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.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Kirchner JE, Woodward EN, Smith JL, Curran GM, Kilbourne AM, Owen RR, Bauer MS. Implementation Science Supports Core Clinical Competencies: An Overview and Clinical Example. The primary care companion for CNS disorders. 2016 Dec 8; 18(6). [view]
2. Young AS, Niv N, Chinman M, Dixon L, Eisen SV, Fischer EP, Smith J, Valenstein M, Marder SR, Owen RR. Routine outcomes monitoring to support improving care for schizophrenia: report from the VA Mental Health QUERI. Community mental health journal. 2011 Apr 1; 47(2):123-35. [view]

VA Cyberseminars

1. Owen RR. Improving prescribing for psychiatric illnesses. QUERI Prescribing Practices. [Cyberseminar]. 2014 Oct 14. [view]

Conference Presentations

1. Owen RR, Hudson TJ, Thrush CR, Williams DK, Armitage TL, Thapa PB. An intervention to implement recommendations of schizophrenia guidelines. Paper presented at: International Congress on Schizophrenia Research; 2005 Apr 1; Savannah, GA. [view]
2. Smith JL, Owen RR, Spollen J, Curran GM. ASSIST Project to Improve Metabolic Side Effect Monitoring of Antipsychotics. Paper presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 29; Little Rock, AR. [view]
3. Smith JL, Owen RR, Curran GM. Barriers to Following Guideline Recommendations for Antipsychotic Medication Management. Poster session presented at: AcademyHealth Annual Research Meeting; 2006 Jun 25; Seattle, WA. [view]
4. Smith JL. Barriers to following guideline recommendations for Antipsychotic Medication Management. Paper presented at: VA HSR&D National Meeting; 2006 Feb 16; Arlington, VA. [view]
5. Young AS, Chinman MJ, Hamilton A, Smith J. Building Quality Improvement Teams to Address Gaps in Care: Tools, Methods, and Evaluation. Paper presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 29; Little Rock, AR. [view]
6. Owen RR, Smith JL, Hudson TJ, Curran GM. Comparison of Strategies to Improve Antipsychotic Monitoring and Management for Schizophrenia. Paper presented at: VA HSR&D National Meeting; 2008 Feb 13; Baltimore, MD. [view]
7. Owen RR, Smith JL, Hudson TJ, Curran GM. Comparison of Strategies to Improve Antipsychotic Monitoring and Management for Schizophrenia. Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 8; Washington, DC. [view]
8. Smith JL, Spollen JJ, Owen RR. Facilitation in Implementing Evidence-Based Practices for Schizophrenia: Researcher & Clinical Leader Perspectives. Presented at: VA Transforming Mental Health Care Conference; 2007 Jul 18; Alexandria, VA. [view]
9. Smith JL, Spollen JJ, Owen RR. Facilitation in Implementing Evidence-Based Practices for Schizophrenia: Researcher & Clinical Leader Perspectives. Paper presented at: University of Alberta Knowledge Translation Annual Forum; 2008 Jun 12; Alberta, Canada. [view]
10. Smith JL, Spollen JJ, Owen RR. Facilitation in Implementing Evidence-Based Practices of Schizophrenia: Researcher & Clinical Leader Perspectives. Presented at: AcademyHealth Annual Research Meeting; 2007 Jun 3; Orlando, FL. [view]
11. Owen RR. Successful Strategies Shown to Help Implement Routine Monitoring. Paper presented at: VA MIRECC Initiative on Antipsychotic Management Improvement, Improving the Health of Veterans Who Receive Antipsychotic Medications Conference; 2010 May 19; Washington, DC. [view]
12. Smith JL, Owen RR, Spollen J. Using External Facilitation to Improve Metabolic Side Effect Monitoring for Veterans Taking Antipsychotics. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 19; National Harbor, MD. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Treatment - Observational
Keywords: Schizophrenia, Translation
MeSH Terms: none