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Health Services Research & Development

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2006 HSR&D National Meeting Abstract


1048 — Barriers to Following Guideline Recommendations for Antipsychotic Medication Management

Author List:
Smith JL (Center for Mental Healthcare & Outcomes Research)
Owen RR (Center for Mental Healthcare & Outcomes Research)
Curran GM (Center for Mental Healthcare & Outcomes Research)

Objectives:
Antipsychotic medication is the most widely utilized treatment for schizophrenia in VA settings, and VA has established guidelines for the appropriate use of these medications. This abstract reports results from a formative evaluation assessing barriers to following guideline recommendations for antipsychotic medication management in a multi-site project to develop and test multi-component interventions to improve care for patients with schizophrenia.

Methods:
Semi-structured qualitative interviews were conducted with key informant mental health leaders and front-line clinicians at ten participating VAMCs. Interviews assessed barriers to following guideline recommendations regarding: (1) use of moderate antipsychotic doses, (2) monitoring for potentially serious metabolic side effects of newer antipsychotic medications, and (3) use of clozapine for treatment-refractory patients. Interviews were coded systematically using qualitative data analysis methods to identify common themes and barriers to following guideline recommendations.

Results:
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.

Implications:
A range of barriers at multiple levels work individually and collectively to limit adherence to guideline recommendations for antipsychotic medication management. Feedback on barriers from site participants has been incorporated into the development of an assortment of intervention tools and strategies that are currently being tested for their effectiveness in improving care for schizophrenia.

Impacts:
Efforts to improve clinical care may be more successful if specific barriers to following guideline recommendations are elicited from stakeholders and addressed in the development of remedial intervention tools/strategies. Incorporating clinical stakeholder feedback into intervention design may also make intervention tools/strategies more relevant to routine clinical practice.


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