Reducing the rates of prescribing high-dose antipsychotics and polypharmacy on psychiatric inpatient and intensive care units: results of a 6-year quality improvement programme

Mace, Shubhra; Taylor, David

doi:10.1177/2045125314558054

Cited by 32 publications

(38 citation statements)

References 38 publications

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“…The NHS trusts other than SLaM had a greater preponderance for prescribing of more than one antipsychotic. Whilst changing polypharmacy prescribing practice is difficult, the SLaM centre has individually reported marked improvements in combination and high-dose prescribing through the use of a quality improvement programme, thus explaining this association [Mace and Taylor, 2014].…”

Section: Main Findingsmentioning

confidence: 99%

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Factors associated with non evidence-based prescribing of antipsychotics

Connolly

Taylor

2014

Therapeutic Advances in Psychopharmacology

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Objectives: Non evidence-based prescribing of antipsychotics is common in the UK and internationally with high doses and polypharmacy the norm. These practices often remain even after systematic attempts are made to change. We aimed to establish which factors are linked to antipsychotic prescribing quality so we can identify and target patients for interventions to improve quality and allow us to understand further the drivers of non evidence-based prescribing. Method: A cross-sectional survey with a collection of factors potentially affecting antipsychotic prescribing quality outcomes was carried out in eight secondary care units in England. Participants were inpatients prescribed regular antipsychotics on the day of the survey. Antipsychotic dose, polypharmacy, type and route were the main outcome measures. Results: Data were collected for 1198 patients. Higher total dose was associated with greater weight, higher number of previous admissions, longer length of admission, noncompliance with medication and use of an atypical antipsychotic. A lower total dose was associated with clozapine use. Polypharmacy was associated with not being a patient at the South London and Maudsley NHS Trust centre, the subject having a forensic history, a greater number of previous admissions and higher total dose. Younger age, not being detained under a Mental Health Act section, atypical antipsychotic use and oral route were predictors of antipsychotic monotherapy. Atypical antipsychotic use was associated with oral route, higher total dose, being administered only one antipsychotic, having had fewer previous antipsychotics and no anticholinergic use. Use of the oral route was associated with not being sectioned under the Mental Health Act, atypical antipsychotic use, younger age, non-schizophrenia diagnosis, fewer previous admissions and a lower total dose. Conclusion: In patients with chronic illness who are detained, heavier, noncompliant, not taking clozapine and on a depot antipsychotic, prescribers use larger doses and antipsychotic polypharmacy. We found that use of percentage of licensed maximum doses favours typical antipsychotics arbitrarily, and that high doses and polypharmacy are inextricably linked.

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Section: Main Findingsmentioning

confidence: 99%

“…These practices often remain even after systematic and vigorous attempts are made to change [Paton et al 2008]. Although individual organisations can make dramatic improvements in prescribing quality through multidisciplinary quality improvement programmes [Mace and Taylor, 2014], such successes are rare.…”

Section: Introductionmentioning

confidence: 99%

Factors associated with non evidence-based prescribing of antipsychotics

Connolly

Taylor

2014

Therapeutic Advances in Psychopharmacology

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“…However, the POMH-UK audit in 2012 15 showed some improvement: HDAT prescribed in 25% and AC prescribed in 36% of patients based on 4596 patients. Mace et al 3 PRN prescriptions were the principal cause of both HDAT and AC prescribing. 9 It is note worthy that NICE published a guideline on violence and aggression in mental health in 2015 that further emphasised the need for good practice when prescribing PRN.…”

Section: Discussionmentioning

confidence: 99%

“…3 HDAT and AC lack evidence of benefit but evidence of harm is compelling. 2 Clozapine augmentation with another antipsychotic is perhaps the only therapeutic area where AC is supportable.…”

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confidence: 99%

“…Thus HDAT and AC should be prescribed as an exception and only after other evidence-based treatment strategies have failed. 1 HDAT and AC are associated with significant adverse effect burden including QTc prolongation, arrhythmias, sudden cardiac death, seizures, increased incidence and severity of adverse effects, longer hospital stay [3][4][5][6] and possibly increased mortality. 7 When managing a patient's mental health, they should not be exposed to higher physical health risk without a proper risk management process in place.…”

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Prescribing quality improvement: reducing high‐dose antipsychotic use

Prajapati¹,

Johnston²,

Ugochukwu³

et al. 2017

Prog Neurol Psychiatry

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Evidence of efficacy for high‐dose antipsychotic therapy (HDAT) and antipsychotic combinations (AC) is lacking, while evidence of harm is compelling. Significantly higher proportions of Norfolk and Suffolk NHS Foundation Trust (NSFT) patients were being prescribed HDAT and AC compared with the national averages. Here, the authors describe a quality improvement program to rationalise and reduce HDAT and AC prescribing in NSFT, to bring it in line with, or below, the national average. The initiative demonstrates that prescribing culture can be improved through a sustained multi‐professional team approach involving education and training, a targeted campaign, a proactive clinical pharmacy team and pharmacists' support.

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Antipsychotic polypharmacy prescribing and risk of hospital readmission

et al. 2017

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ObjectivesThe aim of this study was to determine if there was an association between being discharged on antipsychotic polypharmacy (APP) and risk of readmission into secondary mental health care.MethodsUsing data from the South London and Maudsley (SLAM) case register, service users with serious mental illness (SMI), discharged between 1st January 2007 and 31th December 2014, were followed up for 6 months. Patients were classified as receiving either monotherapy or polypharmacy at index discharge. Multivariable Cox regression models were constructed, adjusting for sociodemographic, socioeconomic, clinical and service use factors.ResultsWe identified 5523 adults who had been admitted at least once to SLAM, of whom 1355 (24.5%) were readmitted into secondary mental health care. In total, 15% (n = 826) of patients were discharged on APP and 85% (n = 4697) on monotherapy. Of these, 30.9% (n = 255) and 23.4% (n = 1100) were readmitted respectively. Being discharged on APP was associated with a significantly increased risk of readmission, in comparison to patients discharged on monotherapy (HR = 1.4, 1.2–1.7, p < 0.001). This association was maintained in the fully adjusted model and following several sensitivity analyses. We further established that patients receiving clozapine APP (n = 200) were at a significantly increased risk for readmission in comparison to patients on clozapine monotherapy (HR = 1.8, 1.2–2.6, p = 0.008).ConclusionsOur results suggest that patients discharged on APP are more likely to be readmitted into hospital within 6 months in comparison to those discharged on monotherapy. This needs to be considered in treatment decisions and the reasons for the association clarified.

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Reducing the rates of prescribing high-dose antipsychotics and polypharmacy on psychiatric inpatient and intensive care units: results of a 6-year quality improvement programme

Abstract: A sustained change in the prescribing culture of an organization can be achieved through a targeted improvement programme.

Cited by 32 publications

References 38 publications

Factors associated with non evidence-based prescribing of antipsychotics

Factors associated with non evidence-based prescribing of antipsychotics

Prescribing quality improvement: reducing high‐dose antipsychotic use

Antipsychotic polypharmacy prescribing and risk of hospital readmission

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