title: Clozapine, concomitant medications and consumers: Assessing the accuracy of medication records and the lived experience of people prescribed clozapine under shared care arrangements
Creators: name: Murphy, Kate
Publisher: name: Griffith University
Year: 2018
Subjects: subject: Clozapine
subject: Antipsychotic medication
subject: Schizophrenia
subject: Shared care medication
subject: Adverse drug events

description: Schizophrenia is a serious long-term mental illness associated with significant morbidity and mortality. Clozapine is the most effective antipsychotic medication for the treatment of schizophrenia, however, due to potentially life-threatening haematological adverse effects, its use is restricted to people who have not responded to an adequate trial of at least two other antipsychotic medications. The high risk of adverse effects, associated mandatory monitoring and prescribing restrictions all mean that clozapine consumers often continue to be managed in a secondary care public mental health (MH) service. In people stabilised on maintenance treatment living in the community, a shared care model, involving collaboration between a psychiatrist in secondary care, a general practitioner (GP) and community pharmacy in primary care is a management option. The aim of shared care is to lessen the burden on the consumer and on the secondary care service by allowing the GP to undertake the majority of monitoring and reduce the frequency of secondary care appointments. While this may appear to be an ideal arrangement, discrepancies in medication information at transitions of care from one health service to another are common and contribute to prescribing errors. Where clinicians do not have full medication information there is potential for inappropriate clinical decision-making and the consumer can be exposed to adverse drug events (ADEs), which are defined as any harm occurring during drug therapy. The overall aim of the study was to generate information and form recommendations to optimise communication pathways and access to accurate medication information between and for stakeholders (secondary care, general practice and community pharmacy) and consumers of a clozapine shared care service. The study was designed to assess the completeness and accuracy of consumer medication records held by shared care stakeholders and to describe the experiences of the consumers. This was an exploratory mixed methods study undertaken in two parts. Firstly, a quantitative approach was used to examine secondary and primary care medication records in a public MH service setting. Fifty-five consumers (aged 18–65 years) prescribed clozapine under shared care were eligible to participate. Information from medication and dispensing records was used by a pharmacist to compile a best possible medication history for each consumer. Discrepancies were identified through reconciliation of stakeholder records with the medication history. Discrepancies were defined as an omission, addition, or administration discrepancy (difference in dose, frequency, or clozapine brand). Thirty-five consumers who had previously consented to review of their medication records were then eligible to participate in Part Two of the study. Participants completed a semi-structured interview that included a number of questionnaires. The questionnaires focused on beliefs about illness and medicines, adverse effects, medication adherence and treatment burden, while the interview focused on advantages and disadvantages of clozapine, shared care, and communication pathways. Analysis was descriptive and thematic. In Part One, 35 (63.5%) consumers consented to review of their records. Overall, 32 of the 35 consumers had at least one discrepancy in their records, with a mean of 4.9 discrepancies per consumer. Of 172 discrepancies, 127 (73.8%) were omissions. Primarily, concomitant medicines were omitted in 19/35 (54%) of secondary care records, while clozapine was omitted in 13/32 (40.6%) of community pharmacy records. In Part Two, 10/35 (28.6%) consumers agreed to participate in an interview. Findings included a low level of treatment burden with minimal adverse effects and medium-to-good adherence. Four inter-related themes surrounding treatment in the clozapine shared care program were identified: (i) understanding of illness and recovery; (ii) positive outcomes of treatment; (iii) treatment burden and acceptance and (iv) communication pathways. All participants described a positive experience with treatment in the clozapine shared care program, citing the efficacy of clozapine and the GP relationship as major benefits. Other findings included the fact that consumers were mostly unaware of any communication that took place between their shared care clinicians and assumed that clinicians had access to accurate medication information. In summary, discrepancies were highly prevalent in the shared care medication records of clozapine consumers in this service, however participants reported positive treatment outcomes. Improved documentation and timely access to accurate and complete medication records for shared care stakeholders is needed to reduce the risk for suboptimal clinical decision-making and ADEs. Expanding the pharmacist's role in this setting could improve timeliness and accuracy in medication-related documentation and communication and make shared care an option for a wider group of clozapine consumers.