Novel program cuts antipsychotics in metabolic patients

NEW YORK – A novel, Web-based health information technology system dramatically reduced the number of high metabolic burden antipsychotics prescribed to Medicaid patients in New York state, according to Dr. Molly Finnerty.

"This is not to say that there aren’t indications [for use of these antipsychotics], or that they can’t be helpful, but it’s ... a quality issue for individuals who already have dysmetabolic conditions," Dr. Finnerty said at the annual meeting of the American Psychiatric Association.

Moreover, "psychiatrists simply may not be aware of medical conditions in their patients," she added. "Real-time" sharing of this identified Medicaid data could help prescribers make better choices from the start, instead of having to switch later.

The tool, known as PSYCKES (Psychiatric Services and Clinical Knowledge Enhancement System), was developed by Dr. Finnerty and her colleagues at the New York State Office of Mental Health to be a HIPAA*-compliant, Web-based platform for analyzing up to 5 years of Medicaid claims data.

In the current study, Dr. Finnerty implemented a tracker function on the system for all adult patients who were prescribed an antipsychotic with a high metabolic burden.

Classification of these so-called high-burden drugs was based on national advisory committee recommendations, which in turn was influenced by the CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) trial. The list included olanzapine and quetiapine, but not risperidone, "which looks better on the lipid profile."

These patients were then flagged by the system if they had claims data for any of several cardiometabolic disorders, including type II diabetes mellitus, obesity, hyperlipidemia, or a history of myocardial infarction. Prescribers were prompted to revisit their choice of antipsychotics, to either choose an alternative agent or eliminate the drug altogether.

The program was introduced at several New York state facilities comprising 2,837 patients with a flagged antipsychotic plus a metabolic condition. Those were compared with 4,721 other patients taking antipsychotics with metabolic conditions who were not served by a PSYCKES facility.

"Not surprisingly, about 80% [of patients receiving the targeted antipsychotics] had a psychotic condition, and this was broadly defined – any schizophrenia, bipolar disorder, or major depressive disorder with psychotic features would end up in that group," Dr. Finnerty said.

Dr. Finnerty found that after a 6-month implementation period, physicians at participating PSYCKES institutions significantly decreased their prescribing of high metabolic burden antipsychotics by 19% over the course of 1 year of use, whereas nonparticipating institutions remained mostly flat, with just a 4% decrease.

"For people with psychotic disorders, you were more likely to be switched from a higher impact antipsychotic to a lower metabolic impact antipsychotic. And for people with nonpsychotic disorders, they were switched off," Dr. Finnerty said.

"When you highlight the metabolic impacts, particularly for people who already have this medical burden, there’s a decrease [in prescription of these medications]."

Drilling down into which patients got switched, the researchers found that polypharmacy, or patients taking four or more psychotropic drugs – potentially a proxy for sicker patients, decreased the likelihood of any drug regimen change.

However, patients taking two or more antipsychotics, specifically, did get switched more often.

Next, the authors assessed whether there was any noticeable increase in hospitalization after switching or discontinuing antipsychotic drugs.

"When we encourage people to take risks and change regimens, are we destabilizing patients?" asked Dr. Finnerty. "Are we meddling?"

The answer, she found, was no: "There was really no difference between participating and nonparticipating hospitals in the relationship between switching or changes in regimen and hospitalization."

PSYCKES is fully supported by the New York State Office of Mental Health. Dr. Finnerty said she had no relevant financial disclosures.

*Correction, 6/4/2014: A previous version of this story misstated the name of the Health Insurance Portability and Accountability Act (HIPAA).

NEW YORK – A novel, Web-based health information technology system dramatically reduced the number of high metabolic burden antipsychotics prescribed to Medicaid patients in New York state, according to Dr. Molly Finnerty.

"This is not to say that there aren’t indications [for use of these antipsychotics], or that they can’t be helpful, but it’s ... a quality issue for individuals who already have dysmetabolic conditions," Dr. Finnerty said at the annual meeting of the American Psychiatric Association.

Moreover, "psychiatrists simply may not be aware of medical conditions in their patients," she added. "Real-time" sharing of this identified Medicaid data could help prescribers make better choices from the start, instead of having to switch later.

The tool, known as PSYCKES (Psychiatric Services and Clinical Knowledge Enhancement System), was developed by Dr. Finnerty and her colleagues at the New York State Office of Mental Health to be a HIPAA*-compliant, Web-based platform for analyzing up to 5 years of Medicaid claims data.

In the current study, Dr. Finnerty implemented a tracker function on the system for all adult patients who were prescribed an antipsychotic with a high metabolic burden.

Classification of these so-called high-burden drugs was based on national advisory committee recommendations, which in turn was influenced by the CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) trial. The list included olanzapine and quetiapine, but not risperidone, "which looks better on the lipid profile."

These patients were then flagged by the system if they had claims data for any of several cardiometabolic disorders, including type II diabetes mellitus, obesity, hyperlipidemia, or a history of myocardial infarction. Prescribers were prompted to revisit their choice of antipsychotics, to either choose an alternative agent or eliminate the drug altogether.

The program was introduced at several New York state facilities comprising 2,837 patients with a flagged antipsychotic plus a metabolic condition. Those were compared with 4,721 other patients taking antipsychotics with metabolic conditions who were not served by a PSYCKES facility.

"Not surprisingly, about 80% [of patients receiving the targeted antipsychotics] had a psychotic condition, and this was broadly defined – any schizophrenia, bipolar disorder, or major depressive disorder with psychotic features would end up in that group," Dr. Finnerty said.

Dr. Finnerty found that after a 6-month implementation period, physicians at participating PSYCKES institutions significantly decreased their prescribing of high metabolic burden antipsychotics by 19% over the course of 1 year of use, whereas nonparticipating institutions remained mostly flat, with just a 4% decrease.

"For people with psychotic disorders, you were more likely to be switched from a higher impact antipsychotic to a lower metabolic impact antipsychotic. And for people with nonpsychotic disorders, they were switched off," Dr. Finnerty said.

"When you highlight the metabolic impacts, particularly for people who already have this medical burden, there’s a decrease [in prescription of these medications]."

Drilling down into which patients got switched, the researchers found that polypharmacy, or patients taking four or more psychotropic drugs – potentially a proxy for sicker patients, decreased the likelihood of any drug regimen change.

However, patients taking two or more antipsychotics, specifically, did get switched more often.

Next, the authors assessed whether there was any noticeable increase in hospitalization after switching or discontinuing antipsychotic drugs.

"When we encourage people to take risks and change regimens, are we destabilizing patients?" asked Dr. Finnerty. "Are we meddling?"

The answer, she found, was no: "There was really no difference between participating and nonparticipating hospitals in the relationship between switching or changes in regimen and hospitalization."

PSYCKES is fully supported by the New York State Office of Mental Health. Dr. Finnerty said she had no relevant financial disclosures.

*Correction, 6/4/2014: A previous version of this story misstated the name of the Health Insurance Portability and Accountability Act (HIPAA).

NEW YORK – A novel, Web-based health information technology system dramatically reduced the number of high metabolic burden antipsychotics prescribed to Medicaid patients in New York state, according to Dr. Molly Finnerty.

"This is not to say that there aren’t indications [for use of these antipsychotics], or that they can’t be helpful, but it’s ... a quality issue for individuals who already have dysmetabolic conditions," Dr. Finnerty said at the annual meeting of the American Psychiatric Association.

Moreover, "psychiatrists simply may not be aware of medical conditions in their patients," she added. "Real-time" sharing of this identified Medicaid data could help prescribers make better choices from the start, instead of having to switch later.

The tool, known as PSYCKES (Psychiatric Services and Clinical Knowledge Enhancement System), was developed by Dr. Finnerty and her colleagues at the New York State Office of Mental Health to be a HIPAA*-compliant, Web-based platform for analyzing up to 5 years of Medicaid claims data.

In the current study, Dr. Finnerty implemented a tracker function on the system for all adult patients who were prescribed an antipsychotic with a high metabolic burden.

Classification of these so-called high-burden drugs was based on national advisory committee recommendations, which in turn was influenced by the CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) trial. The list included olanzapine and quetiapine, but not risperidone, "which looks better on the lipid profile."

These patients were then flagged by the system if they had claims data for any of several cardiometabolic disorders, including type II diabetes mellitus, obesity, hyperlipidemia, or a history of myocardial infarction. Prescribers were prompted to revisit their choice of antipsychotics, to either choose an alternative agent or eliminate the drug altogether.

The program was introduced at several New York state facilities comprising 2,837 patients with a flagged antipsychotic plus a metabolic condition. Those were compared with 4,721 other patients taking antipsychotics with metabolic conditions who were not served by a PSYCKES facility.

"Not surprisingly, about 80% [of patients receiving the targeted antipsychotics] had a psychotic condition, and this was broadly defined – any schizophrenia, bipolar disorder, or major depressive disorder with psychotic features would end up in that group," Dr. Finnerty said.

Dr. Finnerty found that after a 6-month implementation period, physicians at participating PSYCKES institutions significantly decreased their prescribing of high metabolic burden antipsychotics by 19% over the course of 1 year of use, whereas nonparticipating institutions remained mostly flat, with just a 4% decrease.

"For people with psychotic disorders, you were more likely to be switched from a higher impact antipsychotic to a lower metabolic impact antipsychotic. And for people with nonpsychotic disorders, they were switched off," Dr. Finnerty said.

"When you highlight the metabolic impacts, particularly for people who already have this medical burden, there’s a decrease [in prescription of these medications]."

Drilling down into which patients got switched, the researchers found that polypharmacy, or patients taking four or more psychotropic drugs – potentially a proxy for sicker patients, decreased the likelihood of any drug regimen change.

However, patients taking two or more antipsychotics, specifically, did get switched more often.

Next, the authors assessed whether there was any noticeable increase in hospitalization after switching or discontinuing antipsychotic drugs.

"When we encourage people to take risks and change regimens, are we destabilizing patients?" asked Dr. Finnerty. "Are we meddling?"

The answer, she found, was no: "There was really no difference between participating and nonparticipating hospitals in the relationship between switching or changes in regimen and hospitalization."

PSYCKES is fully supported by the New York State Office of Mental Health. Dr. Finnerty said she had no relevant financial disclosures.

*Correction, 6/4/2014: A previous version of this story misstated the name of the Health Insurance Portability and Accountability Act (HIPAA).