title: Quality Improvement Program for Metabolic Monitoring of Youth Prescribed Second Generation Antipsychotics
Creators: name: Aouira, Nisreen
Publisher: name: Griffith University
Year: 2021
Subjects: subject: second-generation antipsychotics
subject: Youths
subject: metabolic monitoring

description: Background: Prescription of second-generation antipsychotics (SGAs) in youths is rapidly increasing globally, despite the potential for significant adverse effects and long-term health consequences. A known adverse reaction resulting from SGAs is metabolic syndrome (MS). Youths exposed to antipsychotics are at higher risk than adults for adverse drug reactions including adverse events such as MS (with weight gain as the most significant adverse outcome) and other long-term endocrinological abnormalities. Lack of timely monitoring for potential adverse effects puts Australian youth at even greater risk. Youths can gain a significant amount of weight after taking antipsychotics even for a short period of time. Hence, metabolic monitoring of antipsychotics is recommended to prevent short and long term adverse drug reactions, especially in children and adolescents. Despite guidelines’ recommendations, health policy recommendation and warnings, adequate antipsychotic metabolic monitoring among youth remains sub optimal causing increase rate of MS thereby leading to increasing burden of illness. Aims: This thesis aimed to conduct quality improvement programs (QIPs) promoting awareness on metabolic monitoring in youths prescribed SGAs. It was hypothesised that quality improvement programs in the form of synthesis of primary evidence, conducting clinical audits and barriers and facilitators analysis through the perspectives of practitioners, patients and carers will help identify existing gaps and provide strategies towards quality use of SGAs. This was achieved through the following specific objectives: 1. Conduct a systematic review to identify the therapeutic role of youth prescribed SGAs. 2. Conduct a systematic review to identify intervention studies for improving rate of metabolic monitoring of youth prescribed SGAs. 3. Perform a clinical audit to compare paper vs. electronic method of documentation of youth prescribed SGA metabolic monitoring parameters. 4. Perform a second series of clinical audit after complete transformation to electronic system of documentation. 5. Conduct semi-structured interviews with prescribers of SGAs for barrier analysis and to identify key strategies. 6. Conduct semi-structured interviews with consumers (young patients and carers) of SGAs for barrier analysis and to identify key solutions. 7. Communicate findings from objectives 1-6 to key stakeholders (decision makers) at the Children’s Health Queensland Hospital and Health Service. Methods: This thesis comprised a mixed method study design. The systematic reviews were developed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). Findings were assessed based on Strength of Evidence Recommendation Taxonomy (SORT) ratings and implications were provided for future research and practice. The next step was conducting a clinical audit on comparison of paper vs. recently introduced electronic method of documentation of youth prescribed SGA metabolic monitoring parameters across study sites at the Children’s Health Queensland Hospital and Health Service in Queensland State of Australia. This was achieved through a retrospective clinical audit (Paper: July 2012- April 2013 / electronic: January 2016 – December 2016). This was followed by conducting a clinical audit of fully transitioned electronic documentation system, through a retrospective cross-sectional study (1st January 2016 – 31st December 2016) as a component of clinical audit. Data from both audits were analysed using SPSS software. The next step was to conduct interviews. The interviews’ questions were formulated based on previous published evidence, aligning with the research aims and discussion with expert opinions and thematically analysed. The questions were then pilot tested and standardised. The semi-structured interviews were conducted with practitioners (psychiatrists), patients (youths who were prescribed SGAs) and their caregivers who all attended Child and Youth Mental Health Services (CYMHS). These interviews focused on barriers to monitoring and strategies to enhance rate of monitoring that could be customised across study sites. The final step of this research was to disseminate the findings of the clinical audits and the interviews, through unstructured virtual interviews, with key stakeholders (director medical services, director research, Prescribers from the study sites and decision makers) using thematic analysis. Thematic analysis was utilised to identify themes and subthemes withing the participants replies and to ensure consistency among the participants. This was done through NVivo software for coding and development of thematic mind map. Key findings: The first systematic review highlighted key gaps in existing evidence, these included: insight to efficacy and implications of SGAs in managing Conduct Disorder (CD) in youths, the use of SGAs in youths should be associated with evidence-based periodic metabolic monitoring and need for integration of psychosocial therapy to be part of the treatment plan for the management of CD in youths. The second systematic review identified following key strategies to enhance metabolic monitoring: periodic reminders for monitoring, recall services (e.g. electronic newsletter, a protocol template) and behavioural interventions (e.g. educational seminars). All these interventions were targeted towards health providers and none of them assessed interventions targeting the young patients. For the first clinical audit, a total of 310 cases were assessed, of which 51 were paperbased and 37 cases were electronic records respectively. Evidence of paper-based documentation of weight was 43% among participants and was comparable with other published clinical audits (p = 0.07). Poor monitoring rates were identified for parameters that required blood tests. Findings revealed poor rate of documentation at 35.1% (13 cases), 5.4% (2 cases) and 8.1% (3 cases) for weight, lipid assessments and glucose monitoring, respectively based on electronic records. The second clinical audit screened 780 patients’ records through CIMHA (the digital electronic medical records system used at the study sites). Eighty-six records were eligible. The most commonly prescribed SGA was quetiapine which was followed by risperidone. Findings from the second clinical audit also revealed poor rate of metabolic monitoring, with 44.2 % patients not receiving any weight measurements and 18.6 % and 14 % received glucose blood tests and lipid assessments, respectively. In terms of the semi-structured interviews, 10 psychiatrists identified and reportedbarriers that included lack of available resources, carers’ disengagement in their youths’ treatments and young patients’ refusal to undergo blood tests. Psychiatrists reported strategies to enhance metabolic monitoring relied on organisational support. The interviews with the young patients and their carers revealed that none of them had any concerns or objections to receiving anthropometric metabolic measurements. However, they seemed concerned to undergo blood tests as part of the metabolic monitoring process. Carers reported that youths increased oppositional behaviour towards engaging in a healthy lifestyle had led to increased conflict between them, as well as the increased workload trying to deal with the metabolic monitoring process. In comparison, youths cited their fear of the needles as barrier to undergo the required blood tests. Additionally, youths generally reported that their dislike to healthy foods and exercise being the most common challenge they face while trying to engage in a healthy lifestyle to manage the SGAs resulted weight gain. Carers most commonly reported suggestion was open, proper and constant communication between them and the mental health providers, including information about the SGAs induced adverse effects and education on metabolic monitoring parameters at the baseline and during the course of SGA therapy. Youths provided examples of strategies to enhance their comfort with undergoing blood tests such as getting their blood tests conducted by the same staff who is a skilled and friendly blood collector. The final stage of this thesis was to interview decision makers who are affiliated with Queensland Health and hold strategic roles. Data analysis of the interviews with decision makers revealed two key strategies to enhance the safe use of SGAs in youths. These strategies included: the prevention approach that focused on preventing and minimising the SGAs induced metabolic adverse effects prior to initiation of therapy, as well as provision of holistic care through multidisciplinary teamwork which enables provision of both physical and mental care to the young patients. The importance of organisational support was emphasised by decision makers to achieve those approaches successfully in the lead to provide young patients and their caregivers with optimum healthcare. The thesis recommended a multilevel intervention as a component of QIP for rational use of SGAs for future research. Conclusion: Metabolic monitoring practice allows early identification of metabolic dysregulation with SGAs thereby informing clinical decision making to mitigate the metabolic sequelae of SGAs. This monitoring is important to achieve successful treatment regimen that involves rational use of SGAs. This thesis identified evidence-based implications, gaps on rate of youths prescribed SGA metabolic monitoring, the barriers to and strategies for metabolic monitoring from the perspectives of diverse stakeholders and communicated findings to the decision makers. The present research findings provide key insights and site-specific strategies as a component of QI development plan towards safe and rational SGA prescribing in a highly vulnerable, complex and severe mental health conditions specific cohort of Australian youths.