1066 — Glucose Monitoring and Management in Veterans with Psychosis Started on New Antipsychotic Medications

Smith JL (VA Mental Health QUERI), Owen RR (VA Mental Health QUERI), Williams S (Center for Mental Healthcare & Outcomes Research (CeMHOR)), Hudson TJ (Center for Mental Healthcare & Outcomes Research (CeMHOR))

Objectives:
Second-generation antipsychotics (SGAs) are prescribed to over 80% of veterans with psychosis. Treatment with some SGAs is associated with metabolic side effects such as overweight/obesity, diabetes, and hyperlipidemia. Recommendations for monitoring and management of these effects are contained in VA clinical practice guidelines for psychoses, obesity, diabetes, and dyslipidemia. We conducted an exploratory analysis to assess whether recommendations for monitoring and management of plasma glucose are followed for veterans with psychosis started on new antipsychotic medications.

Methods:
Data sources included VHA Medical SAS Datasets and National Data Extracts SAS Datasets from the Decision Support System. For patients with a new antipsychotic prescription in FY07 (ie, antipsychotic not filled in the prior 6 months) and an inpatient or outpatient diagnosis of a psychotic disorder (ICD-9 codes 295.x, 296.0-1, 296.4-8, 297.0-3, 297.8-298.4, 298.8-9), we assessed whether they had recommended baseline and follow-up plasma glucose monitoring. For patients with elevated glucose values, we assessed whether they had a repeat test or referral to primary care within 30 days.

Results:
Of 237,242 patients prescribed antipsychotic medication in the first 6 months of FY07, 76,967 (32.4%) had a new antipsychotic prescription during that period. Of these, 34,955 (45.4%) had an inpatient or outpatient diagnosis of psychosis. For patients with psychosis and a new antipsychotic, 20,040 (57.3%) had a plasma glucose test within 30 days of the medication change (“baseline”) and 12,998 (37.2%) had a glucose test between 1-4 months after baseline (“follow-up”). Only 7,793 patients (22.3%) had glucose monitored at both baseline and follow-up. Of patients with glucose tested at baseline, 1,226 (6.1%) had a glucose value over 200 mg/dL. Of these, only 689 (56.2%) had glucose tested again within 30 days, and only 420 (34.3%) had a primary care or diabetes clinic encounter within 60 days of the elevated glucose.

Implications:
Only one in five patients with psychosis started on new antipsychotic medications receive recommended baseline and follow-up glucose monitoring. Improvement is needed in monitoring and management of elevated glucose values for these patients.

Impacts:
Interventions are needed to improve monitoring and management of glucose and other metabolic side effects associated with antipsychotic medications for veterans with psychosis.