RAISE Study Demonstrates Benefits of Computerized Prescriber Support System

A computer-based decision support system can improve prescribing for first-episode psychosis patients when used as part of a comprehensive team-based approach to care, according to the most recent report from the Recovery After Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP). The findings were published September 15 in AJP in Advance.

The prescribing decision support system, known as COMPASS, integrated patient data and preferences with prescribers’ clinical assessments to produce a computer-generated treatment guideline for the patient. The study found that patients whose care was guided by the prescribing decision support system had better outcomes with fewer side effects.

“We believe that this study demonstrates the utility and feasibility of implementing a computerized decision support system,” said RAISE Principal Investigator John Kane, M.D. “We found that such a system showed significant advantages over usual care in increasing the number of medication management visits, improving attitudes toward taking medication, and increasing the likelihood of prescribing practices that are consistent with treatment guidelines.”

He added, “We believe that as part of coordinated specialty care, a focus on optimum psychopharmacological treatment is very important, and it often does not receive sufficient attention.”

The RAISE study compared NAVIGATE, a comprehensive team-based program for first-episode psychosis, to standard community care over two years. More than 700 patients were recruited at two institutions and randomized to receive NAVIGATE or usual care. At least one previous RAISE study demonstrated the effectiveness of psychosocial care, provided as part of the NAVIGATE program.

In the new study, Kane and colleagues compared antipsychotic prescriptions, side effects, and adherence among patients who received NAVIGATE versus those who received community care. Prescription data were obtained monthly. At baseline and at three, six, 12, 18, and 24 months later, participants reported whether they had experienced, during the past 30 days, any of 21 common antipsychotic side effects. Also during this follow-up, vital signs and fasting blood samples were collected, and all patients completed the Adherence Estimator scale, which assesses patient beliefs around adherence to medication.

Kane and colleagues found that NAVIGATE participants had significantly more medication visits compared with community care participants, were significantly more likely to receive an antipsychotic prescription, and were less likely to receive an antidepressant prescription. NAVIGATE participants were also more likely to receive prescriptions conforming to evidence-based best practices formulated as a set of “NAVIGATE first-line principles.”

Additionally, NAVIGATE participants reported fewer side effects at subsequent visits and were significantly less likely to experience sedation and anticholinergic side effects. Finally, scores on the Adherence Estimator scale did not differ between groups at baseline, but decreased significantly among NAVIGATE participants (indicating fewer beliefs associated with nonadherence) but not among community care participants.

Participants and prescribers used COMPASS, a NAVIGATE-developed computerized clinical decision-making tool, accessed via a secure web-based platform.

In comments to Psychiatric News, Kane explained that COMPASS allows participants to record information about symptoms, side effects, treatment preferences, medication adherence and attitudes, and substance use before meeting with prescribing clinicians. These data are summarized by the COMPASS program for review by the prescriber at the beginning of each medication visit. Integrating participant treatment priorities and the prescriber’s assessments, COMPASS provides suggested guideline treatments.

“Prescribers and participants then made medication decisions informed by these recommendations,” Kane said. “NAVIGATE guidelines recommended a prescriber visit at least monthly for the first two years of treatment. Since this system was utilized in community mental health centers, we showed that it was feasible to implement such a program in ‘real world’ settings.”

Kane told Psychiatric News that because depressive symptoms in first-episode patients often remit with antipsychotic treatment alone, prescription of adjunctive antidepressants for all first-episode patients with depressive symptoms is not advised. Previous reports showed NAVIGATE participants had lower levels of depressive symptoms, and the new analysis indicates this was achieved without excessive antidepressant prescription. “The NAVIGATE psychosocial interventions may have contributed to better outcomes for depressive symptoms,” Kane said.

The RAISE study speaks to system-based care. Are there implications for individual prescribers working in private practice or in small group practices? 

“The same principles would apply to prescribers working in other settings or private practice, however, the tools would need to be made readily available,” Kane said. “In order to enable widespread utilization, the tool should be made available as part of an existing electronic medical record (EMR) platform or in a way that it can be easily integrated into an EMR.”

The study was supported by funds from the National Institute of Mental Health and the American Recovery and Reinvestment Act. ■