Transcript 2.15 peter bramallx

Quality improvement programme
Antipsychotic prescribing in
people with a learning disability
Supplementary audit
July 2015
Clinical background
•
LD is formally classified with mental disorders and illnesses but it is
nonetheless distinct from them and it is rare in contemporary practice for
it to be thought of as a psychiatric disorder in and of itself. Despite this,
mental illness, personality disorder and behavioural disorder requiring
clinical intervention are overrepresented in this group
•
As the severity of LD falls, diagnosing mental illness becomes increasingly
difficult and clinicians become more inclined to consider clinical problems
in diagnostic and descriptive ways, invoking the terms ‘challenging
behaviour’ or ‘problem behaviour’.
•
Although the use of antipsychotic medication for psychotic and related
illnesses in people with a learning disability (LD) is relatively
uncontroversial, their common use in the management of behavioural
problems not attributable to diagnosed mental illness is not.
Clinical practice standards
1. The indication for treatment with antipsychotic medication should be
documented in the clinical records (Deb, 2006).
2. The continuing need for antipsychotic medication should be reviewed at
least once a year (Deb, 2006).
3. Side effects of antipsychotic medication should be reviewed at least once
a year. This review should include assessment for the presence of
extrapyramidal side effects (EPS), and screening for the 4 aspects of the
metabolic syndrome: obesity, hypertension, impaired glucose tolerance and
dyslipidaemia (NICE schizophrenia guideline update CG82, 2009).
Compliance with NICE guidelines
While the report for this supplementary audit was being prepared, NICE
published a guideline entitled ‘Challenging behaviour and learning disabilities:
prevention and interventions for people with learning disability whose
behaviour challenges’ (NG11, May 2015).
Practice standard 1 is consistent with recommendations 1.8.4 and 1.8.5.
Practice standards 2 and 3 address aspects of NICE recommendations 1.8.4,
1.8.5 and 1.8.6.
In addition, NICE recommends that treatment for co-morbid mental illness
should be optimised (1.8.1) and that antipsychotic medication should only be
considered if the risk to the person or others is severe, for example violence,
aggression or self-injury (1.8.2). Where the data allow, we included tables or
figures that showed clinical practice in relation to these recommendations.
The Winterbourne View report
The Winterbourne View report, published in 2012, raised concerns about the overuse of psychotropic medicines in people with learning disability. The report recommended
(section 7.31) that 'health professionals caring for people with learning disabilities should
assess and keep under review the medicines requirements for each individual patient to
determine the best course of action for that patient.... Services should have systems and
policies in place to ensure that this is done safely and in a timely manner and should
carry out regular audits of medication prescribing and management...'
For this supplementary audit, the eligibility criteria were therefore expanded to include
all patients with a learning disability under the care of mental health services, regardless
of whether or not they are prescribed antipsychotic medication. This allowed the
prevalence of prescribing of different categories of psychotropic drugs to be
benchmarked across services while also retaining the original focus of this QIP on the
quality of prescribing of antipsychotic medication.
Overprescribing in LD
• NHS England June 2015: Letter by Dr D Slowie and Dr K
Ridge on behalf of NHS England and supported by RCPsych,
RCN, RPS July 2015.
• In December 2012, the Department of Health (DH)
publication “Transforming Care: A national response to
Winterbourne View Hospital” stated that: “7.31 We have
heard deep concerns about the over-use of antipsychotic
and antidepressant medicines. Health professionals caring
for people with learning disabilities should assess and keep
under review the medicines requirements for each
individual to determine the best course of action for that
patient, taking into account the views of the person
wherever possible and their family and/or carer(s)
Method
Data were submitted for
• 54 Trusts
• 338 clinical teams
• 5,654 adult patients with a learning disability
Audit data collected:
• Age, gender, ethnicity, severity of learning disability, comorbid psychiatric diagnoses and care setting
• Diagnosis of epilepsy
• The dose of each oral/short-acting IM and depot/longacting antipsychotic currently prescribed
• The main indications for antipsychotic prescribing
• Other medications for mental health, behavioural problems
or epilepsy
• Evidence of side effect monitoring.
National and Trust level results for practice
standard 1
Practice standard 1: The indication for treatment with antipsychotic
medication should be documented in the clinical records.
Documentation in the clinical records of the reasons for prescribing
antipsychotic medication within the last 12 months in the total
national sample (TNS, n=465) and your Trust (n=28)
TNS
BCUHB
Indication for
prescribing
antipsychotic
medication:
documented in the
clinical records
Not documented in the
clinical records
Practice Standard 1
Practice standard 1: The indication for treatment with antipsychotic medication
should be documented in the clinical records.
Common
indications for
prescribing
Antipsychotic prescribing initiated within
the last 12 months
Antipsychotic prescribing initiated more
than 12 months ago
Baseline
N=328
Re-audit
N=334
Supplementary
N=465
Baseline
N=1,991
Re-audit
N=2,053
Supplementary
N=3,163
1. Agitation and
anxiety
43%
38%
46%
42%
41%
40%
2. Overt aggression
37%
41%
38%
38%
44%
35%
3. Psychotic disorder
42%
43%
35%
42%
39%
42%
4. Threatening
behaviour
27%
23%
25%
31%
27%
30%
5. Self harm/selfinjurious behaviour*
10%
14%
4% / 13%
11%
14%
5% / 14%
6. Obsessive
behaviour
11%
7%
9%
13%
9%
9%
The most common indications for antipsychotic
prescribing where this was initiated more than 12
months ago at supplementary audit by severity of LD
(n=3,163)
Common indications for
prescribing
Mild/borderline
N=1,621
Moderate
N=883
Severe/profound
N=659
Psychotic disorder
55%
37%
15%
Agitation and anxiety
32%
48%
51%
Overt aggression
27%
42%
48%
Threatening behaviour
28%
35%
28%
Self harm/self-injurious
behaviour*
4% / 7%
3% / 15%
8% / 31%
7%
13%
10%
Obsessive behaviour
The use of medicines to treat mental illness,
behavioural problems or epilepsy
Drugs prescribed
Total sample
n=5,654
Mild/ borderline
n=2,973
Moderate
n=1,531
Severe/ profound
n=1,150
Antipsychotic
3,628
64%
1,873
63%
1,022
67%
733
64%
Antidepressant - SSRI
1,616
29%
954
32%
439
29%
223
19%
Antidepressant – other
504
9%
326
11%
111
7%
67
6%
Carbamazepine*
699
12%
251
8%
190
12%
258
22%
Benzodiazepine*
799
14%
362
12%
227
15%
210
18%
Anticholinergic
582
10%
323
11%
141
9%
118
10%
1,125
20%
493
17%
316
21%
316
27%
405
7%
154
5%
98
6%
153
13%
Valproate*
Lamotrigine*
Proportion of patients in the total national sample
prescribed antipsychotics and antidepressants with or
without a relevant psychiatric diagnosis by severity of
learning disability at supplementary audit.
Medicine review
Practice standard 2: The continuing need for antipsychotic medication
should be reviewed at least once a year.
Figure 8: Documentation of decisions at medication review conducted within the
last 12 months for those prescribed antipsychotic medication, and/or other
psychotropic medication, for more than 12 months at supplementary audit.
Monitoring of side effects
Practice standard 3: Side effects of antipsychotic medication should be reviewed at
least once a year. This review should include assessment for the presence of EPS,
and screening for the 4 aspects of the metabolic syndrome: obesity, hypertension,
impaired glucose tolerance and dyslipidaemia.
Figure 9: Nature of documented evidence in the clinical records of clinical
assessment of side effects in the last 12 months in patients prescribed
antipsychotic medication for more than 12 months at baseline, re-audit
and supplementary audit.
Trust level findings
Analyses presented in this section
were conducted for each Trust
individually and for the total sample
to allow benchmarking.
Data from each Trust are presented
by code.
Your Trust code is 102
Practice standard 1: The indication for treatment with antipsychotic
medication should be documented in the clinical records.
Proportion of patients in each Trust for whom antipsychotics were prescribed for
less than 12 months and for whom the clinical reasons for antipsychotic
prescribing is clearly documented: re-audit and supplementary audit.
100%
Reasons not
clearly
documented
80%
60%
Reasons
clearly
documented
40%
Reasons
clearly
documented
at re-audit
20%
0%
2
3
5
8
11
13
16
17
18
21
22
29
31
34
40
56
59
62
65
66
69
72
73
74
77
80
81
84
85
89
92
94
95
99
100
101
102
109
6
42
9
91
51
27
90
15
50
54
79
63
25
104
TNS
Proportion of patients
Trust-level results for practice standard 1
Trust code
Trust-level results for practice standard 2
Practice standard 2: The continuing need for antipsychotic medication
should be reviewed at least once a year.
Proportion of patients in each Trust for whom antipsychotics were prescribed for
more than 12 months and the continuing need for antipsychotic medication was
reviewed: re-audit and supplementary audit.
Trust-level results for practice standard 3
Practice standard 3: Side effects of antipsychotic medication should be
reviewed at least once a year. This review should include assessment for
the presence of EPS, and screening for the 4 aspects of the metabolic
syndrome: obesity, hypertension, impaired glucose tolerance and
dyslipidaemia.
Proportion of patients in each Trust and the total national sample for whom antipsychotics
were prescribed for more than 12 months with documented evidence in their clinical
records of a general assessment of side effects at re-audit and supplementary audit.
Summary for BCUHB
• Above average for standards 1 and 2
• Below average for all aspects of standard 3
(side effect monitoring)
What happens next?
1. Clinicians are invited to reflect on their performance data
and generate and implement action plans as appropriate.
2. Clinicians who do so, should be encouraged to submit
evidence of this process as part of their CPD, to inform
their appraisal and to support revalidation.
3. On the basis of the audit findings, POMH-UK will consider
appropriate change interventions for provision to
participating Trusts to support their local action plans.
Next in BCUHB
• Full results with team breakdown to be
presented in LDS Governance group meeting
and Consultant peer group
• Discuss and agree key practice points
• Re-audit with same/extended standards