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Point of Care

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  • Slide Unlike presentations of clinical study data, this slide set presents: Insights gained by observing physicians in practice who have achieved a measure of success using atypical antipsychotics for treatment of bipolar disorder and schizophrenia. Barriers to successful use that could be addressed by modeling clinical best practices and then implementing these insights. Tools and approaches that can help support physicians in implementing these best practices.

Transcript

  • 1. Optimizing the Use of Atypical Antipsychotics
  • 2. Background – Variations in Care
    • Assumption
    • Most physicians will make similar diagnostic and treatment decisions, and will offer care in similar ways
    • Reality
    • A wide variety of factors influence clinical decisions made by physicians leading to high variability of clinical practice
    • High variability in care can lead to poor patient outcomes including unacceptably high rates of side effects and lack of efficacy
  • 3. Process of Care Participants
    • Canada
    • Dr. Pratap R. Chokka
    • Dr. Pierre Chue
    • Dr. Valerie Tourjman
    • Germany
    • Dr. Brita Dorn
    • Dr. Claus-J ürgen Krafczyk
    • Dr. Markus Leweke
    • Italy
    • Dr. Rocco Pollice
    • Spain
    • Dr. Celso Arango
    • Dr. Francesco Colom
    • Dr. Jose M. Olivares
    • United Kingdom
    • Dr. John Cookson
    • Dr. Tonmoy Sharma
    • United States
    • Dr. Joseph Bryer
  • 4. Table of Contents
    • History of Psychosis Management
    • Variations in Care
    • The Optimal Care Process
      • Overview
      • Barriers and Best Practices
      • Elements: Diagnosis, Medication Initiation, Treatment Optimization, Continuation of Care
    • Putting It All Together
      • The Atypical Antipsychotic CareMap ™
      • Discussion
      • References
  • 5. Objectives
    • To increase awareness of best clinical practices in the management of patients with bipolar disorder or schizophrenia
    • To provide practical information, keys to success, and tools to help practitioners overcome barriers to achieving high quality care
  • 6. Bipolar Disorder and Schizophrenia: A Historical Perspective http://www.mindful-things.com/history_of_psych_home.html#120_70BC 1409 - First asylum in Seville, Spain 1934 - Electroconvulsive therapy (ECT) introduced by von Meduna 1978 - Dopamine hypothesis put forward to explain schizophrenia 1985 - U.S. NIMH's Consensus Conference on ECT concluded risks virtually eliminated and best used for depression and some mania 1300 1400 1900 1990 2005 1330 - Casting out devils in common use 1911 - Bleuler introduced term "schizophrenia" 1932 - Sakel introduced insulin coma therapy for schizophrenia 1952 - French researchers discovered chlorpromazine, marking the beginning of psychopharmacology 1983 - Researchers discover many schizophrenics cannot track moving target visually—close relatives also share this deficiency, even if not schizophrenic
  • 7. Bipolar Disorder and Schizophrenia: A Historical Perspective 1990 2005 1990 - First atypical antipsychotic introduced-clozapine 1992 - APA and CPA establish clearer guidelines and standards for using ECT 1993 - Neuroimaging studies showed frontal, temporolimbic and basal ganglia involved in schizophrenia — Same abnormalities observed with other conditions, though to a lesser degree 1994 - Saykin, et al discover temporolimbic deficits of unmedicated, first-episode schizophrenic patients 2000 - American Psychiatric Association published the DSM-IV-TR , Diagnostic and Statistical Manual of the Mental Disorders Fourth Edition, Text Revision http://www.mindful-things.com/history_of_psych_home.html#120_70BC 2005 - Genetic biomarkers identified as basis for future blood test to confirm diagnosis of schizophrenia or bipolar disease
  • 8. Factors Influencing the Variability of Clinical Practice Clinical Decision Clinical data Beliefs Peers Experience and training Competence Habits Emotions Comfort level
  • 9. Factors Influencing the Variability of Clinical Practice External Influences
  • 10. Variations in Care
    • Can result from the following:
      • The capacity of the local health care system influencing how much care is given
      • The practice styles of local physicians determining the type of care delivered
      • Local medical opinion and resources appearing to be more important than science in determining how medical care is delivered (Wennberg, 2002)
  • 11. Variations in Care
    • Can lead to:
      • An average 17 year lag between the discovery of more effective forms of treatment and their incorporation into routine patient care (Balas, 2003)
      • Avoidable deaths of roughly 79,000/year in U.S. (National Committee for Quality Assurance, 2004)
      • Only 55% of patients receiving recommended care (McGlynn, 2003)
  • 12. Variations in Mental Illness Care
    • 70% of bipolar patients are misdiagnosed before receiving a correct diagnosis (Hirschfeld, 2003)
    • On average, patients with bipolar disorder wait more than 8 years from the start of symptoms before receiving a correct diagnosis (Hirschfeld, 2003)
    • Patients get the correct mental healthcare only about 50% of the time (National Committee for Quality Assurance, 2004)
  • 13. Approaches to Reducing Variability
    • Identify problems and intervene
      • Chart audits and compliance reports
      • Treatment protocols
    • OR
    • Identify best practices as a model
      • Attending physicians teaching residents
      • Experienced clinicians educating others
  • 14. Reducing Variability of Care Through Best Practices
    • Best clinical practices
    • Effective techniques
    • Useful tools
    Reduced variability in patient care & outcomes through
    • Delayed patient treatment
    • Incomplete diagnostic assessments
    • Diverse treatment initiation strategies
    • Degree of intensity of follow-up
    • Lack of continuity of care from inpatient to outpatient
    • Inadequate patient education
    • Environmental stressors
    • Variations in the quality of the patient/physician relationship
    High variability in patient care & outcomes due to Knowledge and Experience
  • 15. Observed Barriers and Expert Approaches to Achieving Optimal Performance with Atypicals Assure continuity and coordination of care, including offering intermediate care Break in continuity of care following discharge Rational approach to medication selection based on patient profile Ad hoc medication selection Rapid dose initiation to gain early control over acute symptoms Slow initial dose titration to avoid side effects Heightened vigilance for early psychosis symptoms Delaying the initial diagnosis Stay alert for first sign(s) of relapse Lack of vigilance around relapse Commit to a treatment and stick with it Failure to give adequate therapeutic trial Think long term when selecting your acute medication Focus on acute management Build rapport beginning with first interaction Neglecting to establish a relationship with the patient Expert Approach (Pearls) Barrier (Perils)
  • 16. Overview of the Optimal Care Process Goal: Achieve best functional outcomes by reducing frequency of relapse
  • 17. Overview of the Optimal Care Process Goal: Achieve best functional outcomes by reducing frequency of relapse Objective: Consider acute symptom control with long-term goals Objective: Adjust treatment program to achieve stability Objective: Maintain care to minimize relapse Objective: Make proper diagnosis, communicate it to patient
  • 18. The Care Process: Diagnosis
    • Objective: Make proper diagnosis and communicate it to the patient
    • Perils
      • Delayed ⁄ Inappropriate diagnosis
      • Patients rarely volunteer information about mania, mood, or anxiety symptoms
      • Cognitive deficits that predict poor outcomes often overlooked
      • Limited patient insights
  • 19. The Care Process: Diagnosis
    • Objective: Make proper diagnosis and communicate it to the patient
    • Pearls
      • Perform comprehensive diagnostic work-up for organic causes and make transparent to patient to establish trust
      • Assess role of drugs, alcohol, and non-adherence as contributing factors
      • If patient is admitted, minimize trauma of the admission process
      • Communicate using effective approaches
      • Establish a treatment plan that includes long-term goals (e.g., medication compliance)
  • 20. Key to Success
    • Build trust beginning with first interaction
  • 21. Diagnosis: Support Resources
    • Many existing resources support diagnosis and overall management strategies
      • Guidelines
        • APA, NICE
        • Regional, local guidelines
      • Assessment instruments
      • Websites
      • DSM and ICD criteria
  • 22. Overview of the Optimal Care Process Goal: Achieve best functional outcomes by reducing frequency of relapse Objective: Consider acute symptom control with long-term goals Objective: Adjust treatment program to achieve stability Objective: Maintain care to minimize relapse Objective: Make proper diagnosis, communicate it to patient
  • 23. The Care Process: Medication Initiation
    • Objective: Consider acute symptom control with long- term goals
    • Perils
      • Lack of documentation of previous of medications, their effectiveness, reported side effects, etc.
      • Failure to identify patients at increased risk for some side effects
      • Selecting medication only for controlling acute symptoms rather than best choice for long-term management
      • Perception of need for slower titration to avoid side effects may lead to sub-therapeutic dosing
      • Failure to reach therapeutic range and maximize the dose of first medication
  • 24. The Care Process: Medication Initiation
    • Objective: Consider acute symptom control with long- term goals
    • Pearls
      • Rapid initiation and sustained use of antipsychotic medication is the cornerstone of successful management
      • Rationally select medication, keeping the end in mind
        • Target most problematic symptoms, but side effect profile may be prime determinant of drug choice
        • Atypical antipsychotics are a medication choice
        • Select medication addressing predominant symptom and having lowest risk of long-term side effects
  • 25. The Care Process: Medication Initiation
    • Objective: To consider acute symptom control with long-term goals
    • Pearls
      • Build early rapport with patient
        • Set expectations regarding side effects, effectiveness, etc.
        • Involve patient in medication selection process
        • Gain early feedback on effects of medication
  • 26. Rational Medication Selection Criteria
    • Benefits
      • Primary diagnosis
      • Severity of acute symptoms
      • Long-term adherence
      • Functional outcome(s)
    • Risks
      • Relative severity of possible adverse events
      • Patient risks for selected side effects (see slide 27)
    • Benefit-risk ratio
      • Effectiveness and side effects of past medication(s)
  • 27. Rational Medication Selection: Potential Adverse Events to Consider
    • Symptoms to consider
      • EPS/Tardive Dyskinesia
      • Akathisia
      • Nausea and vomiting
      • Prolactin elevation/ sexual dysfunction
      • Weight gain
      • Sedation
    • Signs to consider
      • Glucose abnormalities
      • Lipid abnormalities
      • QTc prolongation
      • Hypotension
      • Anti-cholinergic side effects
    When selecting a medication, a clinician should consider both the patient’s needs in the short and the long term and the efficacy and side-effects of various medications
    • References:
    • American Psychiatric Association. Practice Guideline for the Treatment of Patients with Schizophrenia, Second Edition: February, 2004.
    • Bagnall AM, et. Al. A systematic review of atypical antipsychotic drugs in schizophrenia. Health Technology Assessment . 2003;7(13).
    • National Institute for Clinical Excellence. Schizophrenia: Core interventions in the treatment and management of schizophrenia in primary and secondary care. Clinical Guideline 1, December 2002.
  • 28. External Factors Affecting Medication Selection
    • Drug formulary committee
    • Anecdotal experience
    • Availability of samples
    • Patient preference
  • 29. Key to Success
    • Think long term when selecting your acute medication
  • 30. Medication Initiation Tool: Medication Schedule
  • 31. Overview of the Optimal Care Process Goal: Achieve best functional outcomes by reducing frequency of relapse Objective: Balance acute symptom control with long-term goals Objective: Adjust treatment program to achieve stability Objective: Maintain care to minimize relapse Objective: Make proper diagnosis, communicate it to patient
  • 32. The Care Process: Treatment Optimization
    • Objective: Adjust treatment program to achieve stability
    • Perils
      • Medication prematurely deemed ineffective before completing adequate therapeutic trial of 4-6 weeks
      • Unable to identify what information to provide to cognitively challenged patients, and when to provide it
      • Lack of communication and inconsistency of care between inpatient to outpatient settings
        • Especially before first follow up visit for severe, chronic patients
  • 33. The Care Process: Treatment Optimization
    • Objective: Adjust treatment program to achieve stability
    • Pearls
      • Monitor medication effectiveness over adequate therapeutic trial of 4-6 weeks (APA, 2004)
        • Adjust medications to reduce
          • target symptoms
          • residual symptoms
          • emerging side effects
        • Titrate between side effects and symptoms
        • Establish tracking methodology
  • 34. The Care Process: Treatment Optimization
    • Objective: Adjust treatment program to achieve stability
    • Pearls
      • Cognitive therapy and psychoeducation should be continuous, but staged
      • Continue building physician-patient relationship
        • Involve caregiver ⁄ family and monitor environment for stressors (e.g., psychosocial, substance abuse, financial, etc.)
      • Assess and anticipate reasons for non-adherence
      • Prepare patient for return to community and orchestrate continuity of care with outpatient care providers
  • 35. Key to Success Commit to a treatment and stick with it
  • 36. Treatment Optimization Tool: Treatment Plan Checklist
  • 37. Treatment Optimization Tool: My Action/Monitoring Plan
  • 38. Overview of the Optimal Care Process Goal: Achieve best functional outcomes by reducing frequency of relapse Objective: Balance acute symptom control with long-term goals Objective: Adjust treatment program to achieve stability Objective: Maintain care to minimize relapse Objective: Make proper diagnosis, communicate it to patient
  • 39. The Care Process: Continuation of Care
    • Objective: Maintain care to minimize relapse
    • Perils
      • Failing to make plans for continued care after hospitalization leading to early relapse
      • Strong propensity for substance and/or alcohol abuse
      • Bipolar patients may seek to achieve mood elevation
      • Isolation/lack of a caregiver support system
  • 40. The Care Process: Continuation of Care
    • Objective: Maintain care to minimize relapse
    • Pearls
      • Provide appropriate degree of intervention for patients prone to relapse
      • Assure caregiver education and involvement
      • Maintain a high trust relationship
      • Make crisis management resources available
      • Assure strict vigilance to early recognition of relapse symptoms
      • Reinforce medication adherence and avoidance of drugs and alcohol
      • Target optimizing functional outcomes
  • 41. Key to Success Stay alert for first sign(s) of relapse
  • 42. Continuation of Care Tool: Tips for Staying Well
  • 43. Putting It All Together: The Care Process Goal: Achieve best functional outcomes by reducing frequency of relapse Objective: Balance acute symptom control with long-term goals Objective: Adjust treatment program to achieve stability Objective: Maintain care to minimize relapse Objective: Make proper diagnosis, communicate it to patient
  • 44. Putting It All Together: The CareMap ™ Pierre Chue, F Markus Leweke, Ana González-Pinto on behalf of the CareMap Research Team. Sharing best practice in the management of schizophrenia and bipolar disorder: development of an atypical antipsychotic CareMap. Int J Neuropsychopharmacol 2006; 9 (Suppl 1): S261. Abstract number P03.124
  • 45. Summary
    • Goal: Achieve best functional outcomes
    • Keys to success
      • Build trust beginning with first interaction
      • Think about the long term when selecting your acute medication
      • Commit to a treatment and stick with it
      • Stay alert for first sign(s) of relapse
    • Best practices
    • Resources
  • 46. Discussion
  • 47. References
    • American Psychiatric Association. Practice Guideline for the Treatment of Patients with Schizophrenia, Second Edition: February, 2004.
    • Bagnall AM, et. Al. A systematic review of atypical antipsychotic drugs in schizophrenia. Health Technology Assessment . 2003;7(13).
    • Balas EA. Information Systems Can Prevent Errors and Improve Quality. J Am Med Inform Assoc . 2001;8:398-99.
    • Hirschfeld RM, Lewis L, Vornik LA. Perceptions and Impact of Bipolar Disorder: How Far Have We Really Come? Results of the National Depressive and Manic-Depressive Association 2000 Survey of Individuals With Bipolar Disorder. J Clin Psychiatry . 2003;64:161-74.
    • Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington, D.C.: National Academy Press, 2003.
    • McGlynn EA, Asch SM, Adams J, et al. The Quality of Health Care Delivered to Adults in the United States. N Engl J Med . 2003;348:2635-45.
    • National Committee for Quality Assurance. The State of Health Care Quality: Industry Trends and Analysis. Washington, D.C.: NCQA, 2004.
    • National Institute for Clinical Excellence. Schizophrenia: Core interventions in the treatment and management of schizophrenia in primary and secondary care. Clinical Guideline 1, December 2002.
    • Tsuang MT, Nossova N, Yager T, et al. Assessing the validity of blood-based gene expression profiles for the classification of schizophrenia and bipolar disorder: A preliminary report. Part B: Neuropsychiatric Genetics. Am J Med Genetics. 2005;133B:1-5.
    • Wennberg JE. Unwarranted Variations in Healthcare delivery: Implications for Academic Medical Centres. BMJ . 2002;325:961-64.