and quality care. In any given year, 1 in 4 adults in US will suffer with mental illness ~57.7 million in 2004 (NIMH, n.d.) WHO reports mental illnesses 4 of top 10 leading causes of disability in US and other developed countries (NAMI, 2010) Community Mental Health Centers (CMHCs) treat large percentage with services including medication management (APA, 1998) Powers 1

2 Medication management = symptom evaluation and prescribing psychotropic medications including second generation antipsychotics (SGAs) Association between SGAs and cardiometabolic symptoms, associated metabolic syndrome and diabetes (Cassels, 2010) Symptoms = elevated BP and FBG elevated triglycerides central obesity abnormal cholesterol levels (Newcomer, 2007) In 2004, ADA/APA created consensus guidelines for monitoring SE (APA/ADA, 2004) Newcomer, Nasrallah & Lobel (2006) stated lack of knowledge of SE 59% associated weight gain 51% diabetes 22% dyslipidemia Amiel et al. (2008) report rates from retrospective review <20% receive baseline glucose testing <10% receive baseline lipid testing Morrato et al. (2010) 80% psychiatrists aware of guidelines, 2/3 CMHCs had protocols Actual study results = 26.9% baseline glucose; 10% baseline lipids No change in results after publication of guidelines and warnings Explore adherence rates at CMHC in Southeast US by retrospective chart review of electronic medical records (EMR) Patient admitted to services between Oct 2009 to Oct 2010 Select from EMR randomly by utilizing random number generator at random.org 603 EMR reviewed until 50 unique records were obtained meeting all inclusion criteria Must be receiving medication management Prescribed a SGA during course of treatment Powers 2

3 Axis I Diagnosis Cardiometabolic DX Ethnicity Age Smoking Status Gender Past SGA Use **Initiation and One Year Interval Baseline 4 weeks 8 weeks 12 weeks Quarterly Annually Weight (BMI) X X X X X Waist Circumference X X Blood pressure X X X Fasting plasma glucose X X X Fasting lipid profile X X **Fasting lipid profile also recommended every 5 years 76% DX associated with higher predisposition for cardiometabolic risks Ethnicity 88% Caucasian (79.2%) 8% African American (16.5%) 2% Hispanic (3.7%) 2% Other (1.3%) Males = 44% (48.7%) Females = 56% (51.3%) TN statistics in RED (US Census Bureau, 2010) Powers 3

4 INITIAL 54% Previously prescribed a SGA 44% no past SGA usage 2% Unknown 90% did not have a known metabolic disorder 10% have metabolic disorder (4 Diabetes, 1 Metabolic Syndrome) ONE YEAR 74% did not have a known metabolic disorder 6% have metabolic disorder (20/50 missing responses no appt, discharged, no show) BASELINE 3 MONTHS 1 YEAR FBG/FLP 30% (26.9%/10%) 20% 14% Decrease inversely related to increase no show rate Similar monitoring trend for other quantitative data other than waist circumference ( 6%) Future Directions: Do consensus guidelines result in decreasing SE from SGAs? Are recommended monitoring time points beneficial? Are these monitoring practices consistent with evidence based practice and research? Areas for improvement: Structure Process Outcome Structure: Transportation services Increase support staff Clinic hours Process : Templates Flagging documentation Administrator review of EMR Integration of CEU (Donebedian, 1980) Powers 4

5 American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity. (2004). Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care, 27(2), American Psychiatric Association. (1998, December). Guidelines for psychiatric practice in community mental health centers (Reference No ). Washington, DC: The American Psychiatric Association. Amiel JM, MangurianCV, Ganguli R, Newcomer JW. (2008). Addressing cardiometabolic risk during treatment with antipsychotic medications. Current Opinions in Psychiatry, 21(6), Cassels, Caroline. (2010). Metabolic monitoring in patients taking second generation antipsychotics remains poor. Medscape Medical News. Retrieved from Donabedian, A. (1980). Definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press. Montejo, A. L. (2010). The need for routine physical health care in schizophrenia. European Psychiatry, 25, S3 S5. Morrato, E. H., Druss, B., Hartung, D. M., Valuck, R. J., Allen, R., Campagna, E., & Newcomer, J. W. (2010). Metabolic testing rates in 3 state Medicaid programs after FDA warnings and ADA/APA recommendations for second generation antipsychotic drugs. Archives of General Psychiatry, 67(1), National Alliance on Mental Illness (2010). What is mental illness: Mental illness facts. Retrieved August 2, 2010, from National Institute of Mental Health (n.d.). The impact of mental illness on society. Retrieved from Newcomer, J. W. (2007). Metabolic considerations in the use of antipsychotic medications: a review of recent evidence.journal of Clinical Psychiatry, 68 (suppl 1), Newcomer, J. W. (2007). Metabolic syndrome and mental illness. The American Journal of Managed Care, 13, S170 S177. Newcomer, J. W., Nasrallah, H. A., & Loebel, A. D. (2006). The atypical antipsychotic therapy and metabolic issues national survey: practice patterns and knowledge of psychiatrists. Journal of Clinical Psychopharmacology, 24, S1 S6. United States Census Bureau (2010). Tennessee. Retrieved from Powers 5