Baseline metabolic monitoring of atypical antipsychotics in an inpatient setting

Abstract

Background: Atypical antipsychotic agents serve an important role in the treatment of many psychiatric disorders but have the potential to cause adverse effects, notably metabolic disturbances. These agents are known to cause increases in obesity, glucose intolerance, dyslipidemia and hypertension. In 2004, the American Diabetes Association (ADA) and the American Psychiatric Association (APA), in collaboration with other organizations, acknowledged the association between the use of atypical antipsychotics and the development of metabolic abnormalities and provided monitoring recommendations for the use of these agents. Despite these recommendations, rates of monitoring remain low. Objective: The purpose of this study is to assess whether a pharmacist recommendation form is effective in improving baseline metabolic monitoring for patients admitted to an acute inpatient psychiatry unit who are ordered a scheduled atypical antipsychotic. Methods: A pharmacist recommendation form with metabolic monitoring parameters was placed on the charts of patients ordered a scheduled atypical antipsychotic during a two month period. A retrospective chart review was conducted to compare the percentage of baseline monitoring ordered pre-intervention versus the intervention period. Patients ages 18 years or older who were ordered a scheduled atypical antipsychotic were included. Results: During the intervention period, there was a significant increase in documentation for presence or absence of diabetes (p = 0.018) and cardiovascular disease (p < 0.001). A significant difference in the number of orders for hemoglobin A1c (p = 0.007) and lipid panels (p < 0.001) were noted. No other significant differences were found. Conclusion: A pharmacist recommendation form was effective in improving the baseline monitoring of personal history of diabetes and cardiovascular disease and monitoring of hemoglobin A1c and lipid panels, but rates of other baseline monitoring parameters did not improve.

Monitoring of Metabolic Adverse Effects Associated With Atypical Antipsychotics Use in an Outpatient Psychiatric Clinic

“…As suggested by previous research, 8 –11 we speculated several reasons for the lower compliance during the follow-up period. The most apparent one is that practitioners may not remember to order the tests on time due to the variable guideline requirements for each parameter at the specified intervals that make up the follow-up period.…”

“…Since our results for overall monitoring compliance for major parameters showed similar array with the numbers reported in the literature, 3 we believe that the number of 38% reflects a real situation with follow-up monitoring period and is not merely a result of flawed study design ( Figure 2). As suggested by previous research, [8][9][10][11] we speculated several reasons for the lower compliance during the follow-up period. The most apparent one is that practitioners may not remember to order the tests on time due to the variable guideline requirements for each parameter at the specified intervals that make up the follow-up period.…”

“…Previous research in an inpatient setting demonstrated that pharmacist's involvement and education as part of a quality initiative can improve monitoring. 11 With respect to the secondary end points, 10 patients did not have any documentation of being treated for the metabolic comorbidities. Eight of them had a PCP listed in the EMR; however, our study could not truly assess if the patients were actively followed and monitored by the PCP on file.…”

“…Third, although the pattern of our results suggest that complexity or variability of the guidelines may be the major reason for decreased compliance, it may also be influenced by the factors described in previous reports as well. [8][9][10][11] Fourth, the monitoring percentages presented may be underestimated since our study did not capture data on services provided by outside PCP providers who have no access to BHMC EMR. The common practice in the clinic is to encourage patients to bring all recent outside laboratory reports, review them, and scan into the "Media" section in EPIC.…”

“…Previous research in an inpatient setting demonstrated that pharmacist’s involvement and education as part of a quality initiative can improve monitoring. 11…”