Metabolic Testing for Adults in a State Medicaid Program Receiving Antipsychotics: Remaining Barriers to Achieving Population Health Prevention Goals

Cardiometabolic screening and monitoring in patients prescribed antipsychotic drugs in primary care: A population-based cohort study

BACKGROUND

This study aimed to investigate the level of guideline adherence for cardiometabolic health monitoring for patients prescribed antipsychotic medicines in UK primary care.

METHODS

In this population-based retrospective open cohort study, we used dataset of patients from the IQVIA Medical Research Data (IMRD) database between 1st January 2003 to 31st December 2018. Clinical Read codes were used to identify a cohort of adult patients with a diagnosis of Schizophrenia and at least four prescriptions of an anti-psychotic medication within 12 months of diagnosis. We then extracted data in relation to monitoring of cardiometabolic parameters (body compositions, lipids, and glucose outcomes) at baseline, then at six weeks, 12 weeks, and then 12 months. The frequency of outcome monitoring was described using descriptive statistics.

FINDINGS

A total of 11,435 patients were eligible and of them (n = 9707; 84·8%) were prescribed second-generation antipsychotics (SGAs). Only a small portion of the cohort (≈2·0%) received complete monitoring (at time points) for certain outcomes. Just over half the patients (n = 6599, 52%) had evidence of any cardiometabolic baseline testing for any of the study outcomes and the high majority had at least one abnormal lab value at baseline (n = 4627, 96·7%).

INTERPRETATION

In UK primary care, cardiometabolic monitoring practices among patients prescribed antipsychotics remain suboptimal. There is a need to promote guideline adherence to prevent adverse outcomes in antipsychotic users.

Health status of young adults with serious mental illness enrolled in integrated care

AIMS

People with serious mental illness (SMI) are more likely to develop chronic health conditions and die prematurely. Timely identification of modifiable health risk factors may enable early intervention. We aimed to describe the physical health characteristics and service utilization of young people with SMI.

METHODS

Young people with SMI enrolled in an integrated community mental health clinic (CMHC) and primary care program were assessed for physical and mental health history and past year service utilization.

RESULTS

A total of 122 participants, ages 16-35 (m = 27.0 ± 5.0 years), half male, 78.3% White were assessed. Half smoked cigarettes, half had obesity, almost half (47.5%, n = 56) had hypertension, and about a third had laboratory metabolic abnormalities. The group averaged 10.7 ± 5.1 h of sedentary behavior per day. Obesity was associated with high blood pressure, prediabetes, poor self-rated health abilities, sedentary behavior and low health satisfaction. Over half had been to the emergency department (ED) for a medical reason (55.0%, n = 66) and 24.6% had been hospitalized for a health condition in the past year. Over half had a lifetime cardiovascular risk score indicating a 50-67% chance of having a cardiovascular event; simply quitting smoking would reduce the number with this risk by almost half. Most physical health diagnoses were not recorded in the CMHC record.

CONCLUSION

Young people with SMI newly enrolled in integrated care had high rates of smoking, obesity, hypertension, and other cardio-metabolic abnormalities contributing to high risk for future disease. Research is needed to examine appealing, scalable interventions to improve health, reduce unnecessary medical care, and prevent disparate chronic disease in this group.

CRANIUM: a quasi-experimental study to improve metabolic screening and HIV testing in community mental health clinics compared to usual care

BACKGROUND

Individuals with serious mental illness often do not receive guideline-concordant metabolic screening and human immunodeficiency virus (HIV) testing, contributing to increased morbidity and premature mortality. This study evaluates the effectiveness of CRANIUM (Cardiometabolic Risk Assessment and treatment through a Novel Integration model for Underserved populations with Mental illness), an intervention to increase metabolic screening and HIV testing among patients with serious mental illness in a community mental health clinic compared to usual care.

METHODS

The study used a quasi-experimental design, prospectively comparing a preventive care screening intervention at one community mental health clinic (n = 536 patients) to usual care at the remaining clinics within an urban behavioural health system (n = 4,847 patients). Psychiatrists at the intervention site received training in preventive health screening and had access to a primary care consultant, screening and treatment algorithms, patient registries, and a peer support specialist. Outcomes were the change in screening rates of A1c, lipid, and HIV testing post-intervention at the intervention site compared to usual care sites.

RESULTS

Rates of lipid screening and HIV testing increased significantly at the intervention site compared to usual care, with and without multivariable adjustment [Lipid: aOR 1.90, 95% CI 1.32-2.75, P = .001; HIV: aOR 23.42, 95% CI 5.94-92.41, P < .001]. While we observed a significant increase in A1c screening rates at the intervention site, this increase did not persist after multivariable adjustment (aOR 1.37, 95% CI .95-1.99, P = .09).

CONCLUSIONS

This low-cost, reverse integrated care model targeting community psychiatrist practices had modest effects on increasing preventive care screenings, with the biggest effect seen for HIV testing rates. Additional incentives and structural supports may be needed to further promote screening practices for individuals with serious mental illness.

Mortality gap and physical comorbidity of people with severe mental disorders: the public health scandal

BACKGROUND

Patients suffering from severe mental disorders, including schizophrenia, major depression and bipolar disorders, have a reduced life expectancy compared to the general population of up to 10-25 years. This mortality gap requires urgent actions from a public health perspective in order to be reduced.

MAIN TEXT

Factors associated with the high mortality rates in patients with severe mental disorders can be grouped into four groups: those related to the patients, to psychiatrists, to other non-psychiatrist medical doctors and to the healthcare system. Each of these factors should become the target of specific and dedicated interventions, in order to reduce the morbidity and mortality rate in patients with severe mental disorders. All these elements contribute to the neglect of physical comorbidity in patients with severe mental. In particular, the long-standing separation of psychiatry from other branches of medicine and the lack of specific training on this issue further contribute to the poor attention dedicated to management of physical comorbidities. Recently, several professional associations have invited national bodies regulating education of healthcare professionals to include the management of physical health of people with severe mental disorders in undergraduate and postgraduate educational programs.

CONCLUSIONS

The premature mortality in patients with severe mental disorders is a complex phenomenon resulting by the interaction of several protective and risk factors. Therefore, a multilevel approach is needed, in which the different stakeholders involved in health care provision establish workforces for the long-term management of physical and mental health conditions.

Real-World Data on the Adverse Metabolic Effects of Second-Generation Antipsychotics and Their Potential Determinants in Adult Patients: A Systematic Review of Population-Based Studies

INTRODUCTION

To assess the risk of occurrence and potential determinants of metabolic disorders in adult patients treated with second-generation antipsychotics (SGAs) under real-world practice conditions.

METHODS

MEDLINE, EMBASE, and PsycInfo were searched in July 2019 from database inception. We included population-based, longitudinal, comparative studies that report the results of the outcomes of interest for adult participants, including diabetes, ketoacidosis, hyperosmolar hyperglycemic state, weight gain/obesity, dyslipidemia, hypertension, and metabolic syndrome. Two reviewers independently extracted data on the study design, study quality, and study outcomes.

RESULTS

We included 40 studies. Most studies showed that clozapine and olanzapine were associated with an increased likelihood of developing diabetes, while the results for risperidone and quetiapine were mixed. Although less well studied, ziprasidone and aripiprazole appeared to not be associated with the occurrence of diabetes. Information on antipsychotic-induced weight gain/obesity is extremely scarce. Regarding dyslipidemia, aripiprazole was not associated with an increased likelihood of developing dyslipidemia, clozapine was associated with an increased likelihood of developing dyslipidemia, and risperidone, olanzapine, quetiapine, and ziprasidone showed mixed results. Two studies suggested an association between ziprasidone and the occurrence of hypertension. Several studies found that the occurrence of a metabolic disorder acted as a risk factor for the development of other metabolic disorders. We did not find information on brexpiprazole, cariprazine, or lurasidone, and data on any long-acting SGA were lacking.

CONCLUSION

Although there are relevant differences among SGAs concerning the risk of metabolic disorders, it appears that none of the SGAs included in our review are fully devoid of these disturbances.

Providing Health Physicals and/or Health Monitoring Services in Mental Health Clinics: Impact on Laboratory Screening and Monitoring for High Risk Populations

Providing physical health care in specialty mental health clinics is a promising approach to improving the health status of adults with serious mental illness, but most programs examined in prior studies are not financially sustainable. This study assessed the impact on quality of care of a low-cost program implemented in New York State that allowed mental health clinics to be reimbursed by Medicaid for provision of health monitoring and health physicals (HM/HP). Medicaid claims data were analyzed with generalized linear multilevel models to examine change over time in quality of physical health care associated with HM/HP services. Recipients of HM/HP services were compared to control clinic patients [Per protocol (PP)] and with non-recipients of HM/HP services from both intervention and control clinics [As-Treated (AT)]. HM/HP clinic patients, regardless of receipt of HM/HP services, were compared with control clinic patients [Intent-to-Treat (ITT)]. Analyses were conducted with adjustment for patient demographic and clinical characteristics and prior year service use. The PP and AT analyses found significant improvement in measure of blood glucose screening for patients on antipsychotic medication and HbA1C testing for patients with diabetes (AOR range 1.26-1.33) and the AT analysis found significant improvement in cholesterol screening for patients on antipsychotic medication (AOR 1.24). However, ITT analysis found no significant changes in quality of care in HM/HP clinic caseloads relative to control clinics. The low-cost HM/HP program has the potential to benefit patients who receive supported services, but its impact is limited by remaining barriers to service implementation.

Using Claims Data to Assess Treatment Quality of First-Episode Psychosis

OBJECTIVE

Coordinated specialty care (CSC) has become the standard of care for first-episode psychosis (FEP). The gap between CSC best practices and the actual care delivered is unknown. This longitudinal study aimed to measure that gap by using a large Medicaid claims database and 10 quality indicators (QIs) reflecting aspects of CSC and to study the relationship between these QIs and future health care utilization.

METHODS

Individuals with FEP were identified in a Missouri Medicaid claims database. Participants were required to have been eligible for Medicaid benefits for at least 10 months in the year prior to and the year after their first episode of psychosis and to have had no evidence of a prior psychosis diagnosis. Descriptive statistics were generated for each of the QIs, and a stratified Cox regression was used to identify predictors of subsequent health care utilization.

RESULTS

Data were obtained for 6,246 participants, and follow-up lasted a mean of 4.24 years. Significant practice gaps were found in the use and monitoring of antipsychotic medications. Of those prescribed antipsychotic medication, 5% received prescriptions above recommended daily doses, 16% received two or more antipsychotics, and 20% were treated with olanzapine or clozapine. Among the QIs, lack of monitoring for smoking (hazard ratio [HR]=2.71, 95% confidence interval [CI]=2.47-2.97) and lack of integrated care delivery in treatment (HR=2.00, 95% CI=1.92-2.08) were most associated with psychiatric hospitalization.

CONCLUSIONS

In most cases, treatment was far from meeting CSC recommendations, suggesting that implementation of CSC requires substantial modifications to delivery of care for individuals with FEP.

Antipsychotic medication adherence and preventive diabetes screening in Medicaid enrollees with serious mental illness: an analysis of real-world administrative data

BACKGROUND

There is excess amenable mortality risk and evidence of healthcare quality deficits for persons with serious mental illness (SMI). We sought to identify sociodemographic and clinical characteristics associated with variations in two 2015 Healthcare Effectiveness Data and Information Set (HEDIS) measures, antipsychotic medication adherence and preventive diabetes screening, among Medicaid enrollees with serious mental illness (SMI).

METHODS

We retrospectively analyzed claims data from September 2014 to December 2015 from enrollees in a Medicaid specialty health plan in Florida. All plan enrollees had SMI; analyses included continuously enrolled adults with antipsychotic medication prescriptions and schizophrenia or bipolar disorder. Associations were identified using mixed effects logistic regression models.

RESULTS

Data for 5502 enrollees were analyzed. Substance use disorders, depression, and having both schizophrenia and bipolar disorder diagnoses were associated with both HEDIS measures but the direction of the associations differed; each was significantly associated with antipsychotic medication non-adherence (a marker of suboptimal care quality) but an increased likelihood of diabetes screening (a marker of quality care). Compared to whites, blacks and Hispanics had a significantly greater risk of medication non-adherence. Increasing age was significantly associated with increasing medication adherence, but the association between age and diabetes screening varied by sex. Other characteristics significantly associated with quality variations according to one or both measures were education (associated with antipsychotic medication adherence), urbanization (relative to urban locales, residing in suburban areas was associated with both adherence and diabetes screening), obesity (associated with both adherence and diabetes screening), language (non-English speakers had a greater likelihood of diabetes screening), and anxiety, asthma, and hypertension (each positively associated with diabetes screening).

CONCLUSIONS

The characteristics associated with variations in the quality of care provided to Medicaid enrollees with SMI as gauged by two HEDIS measures often differed, and at times associations were directionally opposite. The variations in the quality of healthcare received by persons with SMI that were identified in this study can guide quality improvement and delivery system reform efforts; however, given the sociodemographic and clinical characteristics' differing associations with different measures of care quality, multidimensional approaches are warranted.

Identification and management of cardiometabolic risk in subjects with schizophrenia spectrum disorders: A Delphi expert consensus study

BACKGROUND

Patients with schizophrenia spectrum disorders (SSD) have worse physical health and reduced life expectancy compared to the general population. In 2009, the European Psychiatric Association, the European Society of Cardiology and the European Association for the Study of Diabetes published a position paper aimed to improve cardiovascular and diabetes care in patients with severe mental illnesses. However, the initiative did not produce the expected results. Experts in SSD or in cardiovascular and metabolic diseases convened to identify main issues relevant to management of cardiometabolic risk factors in schizophrenia patients and to seek consensus through the Delphi method.

METHODS

The steering committee identified four topics: 1) cardiometabolic risk factors in schizophrenia patients; 2) cardiometabolic risk factors related to antipsychotic treatment; 3) differences in antipsychotic cardiometabolic profiles; 4) management of cardiometabolic risk. Twelve key statements were included in a Delphi questionnaire delivered to a panel of expert European psychiatrists.

RESULTS

Consensus was reached for all statements with positive agreement higher than 85% in the first round. European psychiatrists agreed on: 1) high cardiometabolic risk in patients with SSD, 2) importance of correct risk management of cardiometabolic diseases, from lifestyle modification to treatment of risk factors, including the choice of antipsychotic drugs with a favourable cardiometabolic profile. The expert panel identified the psychiatrist as the central coordinating figure of management, possibly assisted by other specialists and general practitioners.

CONCLUSIONS

This study demonstrates high level of agreement among European psychiatrists regarding the importance of cardiovascular risk assessment and management in subjects with SSD.

Challenges associated with treating and preventing antipsychotic-induced constipation: considerations and cautions when prescribing novel interventions

Antipsychotic-induced constipation is a treatment-limiting side effect for patients with serious mental illness (SMI). In addition to increased risk of constipation, due to adverse medication effects, individuals diagnosed with SMI are also prone to lifestyle factors that contribute to this medical complication. The USA Food and Drug Administration (FDA) recently released enhanced warnings about the risk of serious, sometimes fatal, complications associated with constipation caused by the antipsychotic, clozapine. It is likely this heightened warning will prompt providers to seek additional means to prevent and treat antipsychotic-induced constipation, despite having no agent with FDA approval for this specific indication. Off-label prescribing of newer medications for the treatment of antipsychotic-induced constipation is associated with risks, many of which are still unknown, considering the exclusion of patients with SMI in studies measuring nonpsychiatric outcomes.

Advocacy for better metabolic monitoring after antipsychotic initiation: based on data from a French health insurance database

Background: Nearly 3% of the population is treated by antipsychotic. The aim of this study was to assess the conformity of monitoring with guidelines to prevent Metabolic Syndrome. Research design and method: The analysis was conducted using SNIIRAM data (2013 to 2017) on a cohort of patients who received at least eight antipsychotic dispensings in the first year. Glucose and lipid testings were recorded according to refunds at initiation [between -3 and 0.5 months], 3 months [between 2 and 4 months], and 12 months [between 11 and 13 months] after, and assuming optimal testing during hospitalization (exclusive of psychiatric unit). Descriptive and comparative analysis, «chi-squared test or Student's t-test», were performed as well as multivariate analysis with logistic regression. Results: 18 760 patients were selected, 14 421 were still alive and monitored at the end of the follow up. In the recommended period, only 2.89% of patients had three complete testings and 50.6% one or two complete testings Non-optimal testing was more likely to occur in children and adults (vs elderly), in patients with less than 3 prescribers, and with universal medical coverage. Conclusion: Monitoring remains dramatically insufficient. New actions involving patients, practitioners, and authorities are warranted.

Cardiovascular risk screening of patients with serious mental illness or use of antipsychotics in family practice

Background

Patients with serious mental illness (SMI) and patients on antipsychotics (AP) have an elevated risk for cardiovascular diseases. In the Netherlands, the mental healthcare for these patients is increasingly taken care of by family practitioners (FP) as a result of a shift from secondary to primary care. Therefore, it is essential to increase our knowledge regarding the characteristics of this patient group and the (somatic) care provided by their FPs. The aim was to examine the rate of cardiovascular risk screening in patients with SMI or the use of AP in family practice.

Methods

We performed a retrospective cohort study of 151.238 patients listed in 24 family practices in the Netherlands.

From electronic medical records we extracted data concerning diagnoses, measurement values of CVR factors, medication and frequency of visits over a 2 year period. Primary outcome was the rate of patients who were screened for CVR factors. We compared three groups: patients with SMI/AP without diabetes or CVD (SMI/AP-only), patients with SMI/AP and diabetes mellitus (SMI/AP + DM), patients with SMI/AP and a history of cardiovascular disease (SMI/AP + CVD). We explored factors associated with adequate screening using multilevel logistic regression.

Results

We identified 1705 patients with SMI/AP, 834 with a SMI diagnosis, 1150 using AP. The screening rate for CVR in the SMI/AP-only group (n = 1383) was adequate in 8.5%. Screening was higher in the SMI/AP − +DM (n = 206, 68.4% adequate, OR 24.6 (95%CI, 17.3–35.1) and SMI/AP + CVD (n = 116, 26.7% adequate, OR 4.2 (95%CI, 2.7–6.6). A high frequency of visits, age, the use of AP and a diagnosis of COPD were associated with a higher screening rate. In addition we also examined differences between patients with SMI and patients using AP without SMI.

Conclusion

CVR screening in patients with SMI/AP is performed poorly in Dutch family practices. Acceptable screening rates were found only among SMI/AP patients with diabetes mellitus as comorbidity. The finding of a large group of AP users without a SMI diagnosis may indicate that FPs often prescribe AP off-label, lack information about the diagnosis, or use the wrong code.

Metformin add-on vs. antipsychotic switch vs. continued antipsychotic treatment plus healthy lifestyle education in overweight or obese youth with severe mental illness: results from the IMPACT trial

Antipsychotics are used for many psychiatric conditions in youth. Although developmentally inappropriate weight gain and metabolic abnormalities, which are risk factors for premature cardiovascular mortality, are especially frequent in youth, optimal strategies to reduce pediatric antipsychotic-induced overweight/obesity are unclear. The Improving Metabolic Parameters in Antipsychotic Child Treatment (IMPACT) was a randomized, parallel group, 24-week clinical trial which enrolled overweight/obese, psychiatrically stable youth, aged 8-19 years, with a DSM-IV diagnosis of severe mental illness (schizophrenia spectrum disorder, bipolar spectrum disorder or psychotic depression), at four US universities. All of them had developed substantial weight gain following treatment with a second-generation antipsychotic. The centralized, computer-based randomization system assigned participants to unmasked treatment groups: metformin (MET); antipsychotic switch (aripiprazole or, if already exposed to that drug, perphenazine or molindone; SWITCH); or continued baseline antipsychotic (CONTROL). All participants received healthy lifestyle education. The primary outcome was body mass index (BMI) z-score change from baseline, analyzed using estimated least squares means. Altogether, 127 participants were randomized: 49 to MET, 31 to SWITCH, and 47 to CONTROL. BMI z-score decreased significantly with MET (week 24: -0.09±0.03, p=0.002) and SWITCH (week 24: -0.11±0.04, p=0.003), while it increased non-significantly with CONTROL (week 24: +0.04±0.03). On 3-way comparison, BMI z-score changes differed significantly (p=0.001). MET and SWITCH were each superior to CONTROL (p=0.002), with effect sizes of 0.68 and 0.81 respectively, while MET and SWITCH did not differ. More gastrointestinal problems occurred in MET than in SWITCH or CONTROL. The data safety monitoring board closed the perphenazine-SWITCH arm because 35.2% of subjects discontinued treatment due to psychiatric worsening. These data suggest that pediatric antipsychotic-related overweight/obesity can be reduced by adding metformin or switching to a lower risk antipsychotic. Healthy lifestyle education is not sufficient to prevent ongoing BMI z-score increase.

Antipsychotic Use Among Youth in Foster Care Enrolled in a Specialized Managed Care Organization Intervention

OBJECTIVE

Little is known about whether interventions implemented by specialized Medicaid managed care organizations (MMCOs) contributed to recent stabilization of antipsychotic prescribing to youths in foster care. This study examined a multimodal antipsychotic intervention implemented by a specialized MMCO for youths in foster care with routine mental health screening, health passports, elective psychiatric consultation line, and retrospective drug utilization reviews to determine whether this multimodal intervention significantly reduced antipsychotic dispensing for youths with conditions without US Food and Drug Administration (FDA)-approved indications.

METHOD

Employing a difference-in-differences design, intervention effectiveness for youths in foster care (age 6-17 years) compared with adopted youthss was examined. Analyses were stratified by FDA-indicated conditions, other externalizing conditions, and other internalizing conditions. Outcomes included predicted annual probabilities of any antipsychotic dispensed, antipsychotic dispensed for ≥90 consecutive days, and glucose and lipid testing.

RESULTS

Intervention-enrolled youths with FDA-indicated conditions, relative to comparison youths, experienced a 0.6% reduction in any antipsychotic dispensed and 3.1% increase for ≥90 consecutive days dispensed in the 2 years following implementation, both nonsignificant differences. Youths with other externalizing disorders experienced significant reductions, relative to comparison youths, in any antipsychotic dispensed (-6.3%, p < .001) and in ≥90 consecutive days dispensed (-5.5%, p < .001). Youths with other internalizing disorders experienced a significant reduction, relative to comparison youths, in any antipsychotic dispensed (-7.6%, p < .001) and in ≥90 consecutive days dispensed (-5.1%, p < .001). Glucose and lipid testing increased at statistically comparable rates for both groups.

CONCLUSION

MMCO implementation significantly reduced antipsychotic medications without FDA-indicated conditions prescribed to youths, while not significantly affecting antipsychotic medications prescribed to youths with FDA-indicated conditions.

Interventions to Improve Metabolic Risk Screening Among Adult Patients Taking Antipsychotic Medication: A Systematic Review

OBJECTIVE

Antipsychotic use is associated with elevated cardiometabolic risk. Guidelines for metabolic risk screening of individuals taking antipsychotics have been issued, but with little uptake into clinical practice. This review systematically assessed interventions that address this guideline-to-practice gap and described their quality, improvement strategies, and effect on screening rates.

METHODS

Studies of interventions that addressed metabolic risk screening of adult patients taking antipsychotics, published from inception to July 2018, were selected from MEDLINE, Embase, PsycINFO, CINAHL, and Cochrane Reviews databases. Information was extracted on study characteristics; improvement strategies at the provider, patient, and system levels; and screening rates in the intervention and comparison groups.

RESULTS

The review included 30 complex interventions that used between one and nine unique improvement strategies. Social influence to shift provider and health organization culture to encourage metabolic risk screening was a common strategy, as were clinical prompts and monitoring tools to capture provider attention. Most studies were deemed at high risk of bias. Relative to comparison groups, the interventions were associated with an increase in median screening rates for glucose (28% to 65%), lipids (22% to 61%), weight (19% to 67%), and blood pressure (22% to 80%).

CONCLUSIONS

This knowledge synthesis points to shortcomings of current interventions to improve antipsychotic metabolic risk screening, both in quality and in outcomes. Findings may be used to inform the design of future programs. Additional interventions are needed to address the current guideline-to-practice gap, in which approximately one-third of patients are unscreened for metabolic risk.

Advancing regulatory science and assessment of FDA REMS programs: A mixed-methods evaluation examining physician survey response

Purpose:

Food and Drug Administration’s (FDA) Draft Guidance for Industry on pharmaceutical REMS (Risk Evaluation and Mitigation Strategies) assessment and survey methodology highlights physician knowledge–attitudes–behaviors (KAB) surveys as regulatory science tools. This mixed-methods evaluation advances regulatory science and the assessment of FDA REMS programs when using physician surveys. We: (1) reviewed published physician survey response rates; and (2) assessed response bias in a simulation study of secondary survey data using different accrual cut-off strategies.

Methods:

A systematic literature review was conducted of US physician surveys (2000–2014) on pharmaceutical use (n = 75). Kruskal–Wallis tests were used to examine the relationships between response rates and survey design characteristics. The simulation was conducted using secondary data from a population-based physician KAB survey on diabetes risk management with antipsychotic use in Missouri Medicaid (n = 973 accrued over 30 weeks). Survey item responses were compared using Pearson’s chi-square tests for two faster completion simulations: Fixed Sample (n = 300) and Fixed Time (8 weeks).

Results:

Survey response rates ranged from 7% to 100% (median = 48%, IQR = 34%–68%). Surveys of targeted populations and surveys using member lists were associated with higher response rates (p = 0.02). In the simulation, 9 of 20 (45%) KAB items, including diabetes screening advocacy, differed significantly using the smaller Fixed Sample strategy (achieved in 12 days) versus full accrual. Fewer response differences were found using the Fixed Time strategy (2 of 20 [10%] items).

Conclusions:

Published data on physician surveys report low response rates with most associated with the sample source selected. FDA REMS assessments should include formal evaluation of survey accrual and response bias.

Effects of primary care clinician beliefs and perceived organizational facilitators on the delivery of preventive care to individuals with mental illnesses

Background

Although many studies have documented patient-, clinician-, and organizational barriers/facilitators of primary care among people with mental illnesses, few have examined whether these factors predict actual rates of preventive service use. We assessed whether clinician behaviors, beliefs, characteristics, and clinician-reported organizational characteristics, predicted delivery of preventive services in this population.

Methods

Primary care clinicians (n = 247) at Kaiser Permanente Northwest (KPNW) or community health centers and safety-net clinics (CHCs), in six states, completed clinician surveys in 2014. Using electronic health record data, we calculated preventive care-gap rates for patients with mental illnesses empaneled to survey respondents (n = 37,251). Using separate multi-level regression models for each setting, we tested whether survey responses predicted preventive service care-gap rates.

Results

After controlling for patient-level characteristics, patients of clinicians who reported a greater likelihood of providing preventive care to psychiatrically asymptomatic patients experienced lower care-gap rates (KPNW γ= − .05, p = .041; CHCs γ= − .05, p = .033). In KPNW, patients of female clinicians had fewer care gaps than patients of male clinicians (γ= − .07, p = .011). In CHCs, patients of clinicians who had practiced longer had fewer care gaps (γ= − .004, p = .010), as did patients whose clinicians believed that organizational quality goals facilitate preventive service provision (γ= − .06, p = .006). Case manager availability in CHCs was associated with higher care-gap rates (γ=.06, p = .028).

Conclusions

Clinicians who report they are likely to address preventive concerns when their mentally ill patients present without apparent psychiatric symptoms had patients with fewer care gaps. In CHCs, care quality goals may facilitate preventive care whereas case managers may not.

Electronic supplementary material

The online version of this article (doi: 10.1186/s12875-017-0693-2) contains supplementary material, which is available to authorized users.

Simulated Effects of Policies to Reduce Diabetes Risk Among Adults With Schizophrenia Receiving Antipsychotics

OBJECTIVE

Second-generation antipsychotics increase the risk of diabetes and other metabolic conditions among individuals with schizophrenia. Although metabolic testing is recommended to reduce this risk, low testing rates have prompted concerns about negative health consequences and downstream medical costs. This study simulated the effect of increasing metabolic testing rates on ten-year prevalence rates of prediabetes and diabetes (diabetes conditions) and their associated health care costs.

METHODS

A microsimulation model (N=21,491 beneficiaries) with a ten-year time horizon was used to quantify the impacts of policies that increased annual testing rates in a Medicaid population with schizophrenia. Data sources included California Medicaid data, National Health and Nutrition Examination Survey data, and the literature. In the model, metabolic testing increased diagnosis of diabetes conditions and diagnosis prompted prescribers to switch patients to lower-risk antipsychotics. Key inputs included observed diagnoses, prescribing rates, annual testing rates, imputed rates of undiagnosed diabetes conditions, and literature-based estimates of policy effectiveness.

RESULTS

Compared with 2009 annual testing rates, ten-year outcomes for policies that achieved universal testing reduced exposure to higher-risk antipsychotics by 14%, time to diabetes diagnosis by 57%, and diabetes prevalence by .6%. These policies were associated with higher spending because of testing and earlier treatment.

CONCLUSIONS

The model showed that policies promoting metabolic testing provided an effective approach to improve the safety of second-generation antipsychotic prescribing in a Medicaid population with schizophrenia; however, the policies led to additional costs at ten years. Simulation studies are a useful source of information on the potential impacts of these policies.

Physical health policies and metabolic screening in mental health care systems of sub-Saharan African countries: a systematic review

BACKGROUND

There is a need for interventions to address the escalating mental health burden in sub-Saharan Africa (SSA). Addressing physical health needs should have a central role in reducing the burden and facilitating recovery in people with severe mental illness (SMI). We systematically investigated (1) physical health policies in the current mental health plans, and (2) the routine metabolic screening rates for people with SMI in SSA.

METHODS

The Mental Health Atlas and MiNDbank of the World Health Organization were screened for physical health policies in mental health plans. Next, we systematically searched PubMed from inception until February 1st, 2017 for relevant studies on metabolic screening rates in people with SMI in SSA.

RESULTS

The current systematic review shows that in 22 screened plans only 6 made reference to a physical health component or policy. Only the South-African mental health plan reported about routine screening and treatment of physical illness for people with SMI. In 2 South-African studies (n = 431) routine screening was unacceptably low with less than 1% adequately screened for all modifiable metabolic syndrome risk factors.

CONCLUSIONS

Our review data clearly show that a physical health policy is yet to be embraced in mental health care systems of most SSA countries. There is a clear need for integrated mental and medical services in SSA. All psychiatric services, including poorly developed community-based primary health care settings should standardly assess the body mass index and waist circumference at initiation of psycho-pharmacotherapy, and afterwards at regular intervals. Optimal monitoring should include assessments of fasting glucose, lipids, cholesterol, and blood pressure. Mental health care providers in SSA countries need to be informed that their roles extend beyond taking care of the mental health of their patients and assume responsibility for the physical health of their patients as well. Policy makers should be made aware that investment in continued medial education and in screening for physical health risks could optimize mental and physical health improvements. The increased physical health needs of people with mental illness should be integrated into the existing Information, Education and Communication public health awareness programs of the World Health Organization.