10 research outputs found
Development and Delivery of a Quality Improvement Program to Reduce Antipsychotic Polytherapy
BACKGROUND: Although antipsychotic polytherapy is considered appropriate in limited circumstances (e.g., during a brief “cross-titration” period when switching medications), its increasing prevalence indicates use beyond this limited scope. Despite absence of support in the medical literature and higher costs, antipsychotic polytherapy is common in the treatment of schizophrenia and related disorders. The highest utilization of antipsychotic polytherapy occurs on psychiatric inpatient units, and in 2008, the Joint Commission released the first set of 7 hospital-based inpatient psychiatric services (HBIPS) core measures, 2 of which assess antipsychotic polytherapy at time of discharge.
OBJECTIVE: To describe the effect on antipsychotic polytherapy at time of discharge of a 2-part quality improvement program composed of educational seminars and prescriber-specific feedback provided to 11 psychiatrists in 4 acute inpatient psychiatric units in 2 hospitals.
METHODS: In a regional academic health care system, we determined the prevalence of antipsychotic monotherapy and polytherapy at time of discharge for all patients discharged on standing antipsychotic medications during 3 periods: (a) a 3-month baseline period (August 2006 through October 2006); (b) in July 2007, after delivery of 4 educational luncheon seminars to 11 psychiatrists from November 2006 through June 2007; and (c) in June 2008, following the provision of monthly prescriber-specific audit feedback from August 2007 through June 2008. To prepare nurses for the change and address possible safety concerns, an educational module was delivered to the psychiatric nursing staff at “best practice” day lectures held in the first quarter of 2007. General themes in the educational presentations included literature-based reviews of (a) safety and efficacy of antipsychotic polytherapy, (b) medical risks of antipsychotic medications, (c) specific versus nonspecific effects of these medications, and (d) effectiveness of first- versus second-generation antipsychotic medications. The prescriber-specific audit feedback was provided in paper form and masked the identity of the other prescribers. The chief of service reviewed audit feedback individually with each psychiatrist on a quarterly basis. The primary outcome measure was the percentage of patients prescribed 2 or more antipsychotics at discharge. A secondary outcome measure was the percentage of patients prescribed 3 or more antipsychotics at discharge. Differences in the primary outcome measure, comparing (a) July 2007 with the baseline period and (b) June 2008 with July 2007, were analyzed using Fisher’s Exact tests. The Cochran-Armitage test for trend was used to assess the relationship between the primary outcome measure and the extent of the intervention, measured as the 3 time periods. For the secondary outcome measure, the Goodman-Kruskal gamma test for ordered categorical data was calculated to examine the association between the proportion of patients receiving 1, 2, or 3 or more antipsychotics at discharge and the 3 time periods.
RESULTS: The percentage of patients prescribed 2 or more antipsychotics at discharge declined from 33.9% at baseline (132 of 389 patients), to 21.8% after delivery of the educational modules (44 of 202 patients, P = 0.002), and to 12.2% after audit feedback (18 of 147 patients, P = 0.023; Cochran-Armitage test for trend P \u3c 0.001). When antipsychotic use was classified as 1, 2, or 3 or more antipsychotic medications, more extensive intervention was associated with decreased combination use (Goodman-Kruskal gamma = 0.39, P \u3c 0.001). In the baseline period, 5.9% of patients were prescribed 3 or more antipsychotics at discharge. Following completion of the educational and audit components, respectively, the proportion of patients prescribed 3 or more antipsychotics declined to 2.5% and then to 0.0%.
CONCLUSION: Educational modules presented to psychiatrists and nurses in group settings were associated with a decrease in the rate of prescribing 2 or more antipsychotics at discharge from acute psychiatric inpatient units. Addition of monthly audit feedback provided to psychiatrists was associated with further decreases
Out on the street: A public health and policy agenda for lesbian, gay, bisexual, and transgender youth who are homeless.
Developing a Pipeline for the Community-Based Primary Care Workforce and Its Leadership: The Kraft Center for Community Health Leadership\u27s Fellowship and Practitioner Programs.
Mental illness stigma and engagement in an implementation trial for Cognitive Processing Therapy at a diverse community health center: a qualitative investigation
Recommended from our members
Facilitators of and barriers to high-resolution anoscopy adherence among men who have sex with men: a qualitative study
Background Anal cancer is a rare malignancy that disproportionately affects men who have sex with men (MSM) and HIV-infected people. Anal cancer is associated with human papillomavirus (HPV) in upward of 90% of cases and is preceded by pre-cancerous changes in cells of the anal canal. High-resolution anoscopy (HRA) is used for the detection, treatment and continued monitoring of anal dysplasia. Practice guidelines regarding anal cancer prevention vary by jurisdiction and institution, and patient engagement is low for high-risk populations such as MSM. The purpose of this study is to characterise perceptions among MSM of barriers to and facilitators of their adherence to HRA follow-up recommendations.
Surveys and in-person focus groups with MSM who were either adherent or non-adherent to HRA follow-up recommendations at a Federally Qualified Health Centre in Boston, MA, which specialises in sexual and gender minority care, were conducted. Facilitators of and barriers to follow-up were identified by deductive content analysis.
Focus group participants identified the following barriers to and facilitators of HRA follow up: (1) patient-level beliefs about HPV-related disease or HRA, ability to engage in care, internalised stigma and physical discomfort; (2) provider-level knowledge and expertise, communication skills and relationship-building with patient; and (3) systems-level societal stigma and healthcare system inefficiencies.
Reinforcing facilitators of and reducing barriers to HRA follow up may improve adherence among MSM. This includes improvements to: patient education, provider training to increase knowledge and cultural sensitivity, public awareness about HPV-related anal cancer, physical discomfort associated with HRA and systems inefficiencies
Provider fidelity and modifications to cognitive processing therapy in a diverse community health clinic: Associations with clinical change.
Black-white disparities in the association between posttraumatic stress disorder and chronic illness
Recommended from our members