Improving Mental Health Outcomes in Veterans Through Dashboard Technology Learning Objectives 1. Describe VA Academic Detailing 2. Show how an increase in metabolic monitoring and a decrease in off-label use of antipsychotics can be achieved and sustained Amy Furman, Pharm.D. Mental Health Data Manager VA Sierra Pacific Network (V21) VA Desert Pacific Network (V22) 3. Demonstrate the VISN 21/22 Academic Detail Dashboard products and tools 2 What is VA Academic Detailing? Academic Educator for Pilot Program Clinical mental health pharmacists Work with mental health providers to provide increased access to current literature Do you have experience working with an Academic Detailing Program? 1. Yes Our Purpose Provide evidence based non-commercial biased educational outreach to patients and providers More appropriately utilize healthcare system resources AIM Using clinical pharmacists as academic educators, partner with MH providers to improve veteran health outcomes for patients using mental health medications by July 212 2. No 3 4 Opportunities to Improve High rate of poly-pharmacy in MH based on 5 drug review Poor coordination of care between MH and PC Low rates of metabolic monitoring in MH Low rates of clozapine and risperidone use High off-label use of Atypical Antipsychotics High dose Low dose Dementia PTSD Which topic is of most interest to you? 1. Improving the monitoring of metabolic syndrome and reducing related risks 2. Fostering greater use of clozapine in refractory patients diagnosed with schizophrenia 3. Decreasing the off-label use of antipsychotics 4. Other 5 6 Page 1 of 7
Structured Educational Outreach Visit Process Topic Key Message Tools Results (metrics) Every message (principle) has tools and a specific metric Cannot determine success of a message without metrics Tools should reinforce message and promote results Metabolic Monitoring Weight, BP, BG, and lipids should be monitored at least annually Consider alternative agents minimize metabolic risk Select agents with more favorable metabolic profiles Key Messages Off Label Use Clozapine Utilization Explore alternate therapeutic FGA and SGA have similar options for patients with PTSD, efficacy as initial therapy Dementia and Sleep Optimize monotherapy before using multi drug therapy Evaluate alternate treatment options before using higher than labeled dosing Clozapine is superior for treatment resistant schizophrenia Efficacy and safety of high dose antipsychotics has not been demonstrated 7 8 Tools Poster to Increase Patient Involvement Evaluate Clinics for Equipment Provider Educational Materials Patient Educational Handouts Letters to the Patient Posters Promoting Patient Involvement Quick Reference Cards for Providers Mental Health Clinical Dashboards Actionable Reports 9 1 Mental Health Dashboards Mental Health Dashboard Benefits Leverages local, regional and national data Daily data extraction from data warehouse Analyzes entire mental health patient population Information can be used to: Track performance administratively Make clinical interventions to improve patient outcomes 11 12 Page 2 of 7
Metabolic Monitoring Dashboard Metabolic Monitoring Dashboard and Reports 13 14 Drill Down Options Making a Difference: Provider Level Data Link to a report of patients requiring action 15 16 Upcoming Appointments Report Drill to Detail Entire Panel Report 17 18 Page 3 of 7
Post Traumatic Stress Disorder Evidence Based Prescribing Dashboard and Reports Re examining our use of Antipsychotics in PTSD, Risk vs Benefit, Are there candidates to do a trial off of antipsychotic 19 2 Risperidone Not Effective in PTSD What about all the other ones Krystal Study JAMA August 211 (1) No difference than placebo in Cognitive Global Impression scale Despite its widespread use, risperidone (Risperdal) is not effective in patients with combat-related PTSD, according to the results of a multicenter VA study. Risperdal, an antipsychotic, has been found successful in treating schizophrenia, bipolar disorder, and some of the symptoms of autistic disorder. The drug acts primarily on the dopaminergic and serotonergic systems. Physicians have been using risperidone and other second-generation antipsychotics as adjunctive therapy for PTSD patients who do not respond to selective serotonin reuptake inhibitors (Saris) believing that it could improve the hyperarousal and re-experiencing symptoms of PTSD US Medicine Report August 211 Examine Opportunities for Interventions Off Label Indications $1,337,68 annualized cost / 2352 patients Which Antipsychotics are used? VISN 21 2352 Patients All Patients Patients >= 12 Fills 2352 338 Avg Cost/ Patient $ 571.41 $ 1,195.65 DrugName WithoutDose Patients Fills Total Cost QUETIAPINE 182 9226 $ 63,738.32 OLANZAPINE 195 127 $ 328,212.97 ARIPIPRAZOLE 32 1355 $ 32,216.16 ZIPRASIDONE 44 232 $ 62,565.2 RISPERIDONE 81 2835 $ 31,652.15 PERPHENAZINE 39 133 $ 6,241.11 CHLORPROMAZINE 19 55 $ 798.25 THIOTHIXENE 3 26 $ 618.87 HALOPERIDOL 61 187 $ 499.24 Consider Role of AP in Off Label Indications (PTSD, Dementia, Sleep) 21 22 Non Evidence Based Prescribing Report Do you currently have a method to evaluate adherence? Upcoming Appointments 1. Yes 2. No Sum of Day s Supply Received Sum of Day s Elapsed = Adherence 23 24 Page 4 of 7
PTSD with an Antipsychotic and No Antidepressant Report Weighing the Risks and Benefits If I am already obese, does it bother me to be put on a drug at risk of causing weigh gain and cardiac risk given I am struggling to get the weight off, and I m trying to get my depression symptoms under control? As a patient would I choose Diabetes over a good night sleep? 25 26 Reducing Risk Increasing Benefit 27 28 Clozapine Dashboard Clozapine Report Allows you to select: Station Mental Health Provider Distance from Medical Center 29 3 Page 5 of 7
Total Hits April July 211 Total Hits By VISN 14 9 12 8 1 7 6 8 6 5 4 VISN 21 VISN 22 3 4 2 2 1 4/1/211 5/1/211 6/1/211 7/1/211 Apr-11 May-11 Jun-11 Jul-11 Hits By Report 6 5 4 Clozapine Metabolic Appointment Metabolic Entire Panel Metabolic Prescriber Appointment Metabolic Prescriber Entire Panel Off Label Appointment Off Label Entire Panel Unassigned Patients Results Interim analysis completed October 21 through February 211 3 2 1 4/1/211 5/1/211 6/1/211 7/1/211 34 e FY21 to FY211 nterim Analysis) % from Baselin (5 Month In 2.5 2 1.5 1.5 MEASURE: Annual Metabolic Monitoring % Change FY21 to FY211 Weight Blood Pressure Glucose/A1c HDL Triglycerides VISN 21 1.4 1 1 1.3 1.3 VISN 22 2.3.6.9.9 Combined VISN 21/22 1.7.6.8 1.2 1 18% 16% 14% 12% 1% 8% 6% 4% 2% % % Patients Receiving Two or More Antipsychotics PolyPharmacy Impact Pre Intervention Post Intervention * P<.1 * p<.1 * P<.1 VISN 21 VISN 22 Combined V21/V22 36 Page 6 of 7
14% 12% 1% Patients Using Low Dosed Antipsychotics Chronically (>9 Days) For Sleep, Dementia & Other Off labeled Indications Pre Intervention Post Intervention Summary of Interim Results: Metabolic Risk Reduction Significant improvements in monitoring was found for combined analysis VISN 21/22 by working with individual facilities to address site barriers. 8% 6% * P <.1 * P <.1 * P <.1 Metabolic control has a longer lag time to impact with the both prescribing changes of antipsychotics and treatment of patients with metabolic abnormalities. 4% 2% % VISN 21 VISN 22 Combined V21/V22 Gap in care between PCP and patient management goals, will be difficult to attain metabolic control for % of the population. 38 Conclusions Mental Health Dashboards and Academic Detailers collaborative model demonstrated early impact on prescribing practices in VISN 21/22. Patient clinical outcomes require a longer duration for measurement period to see the total t impact of the provider behavior change. What OPPORTUNITIES Do You See? How do we Make IT happen? Further evaluation is needed to determine which modalities of this educational model are most effective. 39 4 References 1. Edersheim, JG. Off-label prescribing. Psychiatric Times volume 26, no. 4 accessed at http://www.psychiatrictimes.com/display/article/1168/141983?pagenumber=2 (June 7, 29). 2. O Brien MA, et al. Educational outreach visits: effects on professional practice and health care outcomes (Review). The Cochran Collaborative, 28. 3. A template for establishing and administering prescriber support and education programs: A collaborative, service-based approach for achieving maximum impact. A report by Prescription Policy Choice s Academic Detailing Planning Initiative, 28 4. Siegel, A et al. Academic Detailing to Improve Antihypertensive Prescribing Patterns. Am J Hyperten 23; 16: 58-11. 5. Stender M et al. Medical resource use among patients treated for bipolar disorder: a retrospective, cross sectional, descriptive analysis. Clin Ther 22; 24 (1)1668-16761676 6. Gou JJ et al. Risk of diabetes mellitus associated with atypical antipsychotic use among patients with bipolar disorder: A retrospective, population based, case-control study. J Clnic Psychiatry 26; 67(7) 155-161. 7. Jing et al. Healthcare costs associated with treatment of bipolar disorder using a mood stabilizer plus adjunctive ripiprazole, quetiapine, risperidone, olanzapine or ziprasidone. J Med Economics 29; 12(2): 14-113. 8. Gibson T, et al Cost Burden of Treatment Resistance in Patients with Depression AJMC 21 16, (5);37 377. 9. Rush AJ, et al Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D Report. Am J Psychiatry 26; 163(11); 195-1917. 1. Krystal JH, et al. Adjunctive risperidone treatment for antidepressant-resistant symptoms of chronic military service-related PTSD: a randomized trial. JAMA 211;36(5):493-52. 41 Page 7 of 7