1059 — Clozapine Variation in the VA: A Qualitative Study

Goren JL, Center for Healthcare Organization & Implementation Research, University of Rhode Island; Engle RL, Center for Healthcare Organization & Implementation Research; Rose AJ, Center for Healthcare Organization & Implementation Research; Smith E, Center for Healthcare Organization & Implementation Research; Rickles N, Northeastern University; Christopher M, VISN 22 Desert Pacific Healthcare System; Semla T, VA National PBM; McCullough MB, Center for Healthcare Organization & Implementation Research;

Objectives:
Treatment-resistance schizophrenia (TRS) occurs in 20% of patients. Clozapine is the only medication proven effective for TRS. Within VA, facility-level rates of clozapine prescribing for schizophrenia range from 0%-17.8%. Therefore, we conducted a study to inform development of interventions to maximize appropriate clozapine utilization across VA.

Methods:
We conducted semi-structured phone interviews at five high- and five low-utilization sites, from different regions including urban and rural areas, to identify facilitators and barriers to clozapine use. Interviewees were key-informants of clozapine prescribing processes, including psychiatrists, clinical pharmacist specialists (CPSs) and advanced practice nurses (APNs). Interviews were structured using the Consolidated Framework for Implementation (CFIR) to understand the pre-implementation context. Transcripts were coded in NVivo 10 using an a priori approach based on CFIR and an emergent thematic analysis to identify barriers and facilitators to clozapine prescribing as well as strong clozapine practices.

Results:
Key elements associated with high-utilization included integration of non-physician psychiatric providers (e.g. CPS, APN), clozapine education for clinicians, clear organizational processes, and infrastructure for treatment of severe mental illness (e.g. clozapine clinics, large mental health intensive case management services). High-utilization sites identified barriers to clozapine prescribing and proactively implement solutions. Low-utilization was associated with lack of champions to support clozapine processes and systems of care with limited capacity. Obstacles identified at both high- and low-utilization sites included complex time-consuming paperwork, reliance on a single individual to facilitate processes, and issues related to Veterans living remotely from VA facilities. Strong practices we identified include: 1) assign a CPS to educate clinicians and facilitate clozapine prescribing, 2) education to increase awareness of processes and 3) provision of actionable data (e.g. lists of potential clozapine patients).

Implications:
Implementation efforts to organize, streamline and simplify clozapine processes, and utilization of an antipsychotic dashboard to identify actionable patients in real time are reasonable targets to increase clozapine utilization. Deployment of CPSs at all sites and inclusion of academic detailing responsibilities may increase comfort with clozapine prescribing and processes.

Impacts:
Based on these findings interventions will include increased utilization of non-physician clinicians and changes in organization such as development of clozapine clinics to facilitate prescribing processes.