State-Based Program Reduces Polypharmacy

A statewide initiative in New York using a time-limited policy requiring prior approval for prescription of more than two antipsychotics for a patient, in combination with use of a Web-based application supporting clinical decision making and quality improvement, resulted in a significant and lasting reduction in antipsychotic polypharmacy.

That was the finding from a report in the October Journal of Psychiatric Services.

Following initiation of the effort in April 2004, antipsychotic polypharmacy for patients in the New York State Office of Mental Health (NYSOMH) network of psychiatric hospitals dropped from a baseline of 16.9 per 1,000 patients to as low as 3.9 per 1,000 patients during the period when clinicians were required to obtain prior approval to write a prescription for more than two antipsychotics for a patient.

After termination of the prior-approval policy, the rate of polypharmacy rose again, but remained well below baseline.

Lead author Molly Finnerty, M.D., told Psychiatric News that the effort demonstrates the utility of providing clinicians with information and local oversight to achieve quality-improvement goals (see Program Highlights).

"There is tremendous value to clinicians in being able to access data for clinical decision making when working with people who have been sick over a very long period," she said. "It's hard to address problems when you don't know they exist and don't know what is driving them."

The report describes a three-phase intervention to decrease antipsychotic polypharmacy in the NYSOMH network of psychiatric hospitals.

Phase 1 consisted of implementation of the Psychiatric Services Clinical Knowledge Enhancement System (PSYCKES), a Web-based application supporting clinical decision making and quality improvement. PSYCKES presents patients' medication and treatment histories for quick review, flags practices outside recommended guidelines, and links patient data to guideline-derived measures of adherence to evidence-based practices; quality-indicator reports in PSYCKES summarize performance on polypharmacy and other guideline-driven, cost-conscious indicators.

Then-medical officer of NYSOMH, Louis Oppler, M.D., issued an antipsychotic polypharmacy policy, which required clinical directors to establish procedures to review and approve requests to add additional antipsychotics for any patient in their hospital. Written approval by the hospital's chief medical officer was required for any case approved by the hospital clinical director.

The policy ensured clinically appropriate access by permitting 60 days of overlap during cross-tapers, established systems to allow for expert psychopharmacological consultation, and did not block prescriptions from being filled.

In phase two, hospital leaders received feedback from the office of the medical director identifying specific patients on polypharmacy. Reviews of hospital performance data on the prevalence of antipsychotic polypharmacy and on compliance with the prior-approval policy were incorporated as standing agenda items in routine management meetings between state and hospital leadership.

In phase three, access to PSYCKES continued, but the prior-approval policy and feedback were discontinued.

The first significant decrease in prevalence occurred soon after the beginning of phase 1, when prevalence decreased 43 percent, from 16.9 to 9.7 per 1,000 inpatients. In phase 2, polypharmacy decreased further, and despite the end of state oversight in phase 3, it remained low during the first six months of follow-up, at 3.1 per 1,000 inpatients.

Finnerty said the prior-approval policy acted as a kind of "speed limit" on polypharmacy and differed dramatically from the kinds of utilization review that clinicians have experienced at the hands of private insurers.

"What was different about this is that there was no prospective barrier on patients having prescriptions filled," she said. "Clinicians could write prescriptions as they deemed appropriate. The oversight was local, and the directive [for prior approval] came from a medical director, who was a known quantity to clinicians in the state. This was someone in leadership saying 'This is an important issue we need to pay attention to.'

"The notion that you can have a powerful impact on prescribing with an oversight policy that does not in any way conflict with what is clinically appropriate is an important lesson," Finnerty told Psychiatric News.

"Best Practices: Long-Term Impact of Web-Based Tools, Leadership Feedback, and Policies on Inpatient Antipsychotic Polypharmacy" is posted at < http://ps.psychiatryonline.org/cgi/content/full/62/10/1124>.

Program Highlights

• A Web-based quality improvement tool plus local oversight of prescribing practices significantly reduced antipsychotic polypharmacy in New York state hospitals.

• The prior-approval policy allowed for clinically appropriate prescription of more than two antipsychotics, but acted as a "speed limit" on polypharmacy.

• Adding feedback on adherence to the policy led to further decreases in polypharmacy.

• Though polypharmacy increased again after the prior-approval policy was lifted, it did not return to baseline levels, suggesting that the intervention had long-lasting effects.