Delegating Clozapine Monitoring to Advanced Nurse Practitioners: An Exploratory, Randomized Study to Assess the Effect on Prescription and Its Safety

Abstract

To test whether: (1) psychiatrists will prescribe clozapine more often if they can delegate the monitoring tasks to an advanced nurse practitioner (ANP), (2) clozapine monitoring by an ANP is at least as safe as monitoring by a psychiatrist. Patients from 23 Dutch outpatient teams were assessed for an indication for clozapine. ANPs affiliated to these teams were randomized to Condition A: clozapine monitoring by an ANP, or Condition B: monitoring by the psychiatrist. The safety of monitoring was evaluated by determining whether the weekly neutrophil measurements were performed. Staff and patients were blinded regarding the first hypothesis. Of the 173 patients with an indication for clozapine at baseline, only seven in Condition A and four in Condition B were prescribed clozapine (Odds Ratio = 2.24, 95% CI 0.61-8.21; p = 0.225). These low figures affected the power of this study. When we considered all patients who started with clozapine over the 15-month period (N = 49), the Odds Ratio was 1.90 (95% CI 0.93-3.87; p = 0.078). With regard to the safety of the monitoring of the latter group of patients, 71.2% of the required neutrophil measurements were performed in condition A and 67.3% in condition B (OR = 0.98; CI = 0.16-3.04; p = 0.98). Identifying patients with an indication for clozapine does not automatically lead to improved prescription rates, even when an ANP is available for the monitoring. Clozapine-monitoring performed by an ANP seemed as safe as that by a psychiatrist.

What is the extent of research assessing patients’ and clinicians’ perspectives on clozapine treatment? – a comprehensive scoping review

“…Of the 146 included studies, 39 reported on patient perspectives 22 24 29–38 41–43 56–79 , nine reported on both patient and clinician perspectives 23 25 39 80–85 , and 54 reported on clinician perspectives 86–139 . In 45 studies 139–183 , the origin of some or all reported perspectives was unclear (Figure 2, row 1).…”

“…Of the total 63 studies reporting on clinician perspectives, 34 reported on perspectives belonging to psychiatrists 86–93 95–97 102 103 106 107 109 113 116 119 122–132 134–137 four on perspectives belonging to non-psychiatrists only 39 94 98 138 and 22 on perspectives belonging to a mixture of different clinicians 25 80 82 84 85 88 99–101 104 105 108 110–112 114 115 117 118 121 133 139 . In four studies 23 81 83 120 , the type of clinicians was unclear (Figure 2, row 1).…”

What are the barriers and facilitators of clozapine use in early psychosis? A survey of UK early intervention clinicians

“…Addressing misconceptions around clozapine use through training and patient testimonials is equally important. For example, delegating clozapine monitoring to advanced nurse practitioners did not improve clozapine prescription rates in a randomised trial in the Netherlands 41 . While the study was likely underpowered to detect a difference, the authors suggested that the lack of improvement may have been due to misconceptions about clozapine’s therapeutic potential among prescribing psychiatrists.…”

Evaluation of a Collaborative Care Program for Patients With Treatment-Resistant Schizophrenia: Protocol for a Multiple Case Study

“…Clozapine treatment under the care of the CNS is as safe as that under the care of a psychiatrist. Previous research has shown that patients who are monitored by a CNS tend to use clozapine for longer than those monitored by a psychiatrist [ 29 ]. Treatment by nurses as opposed to physicians also generally leads to longer consultation times, either more or the same amount of information being provided to patients, and higher patient satisfaction with care [ 30 ].…”