Impact of Psychotropic Medication Reviews on Prescribing Patterns
Discussion
This study illustrates the impact of including a psychiatric CPS as part of the interdisciplinary care team. Through the implementation of a PMR process, CPSs were able to provide specific, unbiased recommendations for the safe use of medications. It was felt that CPSs might have a greater impact by offering patient-specific recommendations rather than providing general information about the risks of these medications, which many providers are aware of already. Because nearly half of all recommendations were accepted, the authors feel that the PMR is an effective way to deliver provider education and improve safe prescribing practices.
There will be times when the use of these agents in at-risk populations is justified and appropriately documented, as was the case for 20 patients in this study. The goals of this study were not only to improve the use of evidence-based medications, but also the process of documenting justification for the continued use of these agents. The 22% of recommendations that were declined with justification from the provider were considered successful, because the PMR note prompted the provider to document in a note clear justification for the use of the agent in question.
The majority of recommendations were made to prescribers in the Mental Health Department, which was expected given the 2 classes of medications evaluated in the study. However, primary care prescribers accepted recommendations at the highest rate. There are several possible explanations. First, mental health prescribers are more likely to have complex, treatment-resistant psychiatric patients than do other disciplines. Additionally, these prescribers have an increased level of familiarity and comfort with second-generation antipsychotics and benzodiazepines and may have been more confident in documenting justifications to continue therapy.
Neurologists were the least likely to accept PMR recommendations. Unlike other services, prescribers in the Neurology Department spend a significant amount of their time providing care to patients at a university hospital and, therefore, are not present on the VA campus on a daily basis. This location disparity can lead to less frequent contact between prescriber and CPSs and may impact the professional relationship between these departments. Also, both the Neurology Department and the home-based Primary Care Department did not have staff actively involved in the PDSI, which may have decreased prescriber familiarity with the goals and intentions of PDSI and therefore decreased provider responsiveness to PMR notes.
Sometimes PMR notes were entered in the EMR when the patient did not have an upcoming appointment with the prescriber. As a result, there were instances when recommendations could not be implemented due to time and workload constraints. Many providers acknowledged the importance of shared medical decision making and preferred to wait to make medication adjustments until patients could be seen in the clinic.
Psychotropic medication review is a continually developing process, and these results illustrate provider response to the initial 5 months of a new service. During the time frame, PMR notes had been entered for all veterans identified as using antipsychotics or benzodiazepines in the setting of dementia but for only a fraction of those identified as using benzodiazepines who were aged > 75 years. It is reasonable to expect that as prescribers become more familiar with the PMR process and its intentions, they may be more likely to acknowledge recommendations and to respond with the appropriate documentation.
Psychotropic medication reviews were initiated as part of a PGY-2 psychiatric pharmacy residency project, and as such, the impact on the CPS workflow was not evaluated. Although this study suggests that the use of PMR was effective in improving evidence-based prescribing, it does not evaluate whether this process is sustainable in the long-term for the CPS.
Conclusions
The results of this study illustrate the value of a psychiatric CPS. Through the implementation of a simple PMR service, CPSs were able to impact evidence-based prescribing and related documentation. With nearly 50% of the recommendations accepted, the authors believe that use of the PMR is an effective way to deliver provider education and improve safe prescribing practices. Further review of the PMR process will be needed to evaluate the impact and sustainability on CPS workflow.
