Interventions to Improve Metabolic Risk Screening Among Children and Adolescents on Antipsychotic Medication: A Systematic Review

Abstract

Objective: Antipsychotic use among youth is common and is associated with metabolic side effects such as weight gain. Guidelines recommend periodic screening of metabolic measures in youth prescribed antipsychotics; however, a guidelineto-practice gap exists. We systematically reviewed the literature to synthesize the knowledge from interventions that aim to improve antipsychotic metabolic screening. We described the interventions' effect on screening rates, the strategies used for improvement, and study quality. Methods: We conducted a systematic review of studies that attempted to improve antipsychotic metabolic risk screening practices among pediatric populations published between 2004 and August 2019. We included studies with an improvement intervention that compared screening rates before and after the intervention. We extracted data about study characteristics, screening rates in pre-and postintervention groups, strategies used to influence screening practices, and assessed studies' risk of bias. This review was prospectively registered with PROSPERO #CRD42018088241. Results: We identified six studies that demonstrated modest improvements in median metabolic screening rates for waist circumference (0%-16%), glucose (9%-39%), and lipids (11%-37%). Median postintervention screening rates were higher for weight and blood pressure (84% and 72.5%) compared with glucose and lipids (39% and 37%). Interventions used a variety of improvement strategies to address patient-, provider-, and organization-level barriers for screening, including increasing patient and provider knowledge regarding antipsychotic side effects, fostering social clinical environments that promote screening, and organizational commitment for screening antipsychotic-treated youth. All interventions were deemed at high risk of bias due to uncontrolled design and lack of adjustment for confounders. Conclusions: Included studies reported partial success in improving antipsychotic screening rates but were of poor methodological quality. Common improvement strategies may affect provider behavior to conduct metabolic screening, but these need to be tailored to local resources and organization structure. Future studies need to use rigorous methodology and theoryinformed improvement strategies aligned with organizational actions to prioritize safe and judicious practice of antipsychotics among pediatric populations.

Disruptions in Primary Care among People with Schizophrenia in Ontario, Canada, During the COVID-19 Pandemic

“…Routine (at least yearly) screening of blood pressure, glycosylated hemoglobin (Hb1Ac) and cholesterol levels are recommended in Canada and are particularly warranted among individuals taking antipsychotic medications; however, these are conducted in less than a third of patients. 38 Reduction in frequency of completion of HbA1c tests in the general population is associated with poorer glycemic control and increased progression to chronic kidney disease. 39 Several studies across multiple contexts have demonstrated that patients with schizophrenia and other serious mental illnesses are less likely to receive metabolic screening, compared to the general population.…”

Adherence to antipsychotic laboratory monitoring guidelines in children and youth: a population-based study

“…This assertion is supported by past studies from Canada and the United States finding small changes in monitoring before and after the publication of clinical guidelines (17,37,38). Furthermore, changes in monitoring practices observed in studies of quality improvement educational initiatives targeting prescribers have been modest, with a systematic review of six studies finding median postintervention glucose, lipid, and waist circumference screening rates of 39, 37 and 16%, respectively (39). These findings suggest that the publication of guidelines and interventions targeting clinician knowledge and practice enhancements are insufficient for improving metabolic screening rates in antipsychotic-treated children and youth.…”

Monitoring of Adverse Drug Reaction-Related Parameters in Children, Youth, and Young Adults Prescribed Antipsychotic Drugs by General Practitioners

“…Although the present study showed that monitoring frequencies have increased since 2000, no prominent increase was observed after introduction of the NICE guideline in 2013. Previous studies have also demonstrated that after the introduction of monitoring recommendations, warnings for ADRs, or interventions, monitoring frequencies may increase, but remain inadequate (Morrato et al 2010a ; Mitchell et al 2012 ; Cotes et al 2017 ; Kara and Penner 2021 ; Melamed et al 2021 ). One reason for the outcome of this current study could be that GPs were not aware or insufficiently informed about these new guideline recommendations.…”