Hudson TJ (HSR&D Center for Mental Health and Outcomes Research (CeMHOR) and University of Arkansas for Medical Sciences (UAMS))
Owen RR (CeMHOR, UAMS)
Thrush CR (CeMHOR, UAMS)
Armitage TL (CeMHOR, UAMS)
Thapa PT (UAMS, Arkansas State Hospital)
To compare the effectiveness of an enhanced guideline implementation strategy that included a patient-tailored medication adherence component to a basic implementation strategy without an adherence component.
Data were collected from adults who were experiencing an exacerbation of schizophrenia and were treated at one of six VA Medical Centers in three different networks. At sites receiving the enhanced strategy, a research nurse worked with patients to identify medication adherence barriers and to develop patient-specific strategies to overcome those barriers. Patients enrolled at sites receiving the basic strategy did not receive this intervention. All patients were interviewed at enrollment and 6-months later using the Structured Clinical Interview for the Positive and Negative Syndrome Scale (SCI-PANSS), Barnes Akathisia Rating Scale, the Schizophrenia Outcomes Module (SCHIZOM) and the short form-36 (SF-36). Medication adherence was measured via patient self-report using the SCHIZOM and medical records data.
A total of 348 subjects were included in this analysis (175 at basic sites, 173 at enhanced sites). The majority of patients were male (94%); 69% were African-American. The mean age was 46 years. Patients were moderately ill with a mean PANSS total score of 81.7 at enrollment. We used logistic regression to model adherence at follow-up and controlled for adherence at baseline, patient demographics, site type, VISN, PANSS score and substance abuse. Patients enrolled at sites receiving the enhanced intervention were 1.7 times more likely to be adherent at follow-up (95% CI=1.01 – 3.07). Those who were non-adherent at baseline were less likely to be adherent at follow-up (OR=0.297, 95% CI= 0.18-0.50). Compared with patients treated in VISN C, patients treated in VISNs A and B were 2.15 times (95% CI= 1.13-4.08) and 1.97 times (95% CI= 1.01-3.88) respectively to be adherent at follow-up.
These data suggest that a guideline implementation strategy which includes a patient-centered strategy to identify and overcome barriers to adherence can effectively improve adherence to antipsychotic medications.
This work demonstrates the importance of a patient-centered approach to guideline implementation. More research is needed to determine reasons for variation in the intervention’s effectiveness.