Plan Points Physicians Toward Best Practices in Prescribing
Health care experts frequently lament the gap between what is known about good medical treatment and what is practiced.
A group of Michigan mental health care practitioners and advocates has come up with a plan that tackles an important aspect of that problem in a project called the Michigan Mental Health Evidence-Based Practice Initiative.
With support from the Ethel and James Flinn Foundation, they have produced a comprehensive, multiphase approach to encourage and assist physicians to adopt best practice or evidence-based practice (EBP) in the prescription and monitoring of drugs for people with major depression, bipolar disorder, and schizophrenia. (The terms “best practice” and“ evidence-based” practice are used synonymously in their report.)
Thomas Carli, M.D., chair of the panel, told Psychiatric News that the effort came about after a study by Blue Cross/Blue Shield of Michigan found “unexplained variations in prescription patterns in Michigan.” Carli is a clinical associate professor of psychiatry at the University of Michigan.
He said, “We know that certain treatments for people who have depression, schizophrenia, and bipolar disorder work better than others. Unfortunately, guidelines [promoting effective treatment] are not used frequently enough. For example, only a minority of primary care patients with major depression received recommended dosages and duration of antidepressant medications.”
At the national level, the Institute of Medicine and President Bush's New Freedom Commission on Mental Health had emphasized the importance of finding ways to implement what medical researchers have discovered about effective treatment.
Panel members noted how difficult it is for physicians to keep up with and assess which treatments are best for their patients in light of the amount of information on treatment options.
The 25-member Michigan panel considered various guidelines and algorithms and recommended that the Texas Implementation of Medication Algorithms (TIMA) be modified for use in Michigan.
Carli said that the guidelines and alogorithms the panel considered“ don't differ a great deal” from each other. TIMA has the advantage of including provisions for the education and support of patients and families and could be adopted for use in a variety of settings.
“It was important to find guidelines that will correspond with changes in thinking and knowledge.”
Michael Engel, D.O., a member of the panel and immediate past president of the Michigan Psychiatric Society, pointed out that TIMA is frequently updated.“ It was important to find guidelines that will correspond with changes in thinking and knowledge.”
Both physicians commented on the challenges of implementation.
Carli said, “We know that dissemination of practice guidelines alone will reach too few doctors.”
The Michigan practice initiative differs from efforts to change prescribing practices in other states, such as Missouri and Massachusetts, in its comprehensive nature.
It aims to use multiple strategies to influence practice in a wide variety of settings and to educate a broad range of stakeholders. The panel members wrote, “For the EBP project to succeed, there must be buy-in from stakeholders—practitioners, patients, advocacy groups, payers, and academic researchers on both the broad state and local level.”
Ultimately, the panel wants its recommendations to affect practice by primary care physicians, as well as psychiatrists, and in both the public and private sectors.
Panel members focused considerable attention on identifying barriers to adoption of guidelines and factors that would promote their use.
They reviewed research results on how practice changes occur among physicians and came up with four principles:
Guidelines/algorithms must be easy to use and valuable. | |||||
Guidelines/algorithms by themselves are not enough. They must be part of a broader education and disease-management approach. | |||||
Differences in knowledge and needs among psychiatrists, primary care physicians, and consumers must be part of the action plan. | |||||
The action plan should be rolled out over time, with pilot programs to enlist opinion leaders and early adopters. | |||||
Mark Reinstein, Ph.D., president and CEO of Michigan's Mental Health Association, told Psychiatric News that TIMA, as currently presented, would be very difficult for a family member or patient to understand. Success of the project for these individuals will require considerable redesign of how TIMA is presented.
The first stage of the initiative was conducted concurrently with deliberations of the Michigan Mental Health Commission. “We were able to get strong support from the commission for evidence-based practice as a core ingredient of system reform,” Carli said.
The Flinn Foundation supported staff work of the Michigan Mental Health Commission, as well as of the prescribing initiative.
The next step will be the issuance of a request for proposal for three to five pilot projects that would run for approximately three years. The aim of those projects is to identify “innovative and early adopting champions” to implement and test the TIMA and other related EBPs, with the expectation that success of the pilots will help promote use elsewhere.
Among the sites being considered are state hospitals, university consortia, and private mental health practices with a university affiliation.
That stage will be funded by the Flinn Foundation and other sources yet to be identified.
“Closing the Quality Gap in Michigan: A Prescription for Mental Health Care” is posted online at<www.mimentalhealthebp.net/action_plan.htm>.▪
