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SHP 08-146 – HSR&D Study

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SHP 08-146
Management of Metabolic Side Effects of Antipsychotics in Six VISNs
Richard R. Owen Jr. MD
Central Arkansas Veterans Healthcare System Eugene J. Towbin Healthcare Center, Little Rock, AR
No. Little Rock, AR
Funding Period: June 2008 - March 2010

BACKGROUND/RATIONALE:
Treatment with newer antipsychotic medications is associated with risk of weight gain, diabetes, and hyperlipidemia. This study examined current practices for monitoring and management of metabolic side effects and explored the extent to which patient characteristics, such as comorbidities, affect monitoring and management rates.

OBJECTIVE(S):
The project's objectives were to:
1) Determine the extent to which patients who develop metabolic side effects during antipsychotic treatment receive guideline-concordant management of these side effects.
2) Identify patient characteristics that affect the likelihood of receiving recommended side effect monitoring and management.

METHODS:
We identified VISN 16 Veterans that received a new ("index") prescription for an antipsychotic agent from Apr 1-Dec 31, 2006, defined as the start of, addition of, or switch to a new antipsychotic not prescribed in the previous 6 months. We first determined proportions of patients monitored for weight, body mass index (BMI), glucose or hemoglobin A1c (HgbA1c), and low-density lipoprotein (LDL) on the index date ( 30 days) and at the recommended 90-day follow-up ( 30 days). Among those who had weight gain (> 7% from baseline) or abnormal results at follow-up, we examined the proportions of patients who received guideline-recommended medication, a MOVE! program encounter, a primary care visit, or a diabetes or endocrine clinic visit within 60 days of the abnormal result, We next compared the frequency of these measures in patients with and without evidence of diabetes in the 6 months prior to the index prescription. Second, we examined the association of patient characteristics with indicators of follow-up monitoring and side effect management using bivariate analysis and multivariate logistic regression models. Independent variables included patient demographics; diagnoses of medical comorbidities 6 months prior to the index prescription date; and diagnoses of schizophrenia or bipolar disorder at any time during FY06-07.

FINDINGS/RESULTS:
Monitoring rates for metabolic side-effects were low at the time of the new antipsychotic prescription [weight (77%); BMI (72%); glucose or HgbA1c (59%), and LDL (42%)], and they were even lower during the 90 day follow-up period [weight (54%), BMI (51%), glucose/HgbA1c (37%), and LDL (23%)]. Patients without pre-existing diabetes were significantly less likely than patients with diabetes to have each of the metabolic parameters monitored at follow-up.. In patients without pre-existing diabetes, about two-thirds of patients with each metabolic abnormality had a primary care visit or guideline-recommended medication (for diabetes or dyslipidemia). Referral to the MOVE! weight management program or specialty care clinics was rarely recorded for any of the four metabolic side-effects investigated. Females were also less likely to have primary care visits following elevated LDL, elevated glucose/HgbA1c, or weight gain. Patients with bipolar disorder but not those with schizophrenia were significantly more likely to be monitored for all metabolic abnormalities. Similarly, patients with schizophrenia were less likely to have primary care visits following detection of a metabolic abnormality. Diagnoses of diabetes, dyslipidemia, obesity and hypertension were significant predictors of monitoring and management of most metabolic abnormalities during the follow-up period. Older patients were more likely to be managed for elevated HgbA1c and LDL. Consistent with recent reports, this study also found that the majority of patients receiving new prescriptions for antipsychotic medications did not have psychotic disorders such as schizophrenia or bipolar disorder.

IMPACT:
This study is the largest and most comprehensive examination to date of monitoring and management of antipsychotics' metabolic side effects among Veterans receiving antipsychotics, and included all such patients regardless of diagnosis. Quality improvement efforts are urgently needed to increase monitoring for and management of these antipsychotic side-effects, and to ensure that antipsychotics are prescribed for appropriate indications.

PUBLICATIONS:

Journal Articles

  1. Viverito K, Owen R, Mittal D, Li C, Williams JS. Management of new hyperglycemia in patients prescribed antipsychotics. Psychiatric services (Washington, D.C.). 2014 Dec 1; 65(12):1502-5.
  2. Mittal D, Li C, Viverito K, Williams JS, Landes RD, Thapa PB, Owen R. Monitoring for metabolic side effects among outpatients with dementia receiving antipsychotics. Psychiatric services (Washington, D.C.). 2014 Sep 1; 65(9):1147-53.
  3. Mittal D, Li C, Williams JS, Viverito K, Landes RD, Owen RR. Monitoring veterans for metabolic side effects when prescribing antipsychotics. Psychiatric services (Washington, D.C.). 2013 Jan 1; 64(1):28-35.
  4. Li C, Mittal D, Owen RR. Impact of patients' preexisting metabolic risk factors on the choice of antipsychotics by office-based physicians. Psychiatric services (Washington, D.C.). 2011 Dec 1; 62(12):1477-84.
Conference Presentations

  1. Mittal D. Outpatients with Dementia Receiving Antipsychotics: Metabolic Side-Effects Monitoring Practices. Paper presented at: American Association for Geriatric Psychiatry Annual Meeting; 2015 Mar 29; New Orleans, LA.
  2. Viverito KM, Owen RR, Mittal D, Li C, Williams JS. Do Veterans Prescribed Antipsychotics Receive Recommended Monitoring for Metabolic Side Effects? Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 19; National Harbor, MD.
  3. Owen RR, Mittal D, Li C, Williams S, Viverito KM. Rates of Monitoring for Metabolic Side Effects of Antipsychotics at 32 VA Medical Centers. Poster session presented at: American Psychiatric Association Annual Meeting; 2012 May 7; Philadelphia, PA.
  4. Mittal D, Williams S, Li C, Viverito KM, Owen RR. Do Outpatients with Dementia or Delirium Receive Recommended Monitoring for Metabolic Side Effects When Prescribed Antipsychotics? Poster session presented at: American Association for Geriatric Psychiatry Annual Meeting; 2012 Mar 16; Washington DC.
  5. Mittal D, Li C, Williams S, Smith JL, Owen RR. Monitoring and Management of Metabolic Side-Effects of Antipsychotics in Patients with Newly Prescribed Antipsychotics at VISN 16. Poster session presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 28; Little Rock, AR.


DRA: Mental, Cognitive and Behavioral Disorders
DRE: none
Keywords: none
MeSH Terms: none

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