Medication Monitoring Clinic at Eastwood Adult Mental Health Team
Background:
Antipsychotic medications have a central role in psychiatric practice, being used not only for schizophrenia, but increasingly for affective disorders, and in an off-license basis for anxiety disorders and to manage symptoms of personality disorder1 . Antipsychotics have numerous significant side effects including weight gain, type II diabetes, dyslipidaemias, and cardiac dysrhythmia.
Monitoring for adverse metabolic effects is essential for the safe use of antipsychotics and guidelines in NICE and the Maudsley recommend at least annual blood and ECG monitoring for patients receiving antipsychotic medications2,3. Presently this is performed either by GPs as part of the annual physical health review recommended for patients with enduring mental illness and supported by QoF payments, or increasingly it is performed “in-house” by CMHTs establishing medication monitoring clinics.
The Eastwood AMHT has run a Medication Monitoring Clinic (MMC) since 2003. This is run by CPNs with an SHO reviewing the results. Patients on antipsychotics are referred to the MMC using a standardised form available on the shared drive. Generally patients are referred by the clinician prescribing their antipsychotic medication. Patients are sent appointments to attend the clinic. At the MMC they have their pulse, BP, BMI, and smoking status recorded. Patient reported side effects are measured by the Lunser scale. Blood is taken and tested for FBC, U&Es, LFTs, GGT, TFTs, glucose, and lipids. Patients are referred from the MMC for an ECG which is generally performed at the Victoria Hospital. This protocol is based on the above recommendation from NICE and the Maudsley, and the local GG&C Physical Health Policy3. This was initially limited to patients with ICD-10 F2/F3 diagnoses but has since been expanded to all patients prescribed psychotropic medications requiring monitoring, regardless of diagnosis.
For such monitoring to occur successfully it is necessary that first patients receiving antipsychotic medications are highlighted as needing monitoring, and secondly that such patients actually attend for the recommended monitoring. Anecdotally it had been suggested that patients prescribed (typically low-doses) of antipsychotic for off-label indications like personality disorder were less likely to be referred to the MMC and so less likely to receive the required monitoring for antipsychotic medications.
In this audit we aimed to assess the adequacy of physical health monitoring in patients on the Eastwood caseload receiving antipsychotic drugs, regardless of their diagnosis. In particular we sought to identify what percentage of eligible patients were referred to the MMC; what percentage of patients referred to the MMC actually attended; and what percentage of patients who for whatever reason did not attend the MMC had physical monitoring performed elsewhere.
Methods:
In order to ensure inclusion of patients on antipsychotics for indications other than psychotic disorders, we identified patients by reviewing the caseload as a whole rather than focusing on specific diagnoses.
A report of all patients currently on the Eastwood caseload was generated on 19/10/15. This consisted of 589 patients. To facilitate the timely completion of the audit we randomly selected 200 patients from this total caseload, using a random number generator on Excel, to be included in the audit.
The notes of the 200 patients were reviewed. Patients prescribed antipsychotic medications were included in the study. The current antipsychotic prescription was based on their most recent clinic or discharge letter, or their ECS in cases where the notes were unclear. Diagnoses were also recorded based on the most recent clinic or discharge letter, or PiMS where the notes were unclear.
For patients receiving antipsychotics Clinical Portal was reviewed to assess if they had received relevant blood monitoring (FBC, U&Es, LFTs, GGT, TFTs, glucose, lipids) in the past year, and Clinical Portal and the patient notes were searched for an ECG within the past year. The dates of bloods and ECGs were cross-referenced with MMC appointments, hospital admission episodes on Clinical Portal, and the clinical details of the tests themselves, to determine where testing took place. Patients notes and the MMC caseload list were reviewed to determine if patients had been referred to the MMC and whether they attended offered appointments.
Data were recorded anonymously in Excel. We recorded information on age and gender, diagnosis, antipsychotic drug and dose, whether the above physical monitoring was performed, where this monitoring was performed, whether the patient was referred to the MMC, and whether they attended the MMC.
All patients attending the MMC had BP, pulse, BMI, smoking status, and side effects recorded as per the GGC physical health policy. Unfortunately we did not have access to whether such monitoring was performed at GP practices or other settings and regardless this information was not communicated to the mental health team. As such we elected to limit our analysis to blood tests and ECGs.
Results:
200 patients were selected at random from the 589 patient Eastwood caseload for inclusion in this audit. Of these, 79 (39.%) were prescribed at least 1 antipsychotic drug. 7 patients were on 2 antipsychotics. Only 1 patient was on high-dose antipsychotic treatment.
Table 1 shows the frequency of prescription of different antipsychotic drugs in this group. Quetiapine, olanzapine, and risperidone were by far the most widely prescribed. 11 patients were prescribed a depot. 3 were prescribed clozapine. The primary diagnosis of these patients are shown in table 2. As expected most patients were prescribed antipsychotics for psychotic disorders however 31 (39%) were prescribed antipsychotics for off-label indications.
48 (60.8%) were female versus 134 (67%) in the total sample. The average age of people receiving antipsychotics was 46.3 (SD=12); versus 46.8 (SD=13) in the total sample.
Aripiprazole (oral) / 10 (+1)
Aripiprazole (depot) / 1
Chlorpromazine / 1 (+3)
Zuclopenthixol (oral) / 1
Zuclopenthixol (depot) / 3
Clozapine / 4
Flupenthixol (oral) / 1 (+1)
Flupenthixol (depot) / 4
Fluphenazine (depot) / 1
Olanzapine / 15
Paliperidone (depot) / 2
Quetiapine / 20
Haloperidol / 0 (+1)
Risperidone / 14
Sulpride / 1
Table 1: Breakdown of prescribed antipsychotics in the sample.
Anorexia Nervosa / 1BPAD / 13
Depression / 13
GAD / 1
OCD / 6
PD / 10
Psychotic Disorder / 9
Schizoaffective Disorder / 6
Schizophrenia / 26
Table 1: Primary diagnosis of patients prescribed antipsychotics.
63 (78.8%) patients receiving antipsychotics were referred to the MMC. Of those referred 48 (76.2%) attended the clinic and had their monitoring performed. A further 26 patients who did not attend the MMC, had bloods performed elsewhere. Table 3 outlines the monitoring received and its source. As can be seen almost all patients attending the MMC had all of their relevant blood monitoring performed, however 11 (23%) did not have an ECG performed despite being referred by the MMC. Patients attending their GP for a mental health review had almost all their relevant bloods performed, however none of these patients had an ECG performed. Patients admitted to Leverndale in the past year all had an ECG performed during their stay and had most of their monitoring bloods performed however only 2 had their lipids measured. Patients receiving bloods at their GP for other purposes or in a general hospital setting were unlikely to have all their required monitoring performed (particularly lipids and ECGs).
Source / MMC / GP (MH) / GP (other) / Leverndale / A&E / General Hospital / Eating disorder ServiceNumber / 48 / 6 / 8 / 6 / 3 / 2 / 1
FBC / 48 / 6 / 8 / 6 / 3 / 2 / 1
U&E / 48 / 6 / 8 / 6 / 3 / 2 / 1
LFT / 48 / 6 / 7 / 6 / 3 / 2 / 1
GGT / 41 / 1 / 2 / 2 / 1 / 0 / 1
TFTs / 47 / 6 / 6 / 4 / 2 / 2 / 1
Glucose / 48 / 6 / 7 / 6 / 2 / 2 / 1
Lipids / 46 / 5 / 2 / 2 / 2 / 0 / 1
ECG / 37 / 0 / 2 / 6 / 2 / 1 / 1
Table 3: Rates of physical monitoring in patients receiving antipsychotics stratified by source of monitoring tests.
16 patients receiving antipsychotics were not referred to the MMC. Table 4 shows the diagnoses of patients not referred. The 4 of the patients with schizophrenia or other psychotic disorders were attending annual mental health monitoring at their GP and this was recorded in the notes. The patient with anorexia nervosa received annual monitoring through the eating disorder service and this was also recorded in the notes. 10 (62.5%) of patients not referred to the MMC were receiving antipsychotic medications for off-label indications.
Personality Disorder / 4Anorexia Nervosa / 1
Schizoaffective disorder / 2
Psychotic Disorder / 1
Depression / 5
Schizophrenia / 2
BPAD / 1
Table 4: Diagnoses of patients not referred to the MMC.
14 patients were referred to the MMC but did not attend. Table 5 shows the diagnoses of those referred but not attending. As can be seen patients referred but not attending are more likely to have a psychotic illness. All but 2 of these received some form of monitoring elsewhere, however only 2 attended for specific GP mental health monitoring and 1 had monitoring performed whilst an inpatient at Leverndale. The remainder had monitoring performed sporadically and for unrelated reasons. Both patients who received no monitoring at all in the past year had a diagnosis of schizophrenia.
Schizophrenia / 5Schizoaffective disorder / 1
BPAD / 4
OCD / 2
Depression / 2
Table 5: Primary diagnosis of patient referred to the MMC but not attending.
Discussion:
This audit investigated the adequacy of physical health monitoring of patients prescribed antipsychotic medications, regardless of diagnosis, in the Eastwood caseload. We identified high (39%) rates of off-label prescribing supportive of the necessity of this audit and our approach to case identification.
In this sample of the total caseload we identified a high rate of referral to the MMC of 78.8%. In addition to this a number of those not referred had established monitoring elsewhere which was noted by the treating team. The majority of patients not referred to the MMC were receiving antipsychotics for off-label indications, which is supportive of our hypothesis that patients started on antipsychotics for off-label indications are less likely to be referred for monitoring. Of patients referred to the MMC attendance rates were good at 76.2%. The majority of those referred to the MMC but not attending had psychotic illnesses which may contribute to their non-attendance. When patients attended the MMC they had almost all of their relevant blood monitoring performed, several missed out on certain tests and this likely represents human error in ticking the relevant boxes on blood forms. It is unclear how many blood samples were fasted. Notably 23% of MMC patients did not receive an ECG despite being referred for one. ECGs are performed at a separate appointment, in a different venue, which likely introduces the attrition identified here. The vast majority (97.4%) had some monitoring performed through the year, if not through the MMC or GP Mental Health Checks, then through other healthcare encounters. Those receiving sporadic testing elsewhere were unlikely to have their lipids measured or to record an ECG.
Through this audit we have identified that the Eastwood MMC is performing well in monitoring patients on antipsychotics, however there are certain areas in which its performance could be improved:
1) It should be standard practice when prescribing an antipsychotic to refer the patient to the MMC. We propose education to all prescribing members of staff that when starting an antipsychotic they should also refer the patient to the MMC. Education will also make it clear to all staff the process of making such referrals and identify the relevant paperwork. One possible source of missed referral is patients who start an antipsychotic as an inpatient. Education would clarify that it is the responsibility to the team starting the antipsychotic to refer to the MMC, and the responsibility of the SHO to ensure that this paper work is completed (eg. When completing the discharge letter).
2) A form is completed each time a patient attends the MMC recording their attendance and what tests were performed. Currently this is kept at the MMC and a copy sent to the GP. A further copy should be sent to the patients mental health notes so that doctors are able to quickly see if a patient has attended and make decisions accordingly.
3) We would further propose that a letter be sent to the referring clinician if the patient does attend for their appointment, with a further letter being sent if the patient has not attended in >1 year. This will allow proper information sharing between the team and allow the clinician to determine what steps can be taken to support attendance or determine what changes might be needed to the prescription if adequate monitoring is not possible.
4) A significant percentage of MMC patients do not have ECGs due to non-attendance of appointments. We would propose that the referring clinician should be informed of patients not attending for their ECG to allow them to re-refer or reconsider the prescription if adequate monitoring is not possible. A further possible proposal is that an SHO attend the MMC and perform ECGs on the patients who attend. This would be resource demanding but would guarantee higher rates of ECGs.
References:
1- Paton C Et Al The use of psychotropic medications in patients with emotionally unstable personality disorder under the care of UK mental health services. J Clin Psychiatry 2015 76(4): e512-8
2- NICE Psychosis and schizophrenia in adults: prevention and management. Feb 2014.