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The Effectiveness of Guideline Implementation Strategies on Improving Antipsychotic Medication Management for Schizophrenia

Owen, Richard R. MD*†; Hudson, Teresa PharmD*†; Thrush, Carol EdD; Thapa, Purushottam MD, MPH†§; Armitage, Tracey MS*; Landes, Reid D. PhD

doi: 10.1097/MLR.0b013e3181653d43
Original Article

Objectives: To compare the effectiveness of a conceptually-based, multicomponent “enhanced” strategy with a “basic” strategy for implementing antipsychotic management recommendations of VA schizophrenia guidelines.

Methods: Two VA medical centers in each of 3 Veterans Integrated Service Networks were randomized to either a basic educational implementation strategy or the enhanced strategy, in which a trained nurse promoted provider guideline adherence and patient compliance. Patients with acute exacerbation of schizophrenia were enrolled and assessed at baseline and 6 months and their medical records were abstracted; 291 participants were included in analyses. Logistic regression models were developed for rates of: (1) switching patients from first-generation antipsychotics (FGA) to second-generation antipsychotics (SGA), and (2) guideline-concordant antipsychotic dose.

Results: Of participants prescribed FGAs at baseline, those at enhanced sites were significantly more likely than participants at basic sites to have an SGA added to the FGA during the study (29% vs. 8%; adjusted OR = 7.7; 95% CI: 2.0–30.1), but were not significantly more likely to be switched to monotherapy with an SGA (29% vs. 23%). Guideline-concordant antipsychotic dosing was not significantly affected by the intervention.

Conclusions: The enhanced guideline implementation strategy increased addition of SGAs to FGA therapy, but did not significantly increase guideline-recommended switching from FGA to SGA monotherapy. Antipsychotic dosing was not significantly altered. The study illustrates the challenges of changing clinical behavior. Strategies to improve medication management for schizophrenia are needed, and must incorporate recommendations likely to emerge from recent research suggesting comparable effectiveness of SGAs and FGAs.

From the *VA Health Services Research and Development Center for Mental Healthcare and Outcomes Research (CeMHOR), Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas; the †Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Arkansas for Medical Sciences (UAMS), Little Rock, Arkansas; ‡Office of Educational Development, UAMS, Little Rock, Arkansas; §Arkansas Department of Human Service, Division of Behavioral Health Services, Little Rock, Arkansas; and ¶Department of Biostatistics, College of Medicine, UAMS, Little Rock, Arkansas.

Supported by a grant (CPG 97-027) from the Department of Veterans Affairs Health Services Research and Development Service, the VA South Central MIRECC, and the VA Mental Health Quality Enhancement Research Initiative (MH QUERI).

The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

Reprints: Richard R. Owen, MD, Center for Mental Healthcare & Outcomes Research (152/NLR), Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114. E-mail:

© 2008 Lippincott Williams & Wilkins, Inc.