Late-life schizophrenia: Optimizing treatment

Management of late-life schizophrenia requires an assessment of several clinical factors to optimize outcome. These factors include the recognition of differences in symptom characteristics in late life as well as an appraisal of potential age-related physiologic changes. Comorbid medical conditions and vulnerabilities to adverse events such as heart disease are additional factors that weigh into medication management decisions for this population. This article reviews issues in the use of antipsychotic medications among older adults with schizophrenia. Recommendations regarding safety monitoring are reviewed, as well as data on important issues regarding diabetes mellitus and cerebrovascular disease. Taken together, the management of the older person requires an integration of several sources of information from the patient, including an assessment of laboratory and physical examination parameters, as well as symptomatic response.     

Evaluation of a computer‐based intervention to enhance metabolic monitoring in psychiatry inpatients treated with second‐generation antipsychotics

What is known and Objective: Second‐generation antipsychotics (SGAs) play an important role in the pharmacologic management of various psychiatric conditions. Use of these medications has been associated with metabolic complications. Adherence to guideline‐recommended monitoring is suboptimal. We evaluated the effect of a computerized physician order entry (CPOE) pop‐up alert designed to improve rates of laboratory metabolic monitoring of patients treated with SGAs on a University Hospital inpatient psychiatry unit. Methods: A single‐centre, retrospective chart review was performed in which patient demographics and SGA drug and laboratory data were extracted from the CPOE database. We assessed the number of orders for appropriate metabolic monitoring data for patients admitted within a 6‐month period before or after the alert implementation. Results and Discussion: Pre‐alert (n = 171) and post‐alert (n = 157) groups were similar with respect to age, length of stay, sex, race and comorbidities. Following alert implementation, significant increases in monitoring both random (92·4% vs. 100%) and fasting (46·8% vs. 70%) glucose levels as well as random (28·7% vs. 74·5%) and fasting (18·7% vs. 59·9%) lipid panels (all P ≤ 0·001) were observed. The number of patients with both a fasting glucose level and fasting lipid panel available for monitoring increased from 12·9% to 47·8% (P < 0·0001). Significantly more post‐alert laboratory orders were submitted at the same time as the SGA drug order (P < 0·0001), suggesting that the alert itself had a direct influence on the ordering of metabolic monitoring labs. What is new and Conclusions: Implementation and use of an electronic pop‐up alert in an inpatient psychiatric unit significantly improved rates of ordering fasting blood glucose and lipid levels for inpatients treated with SGAs. Overall rates remain suboptimal, suggesting a need for additional strategies to further improve metabolic monitoring.     

Pain Conditions Ranked by Healthcare Costs for Members of a National Health Plan

Healthcare resource utilization (HCRU) and associated costs specific to pain are a growing concern, as increasing dollar amounts are spent on pain‐related conditions. Understanding which pain conditions drive the highest utilization and cost burden to the healthcare system would enable providers and payers to better target conditions to manage pain adequately and efficiently. The current study focused on 36 noncancer chronic and 14 noncancer acute pain conditions and measured the HCRU and costs per member over 365 days. These conditions were ranked by per‐member costs and total adjusted healthcare costs to determine the most expensive conditions to a national health plan. The top 5 conditions for the commercial line of business were back pain, osteoarthritis (OA), childbirth, injuries, and non‐hip, non‐spine fractures (adjusted annual total costs for the commercial members were $119 million, $98 million, $69 million, $61 million, and $48 million, respectively). The top 5 conditions for Medicare members were OA, back pain, hip fractures, injuries, and non‐hip, non‐spine fractures (adjusted annual costs for the Medicare members were $327 million, $218 million, $117 million, $82 million, and $67 million, respectively). The conditions ranked highest for both per‐member and total healthcare costs were hip fractures, childbirth, and non‐hip, non‐spine fractures. Among these, hip fractures in the Medicare member population had the highest mean cost per member (adjusted per‐member cost was $21,058). Further examination specific to how pain is managed in these high‐cost conditions will enable providers and payers to develop strategies to improve patient outcomes through appropriate pain management.