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Articles   |    
Antipsychotic Prescribing Pathways, Polypharmacy, and Clozapine Use in Treatment of Schizophrenia
Jessica L. Gören, Pharm.D.; Mark Meterko, Ph.D.; Sandra Williams, M.S.; Gary J. Young, J.D., Ph.D.; Errol Baker, Ph.D.; Chia-Hung Chou, Ph.D.; Amy M. Kilbourne, Ph.D., M.P.H.; Mark S. Bauer, M.D.
Psychiatric Services 2013; doi: 10.1176/appi.ps.002022012
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Dr. Gören is affiliated with the Department of Pharmacy Practice, University of Rhode Island, Kingston (e-mail: jgoren@challiance.org). Dr. Gören, Dr. Meterko, Ms. Williams, Dr. Young, Dr. Baker, and Dr. Bauer are with the Veterans Affairs (VA) Center for Organization, Leadership and Management Research, VA Boston Healthcare System, Boston. Dr. Young is also with the Center for Health Policy and Healthcare Research and Dr. Chou is with the School of Pharmacy, both at Northeastern University, Boston. Dr. Kilbourne is with the Health Services Research and Development Service, Center for Clinical Management Research, VA Ann Arbor, Ann Arbor, Michigan.

Copyright © 2013 by the American Psychiatric Association

Abstract

Objective  To ensure optimal care for patients with schizophrenia, antipsychotic medications must be appropriately prescribed and used. Therefore, the primary objectives of this study were to identify and describe pathways for antipsychotic prescribing, assess the consistency of observed pathways with treatment guidelines, and describe variability across facilities.

Methods  Data from Veterans Affairs administrative data sets from fiscal year (FY) 2003 to FY 2007 were gathered for analysis in this retrospective cohort study of antipsychotic prescribing pathways among 13 facilities across two regional networks. Patients with a new episode of care for schizophrenia or schizoaffective disorder in FY 2005 were identified, and antipsychotic prescribing history was obtained for two years before and after the index diagnosis. Demographic characteristics and distribution of comorbidities were assessed. Median medical center rates of polypharmacy were calculated and compared with Fisher’s exact test.

Results  Of 1,923 patients with a new episode of schizophrenia care, 1,003 (52%) had complete data on prescribing pathways. A majority (74%) of patients were prescribed antipsychotic monotherapy, and 19% received antipsychotic polypharmacy. Of patients receiving antipsychotic polypharmacy, 65% began polypharmacy within 90 days of starting any antipsychotic treatment. There was a fourfold difference in polypharmacy across facilities. Antipsychotic polypharmacy was not associated with geographic location or medical center patient volume. Clozapine utilization was low (0%–2%).

Conclusions  Retrospective examination of longitudinal prescribing patterns identified multiple antipsychotic prescribing pathways. Although most patients received guideline-concordant care, antipsychotic polypharmacy was commonly used as initial treatment, and there was substantial variability among facilities. Study findings suggest the utility of secondary data to assess treatment adaptation or switching for practical clinical trials.

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Figure 1 Antipsychotic (AP) prescribing pathways among veterans with schizophrenia or schizoaffective disordera

a Guideline-concordant pathways are in boldface.

Figure 2 Rates of polypharmacy for treatment of schizophrenia or schizoaffective disorder, by VHA facilitya

a N indicates the facility denominator of total analytic sample cases. VHA, Veterans Health Administration

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Table 1Observed distribution of antipsychotic prescribing pathways for VHA patients with schizophrenia or schizoaffective disordera
Table Footer Note

a VHA, Veterans Health Administration

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Table 2Demographic and clinical characteristics of VHA patients with schizophrenia or schizoaffective disordera
Table Footer Note

a VHA, Veterans Health Administration. Because of missing data, the denominator for percentages is not the group maximum for all variables.

Table Footer Note

b Patients may appear in more than one category.

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