Evaluation of lipid and glucose monitoring after implementation of a pharmacist initiated antipsychotic monitoring form.

1. Evaluation of lipid and glucose monitoring after implementation of a pharmacist initiated antipsychotic monitoring form. Erin McCleeary Monthei, Pharm.D.1 & Eric C. Kutscher, Pharm.D., BCPP 1,2 1 Avera Behavioral Health Center, 2 South Dakota State University College of Pharmacy Background • Patients with mental illness have a decreased life expectancy with the majority of premature deaths being related to cardiovascular events.1,2 • Patients of public mental health clinics had a shorter life expectancy of 13-30 years.3 • Antipsychotics are associated with metabolic effects including increased body weight, cholesterol, and glucose. • In 2004, the American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologist, and North American Association for the Study of Obesity released consensus guidelines (ADA/APA guidelines) for monitoring with second generation antipsychotics.4 • Adherence to guidelines has been found to be low in previous studies. • - Adherence to baseline glucose testing varies • from 19-38.9%.5,6,7,8 • - Adherence to baseline lipid monitoring was • found to be between 6-24.5%.5,6,7,8 • - In a single study, only 5% of patients had both • baseline glucose and lipid testing.5 Primary Objective • To determine if the metabolic monitoring form for antipsychotics initiated by pharmacists improves adherence to ADA/APA guidelines in an inpatient psychiatric population. Secondary Objective • To determine what factors may affect adherence to the ADA/APA guidelines for patients on scheduled antipsychotics. Preliminary Conclusions • Lipid and glucose/A1c baseline monitoring rates were found to be higher than previously published rates pre- and post-analysis. • Post-intervention rates of baseline monitoring increased; however, the increase was not statistically significant. • Additional studies are needed to determine why providers are not adhering to ADA/APA guidelines and if other interventions would be more effective. Preliminary Results • Preliminary results are for patients started on an antipsychotic during admission (baseline monitoring). • Age, race, days on antipsychotic, length of stay, and co morbidities were included in the preliminary analysis • - In the pre-intervention group, patients with • schizophrenia were significantly more likely to • have baseline lipid monitoring (p=0.0418). • - In the post-intervention group and in combined • data, patients with a diagnosis of diabetes • were more likely to have baseline lipid and • glucose/A1c monitoring ( p=,0.0475, p=0.0496). • - All other results were not statistically significant. Demographics References Newcomer JW, Hennekens CH. Severe mental illness and risk of cardiovascular disease. J Am Med Assoc. 2007;298:1794-6. Viron MJ, Stern TA. The impact of serious mental illness on health and healthcare. Psychosomatics. 2010;51:458-64. Colton CW, Manderscheid RW. Congruencies in increased mortality rate, years of potential life lost, and causes of death among public health clients in eight states. Prev Chronic Dis[serial online]. 2006;3. Available at: http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm. Accessed August 18, 2011. American Diabetes Association; American Psychiatric Association; American Association of Clinical Endocrinologists; North American Association for the Study of Obesity: Consensus development conference on antipsychotics drugs and obesity and diabetes. Diabetes Care. 2004;27:596-601. Morrato EH, Newcomer JW, Allen RR, Valuck RJ. Prevalence of baseline serum glucose and lipid testing in users of second-generation antipsychotic drugs: a retrospective, population-based study of medicaid claims data. J Clin Psychiatry. 2008;69:316-22. Morrato EH, Druss B, Hartung DM, et al. Metabolic testing rates in 3 state medicaid programs after FDA warnings and ADA/APA recommendations for second-generation antipsychotic drugs. Arch Gen Psychiatry. 2010;67:17-24. Barnett M, VonMuenster S, Wehring H, et al. Assessment of monitoring for glucose and lipid dysregulation in adult Medi-Cal patients newly started on antipsychotics. AnnClin Psychiatry. 2010;22:9-17. Haupt DW. Rosenblatt LC, Kim E, Baker RA, Whitehead R, Newcomer JW. Prevalence and predictors of lipid and glucose monitoring in commercially insured patients treated with second-generation antipsychotic agents. Am J Psychiatry. 2009;166:345-53. Methods Design • A retrospective chart review will be completed on patients meeting inclusion criteria. Data Collection • Background characteristics • Medication information • Antipsychotic(s) • Start/stop date of medications • Date of last lipid panel and/or glucose or A1c at an Avera Facility Inclusion/exclusion criteria • Patients age 18-65 years old admitted to an adult behavioral health unit on at least one scheduled antipsychotic. Patients were excluded if they were hospitalized less than 48 hours, pregnant, residents of a correctional facility. • Based on the time periods chosen for study and Avera Behavioral Health’s formulary, lurasidone was not included in the analysis. • Patients were not included in analysis if the antipsychotic was stopped during hospitalization. Implementation • The study was approved by the Avera Institutional Review Board as an exempt project. • The unit pharmacist is responsible for evaluating patients on a scheduled antipsychotic and placing a completed metabolic monitoring form in the chart. • Data was collected From April and November 2011 • The primary investigator preformed all chart review and assessed for adherence and appropriateness of glucose and lipid panel orders. Data Management and Analysis • Data was entered into a secure database and exported into SAS version 9.2 for analysis • Fisher’s exact tests and Mann Whitney Wilcoxon tests were used for data analysis. Statement of the Problem • Monitoring for metabolic effects of antipsychotics according to recommendations by the ADA/APA guidelines has been shown to be <40% in several studies. Currently there is a lack of data on ways to increase adherence to these guidelines on an inpatient basis. * Analysis in process †Percentages do not add up to 100% as many patients had more than one diagnosis at discharge Comparison of Monitoring Rates Pre- and Post-Intervention Metabolic Monitoring Form Disclosure and Acknowledgements • The authors of this presentation have no possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation. • We would like to thank the Avera Behavioral Health Center pharmacists for their support in implementation of the metabolic monitoring form and Aireen Guzman for her assistance in statistical analysis.