Hearts and Minds: How to tackle metabolic syndrome?

Hearts and Minds: How to tackle metabolic syndrome? David Menkes, Psychiatrist University of Auckland Alex Holt, Health Informatician University of Otago

Collaboration from:
Waikato Clinical School
University of Auckland
Pharmacy 547, Hamilton
Waikato, Waitemata and Otago DHBs
NZ Pharmacovigilance Centre
University of Otago
Ministry of Health
RANZCP

Metabolic Syndrome - 1
Central obesity plus one or more of:
Impaired glucose tolerance (often progressing to diabetes mellitus)
Elevation of lipids, notably triglycerides and/or LDL cholesterol
Hypertension
Metabolic syndrome is associated with
Atherogenesis, cardiovascular disease
Heart attacks, stroke
Elevated morbidity and mortality

Metabolic syndrome - 2
Risk factors include
Genetic predisposition
Diet (calorie dense, high fat)
Inadequate physical activity
Second generation ‘atypical’ antipsychotic drugs (clozapine, olanzapine, risperidone, quetiapine…)
Notable co-incidence and interaction of risk factors

Metabolic syndrome - 3
Problems in detection and management
Dominant culture…affluenza?
Convenience of fast food, motor cars, etc.
Complex problem across primary, secondary care
Chronic mental illness poses particular problems
Material disadvantage
Poor insight and motivation
Physical health generally poor
Second generation antipsychotics aggravate ++
Information sharing a persisting problem in chronic disease management, notably in metabolic syndrome

Metabolic syndrome … efforts at management
Monitoring and intervention standards
Largely agreed within and across countries
Implementation very inconsistent
Morbidity and mortality persist… constituting vast unmet need
Why has it been so difficult to get traction on this problem?

Metabolic syndrome…getting it right
Effective management of metabolic syndrome in patients with psychiatric illness requires effective coordination of
psychiatry (incl. AMHS teams)
GP
pharmacy
In turn, this requires effective data management, and availability of
Clinical information regarding patients
Evidence-based decision support

Useful references
Byrne P. BMJ 2007; 334: 686-692
Tschoner A et al. International Journal of Clinical Practice 2007; 61: 1356-1370
*World Federation for Mental Health. Journal of Clinical Psychiatry 2005; 66: 790-798
*NZ Mental Health Metabolic Working Group Initiative 2006:1-40 (available as pdf)
* Sponsored by industry

Sources of bias in research-derived evidence
explicit, e.g., according to sponsor’s specification or expectation
implicit, e.g., due to context, values, or beliefs
N.B. sources may or may not be recognized. If recognized, they may or may not be acknowledged

Leo Tolstoy
I know that most men, including those at ease with problems of the greatest complexity, can seldom accept even the simplest and most obvious truth if it be such as would oblige them to admit the falsity of conclusions which they have delighted in explaining to colleagues, which they have proudly taught to others, and which they have woven, thread by thread, into the fabric of their lives

Mechanisms of bias effects on data or ‘results’
collection
analysis
interpretation
communication
promotion

Thucydides
When a man finds a conclusion agreeable, he accepts it without argument, but when he finds it disagreeable, he will bring against it all the forces of logic and reason

Online CME, courtesy of Bristol-Meyers Squibb and Otsuka
Note: the most comprehensive, useful summary (JCP 2005) sponsored by same pair of companies. ? More than a coincidence
How about the NZ Mental Health Metabolic Working Group Initiative…

sponsorship had “no effect” on the choice of studies, or the conclusion

The outlook in Waikato
How many patients affected?
Numbers dispensed atypical APDs (2003-4):
1758 in Hamilton
1283 other Waikato
1985 Tauranga
705 Rotorua
Major opportunity to study ethnicity effects on metabolic syndrome and APDs

The proposed plan I
The Register
Develop for all APD-treated patients in Hamilton (later extensions possible)
Expansion of existing IMMP database may prove easiest, but would still require extra resources (at least 1.0 FTE) plus IT
Register would need to
capture all relevant dispensing and lab data, and
be available on-line 24/7 for decision support

The proposed plan II
Promotion and recruitment
Patients
GPs
Psychiatrists
Other AMHS personnel
Inpatient and community
Endocrinologist
Specialty team (Menkes, Puckey, Leathart, Abdul-Hussain, Kanniah, Wu, Harrison-Woolrych, Kennedy, Clark…et al)

The proposed plan III
Routine measurements
Baseline
Ongoing
Proposed as psychiatrist responsibility
Monitoring and feedback from Team/547
Research measurements
Genetic
Metabolic

The proposed plan IV
Interventions based on agreed algorithm
APD dose change, switch, withdrawal
Adjunctive medication?
Metformin
Reboxetine/atomoxetine
Sibutramine
Diet advice
Physical activity
Role of GP, other providers to be agreed

The proposed plan V
Follow-up by
AMHS
GP (by agreement)
Other provider (by agreement)
Outcome data capture
To WDHB notes
To GP
To IMMP
To research team

Summary
Metabolic syndrome in chronic mental illness
is aggravated, if not caused, by SGAs
increases morbidity and mortality
management impaired by poor information sharing
also poses litigation and institutional risks
Risks can be addressed by effective collaboration
specialist mental health teams (multidisciplinary)
GPs
Pharmacists
Physical educationalists
Dieticians

Ways forward
Consider local, regional, and national strategies
Exploit existing resources
Professional knowledge and skill
Information Technology
Organizational/cultural
Develop specifications for information system to
Capture and provide relevant clinical data to specialist services, GP, and pharmacy
Provide effective decision support to clinicians

GP secondary care pharmacy information repository + decision support individual laboratory Model of gated* electronic information flow * each indicated path will have defined fields and access criteria

Proposed interim plan
extend IMMP monitoring of SGAs for one year to determine the most cost-effective starting point for national system
Examine interoperability of available information systems to meet agreed specification
Establish administrative support to assist planning and resourcing
Service development
Research

Conclusion
Metabolic syndrome in chronic mental illness
aggravated by second generation antipsychotics
increases morbidity and mortality
management impaired by poor information sharing
Risks can be addressed by effective shared care between
specialist mental health teams (multidisciplinary)
GPs
Pharmacists
Physical educationalists
Dieticians
other allied health professionals

Hearts and Minds: How to tackle metabolic syndrome?

by Health Informatics New Zealand on Nov 17, 2007

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