MIRECC Initiative on Antipsychotic Management Improvement (MIAMI)

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MIRECC Initiative on Antipsychotic Management
Improvement (MIAMI)

• Teresa Hudson, PharmD
• Center for Mental Healthcare and Outcomes
  Research
• South Central Mental Illness Research Education
  and Clinical Center

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Those who cannot remember the past are condemned
to repeat it
George Santayana
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MIAMI Journey

• 1998-2000
• Recognition of the metabolic effects of
  antipsychotic medications - particularly the
  newer, second-generation antipsychotics (SGA)
• Case reports of deaths among individuals
  receiving atypical antipsychotics

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Antipsychotics and Weight
Weight gain in Kg
Allison et al Am J Psychiatry 1999
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Antipsychotics Diabetes
c
b
of patients with DM
a
a plt.07
Age (yrs)
b p.002
Sernyak et al Am J psychiatry 2002
c p.003
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Antipsychotics and Hyperlipidemia

• Retrospective Case/Control Study (UK)
• n8866
• Olanzapine vs no AP
• OR 4.65 plt.001
• Olanzapine vs Traditional AP
• OR 3.36 Plt.0001
• Risperidone vs no AP
• OR 1.12 p.72
• Risperidone vs Traditional AP
• OR .81 p.52

Koro et al 2002
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Clinical Antipsychotic Trials of Intervention
Effectiveness (CATIE)

• Double-blind clinical compared the effectiveness
  of atypical antipsychotics among schizophrenia
  patients
• NIH-sponsored study
• January 2001-December 2004
• 57 sites in the US
• Phase I subjects randomly assigned to SGA or
  perphenazine
• Phase II People who discontinued phase I
  medications

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CATIE (Phase II)

• Olanzapine patients
• Gained more weight than patients on other drugs
• Mean 1.3 lbs/month
• Higher proportion of patients gain gt7 of their
  body weight
• 8 d/c drug because of weight gain or metabolic
  effects
• Ziprasidone
• Mean loss of 1.7lbs/month
• No patients d/c drug because of weight gain or
  metabolic effects
• Risperidone
• Negligible weight gain
• 5 d/c drug because of weight gain or metabolic
  effects
• Quetiapine
• Neglible weight gain
• 10 d/c drug because of weight gain or metabolic
  effects

Stroup et al Am J Psych 2006
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MIAMI Journey

• 2003
• VA/DOD Clinical Practice Guideline for the
  Management of Diabetes Mellitus in Primary Care
• 2004
• Consensus guidelines for physical health
  monitoring of patients with schizophrenia (Am J
  Psych 2004)
• Consensus conference on antipsychotic drugs and
  obesity and diabetes (J Clin Psych 2004)
• Updated VA/DOD Clinical Practice Guidelines for
  Management of Psychosis

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MIAMI Journey

• 2003-2008
• Emerging evidence that despite the various
  guidelines, rates of metabolic monitoring were
  fairly low

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Metabolic Screening Rates

• Medicaid Paid claims from 5 states
• 1998-2003
• n55,436 recipients with 180 days continuous
  enrollment and claim for SGA
• Evaluated predictors of blood glucose and lipid
  testing 14 days before or 28 days after claim for
  SGA
• Controlled for age, ethnicity, schizophrenia,
  preexisting metabolic disorder, index SGA and
  year of index prescription claim
• Morrato et al J Clin Psych 2008

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Metabolic Screening Rates

• Male and non-white patients were less like to
  receive baseline glucose monitoring
• (no demographic difference for lipid screening)
• California recipients more likely to receive
  monitoring compared with recipients of other
  states
• Significant increase in testing based on year of
  index rx.
• Diagnosis of schizophrenia significantly
  associated with baseline glucose monitoring but
  not lipid screening.
• Preexisting diabetes and dyslipidemia associated
  with 2-3 fold increase in monitoring.
• Olanzapine patients more likely than risperidone
  patients to receive monitoring
• Morrato et al J Clin Psych 2008

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Metabolic Screening Rates

• Quasi-experimental design to evaluate metabolic
  screening among individuals receiving SGA
  (atypical) antipsychotics before and after
  APA/ADA guidelines.
• Paid Claims from Commercial Insurance Plan
• Used a cohort of patients with diabetes with no
  MH diagnosis and no antipsychotic as comparison
  group
• Used time series models to account for temporal
  trends and control for pre-existing conditions
  (DM, hyperlipidemia before start of SGA)
• Morrato et al Diabetes Care 2009

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Metabolic Screening Rates (GLUCOSE)

• Rate among all SGA users
• 23
• Rate among persistent users
• 38

Testing Rates Among Antipsychotic Users
Morrato et al Diabetes Care 2009
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Metabolic Screening Rates (Lipids)

• Rate among all SGA users 8
• Rate among persistent SGA users 23

Testing Rates Among Antipsychotic Users
Morrato et al Diabetes Care 2009
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MIAMI Journey

• 2007
• VA OIG Report Healthcare Inspection Atypical
  antipsychotic medications and diabetes screening
  and management
• January 1 December 31, 2006
• Analyses of national, VISN, and facility
  endocrine performance measure scores for blood
  pressure, LDL-C, and HbA1c.
• Reviewed medical records
• MH patients
• Age 35-50
• Rx for antipsychotic medications
• Diagnosis of DM or were MH patients at risk for
  development of the disease

http//www4.va.gov/oig/54/reports/VAOIG-05-00680-3
7.pdf
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OIG Findings
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OIG Findings
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OIG Findings

• Monitoring for Diabetes

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MIAMI Journey OIG Recommendations

• implement and document weight reduction
  strategies
• improve treatment and documentation of
  interventions for elevated fasting blood glucose
  levels
• implement interventions to maintain blood
  pressures less than 140/90 for younger patients
  without diabetes who are prescribed atypical
  antipsychotic medications.
• achieve target blood glucose levels for younger
  patients with diabetes who are prescribed
  atypical antipsychotic medications

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MIAMI Journey

• 2008
• VA Office of Mental Health Services Report of
  the Workgroup on Atypical Antipsychotic
  Medications and Diabetes Screening and
  Management.
• Assure access by primary care and MH clinicians
  to guidance documents
• Ensure mental health clinics are able to follow
  recommendations for monitoring of metabolic risk
  factors
• Improve coordination between Primary Care and
  Mental Health
• Improve referral of patients with identified
  metabolic risk factors

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2009 MIAMI is funded

• VA Office of Mental Health Services Initiative
• National program to implement recommendations
  from the Atypical Antipsychotics Workgroup
• 2-year Initiative
• Goal improve monitoring for and management of
  physical health problems among veterans taking
  atypical antipsychotic medications
• Administered by the VISN 22 and 16 MIRECCs in
  conjunction with Mental Health QUERI

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MIAMI Goals

• Improve Adherence to ADA/APA guidelines around
  antipsychotic medication monitoring
• Improve VHA facilities metabolic monitoring
  performance measures
• Decrease the percent of veterans who are
  prescribed antipsychotic medications who are
  obese
• Increase the use of individual or group
  counseling among veterans who are prescribed
  antipsychotic medications and are obese

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MIAMI Activities

• Develop and Disseminate effective tools for
  implementing antipsychotic monitoring programs
• Educate champions who will go back to their
  facilities/VISNs and educate others
• Utilize VHS DSS and VA Corporate Data Warehouse
  to evaluate change in monitoring in VA

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MIAMI Resources

• Technical Assistance Center (TAC)
• Support sites implementing routine monitoring
• Sites determine program design
• Intranet Site
• Provides access to educational materials
• Data Analysis
• Monitoring rates at baseline and over 1 year
  period

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Why is MIAMI so Exciting?!!!

• Opportunity for researchers/clinicians/administrat
  ors to pool our resources and work together to
  improve care of veterans
• Tools are available but HOW those tools are used
  is a LOCAL decision
• Opportunities for facilities to easily share
  information
• Opportunity for researchers to learn what else is
  needed to help with metabolic monitoring and
  management
• May provide a model for improve other aspects of
  MH treatment for veterans

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