title: The effectiveness of guideline implementation strategies on improving antipsychotic medication management for schizophrenia.
abstract: OBJECTIVE
  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.
authors.affiliation: VA Health Services Research and Development Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas 72114, USA. Richard.Owen2@va.gov
authors.forename: Richard R
authors.initials: RR
authors.lastname: Owen
authors.forename: Teresa
authors.initials: T
authors.lastname: Hudson
authors.forename: Carol
authors.initials: C
authors.lastname: Thrush
authors.forename: Purushottam
authors.initials: P
authors.lastname: Thapa
authors.forename: Tracey
authors.initials: T
authors.lastname: Armitage
authors.forename: Reid D
authors.initials: RD
authors.lastname: Landes
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D014150:Antipsychotic Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D005260:Female; D019983:Guideline Adherence; D019538:Health Care Surveys; D006787:Hospitals, Veterans; D006801:Humans; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011785:Quality Assurance, Health Care; D012559:Schizophrenia / Q000188:drug therapy*; D014481:United States
chemical_list: D014150:Antipsychotic Agents