Category: Federal Forum Posters
Purpose: Metabolic adverse effects are major concerns with second-generation antipsychotics (SGAs), however adequate monitoring for these symptoms is rarely achieved. An electronic monitoring tool, referred to as a clinical reminder, was previously implemented at this facility. This tool flags the electronic health record of patients prescribed a SGA and missing recommended monitoring parameters. Clicking the flag opens a dialogue box which prompts ordering of labs. The purpose of this quality improvement project is to evaluate utilization of the tool, determine if monitoring was performed, and address discrepancies. The primary outcome was percentage of patients with incomplete reminders who received recommended monitoring.
Methods: This quality improvement project was approved by the Pharmacy and Therapeutics Committee prior to implementation and IRB approval was not required. Patients without a completed SGA reminder were identified using the psychotropic drug safety initiative (PDSI) dashboard, a nation-wide informatics tool within the Veterans Affairs system. After the initial list was obtained, chart reviews were conducted to obtain basic demographic information and metabolic monitoring parameters. Patients without a completed reminder who required additional monitoring were identified and a consult was entered to assign them to a mental health clinical pharmacy specialist (CPS). The CPS conducted initial and follow-up visits with patients. During these visits the purpose of metabolic monitoring was explained and patients were requested to complete missing monitoring parameters. If patients were agreeable to completing monitoring, the CPS entered the appropriate laboratory orders. Finally, follow-up chart reviews were performed. For patients to be included in this project they had to be actively assigned to this facility for care, have an incomplete SGA reminder, and require additional metabolic monitoring. Exclusion criteria included patients not assigned to this facility, patients receiving hospice or palliative care, and patients maintained by non-VA psychiatrists.
Results: Sixty-six patients were identified through the PDSI dashboard, 35 were excluded. Consults were entered for the remaining 31 patients. Twenty-two patients accepted the initial appointment and nine did not. Most patients who accepted the initial consult were white (77.3%) with an average age of 55 years old and average BMI of 31.6±7.4kg/m2. Average fasting plasma glucose (110.4±46.9mg/dL) and hemoglobin A1c (5.9±1.2%) were indicative of prediabetes. Lipid profiles reflected slight elevations in triglyceride (183±93mg/dL) and LDL (105±39.5mg/dL), with HDL levels on the lower end of normal (48±15mg/dL), and cholesterol within normal limits (189±49mg/dL). At baseline, 77.3% had no fasting lipid panel within the previous 6 months, 68.2% had no fasting plasma glucose or hemoglobin A1c in the previous 6 months, and 54.5% did not have a recorded weight within the previous 3 months. Of the 22 patients seen in clinic 2 were found to be no longer actively taking an SGA. The remaining 20 patients were agreeable to updating necessary laboratory work, however only 9 of these patients actually went on to obtain appropriate monitoring. A total of 53 laboratory orders were entered by the mental health CPS. No clinical interventions were made by the mental health CPS.
Conclusion: The adherence rate to metabolic monitoring observed, although low, was consistent with findings in other studies. This quality improvement project highlighted the difficulty associated with maintaining appropriate follow up with patients, specifically within a mental health population. Barriers to adequate monitoring are multifaceted and even with concentrated effort are difficult to overcome. This was the first evaluation of the SGA monitoring tool at this facility and potentially laid the groundwork for future optimization of the tool.