Organizational Characteristics of Veterans Affairs Clinics With High and Low Utilization of Clozapine.
Twenty to thirty percent of patients with schizophrenia experience treatment resistance. Clozapine is the only medication proven effective for treatment-resistant schizophrenia. However, in most settings less than 25% of patients with treatment-resistant schizophrenia receive clozapine. This study was conducted to identify facilitators of and barriers to clozapine use to inform development of interventions to maximize appropriate clozapine utilization.



Seventy semistructured phone interviews were conducted with key informants of clozapine processes at U.S. Department of Veterans Affairs medical centers in various U.S. regions, including urban and rural areas, with high (N=5) and low (N=5) rates of clozapine utilization. Interviewees included members of mental health leadership, psychiatrists, clinical pharmacists, and advanced practice nurses. Interviews were analyzed by using an emergent thematic strategy to identify barriers and facilitators related to clozapine prescribing.



High utilization was associated with integration of nonphysician psychiatric providers and clear organizational processes and infrastructure for treatment of severe mental illness, for example, use of clozapine clinics and mental health intensive case management. Low utilization was associated with a lack of champions to support clozapine processes and with limited-capacity care systems. Obstacles identified at both high- and low-utilization sites included complex, time-consuming paperwork; reliance on a few individuals to facilitate processes; and issues related to transportation for patients living far from care facilities.



Implementation efforts to organize, streamline, and simplify clozapine processes; development of a multidisciplinary clozapine clinic; increased capacity of existing clinics; and provision of transportation are reasonable targets to increase clozapine utilization.
Dr. Gören is with the Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston (e-mail: jgoren@challiance.org ). She is also with the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, where Dr. Rose, Dr. Smith, and Dr. McCullough are affiliated. Dr. Rose is also with the Department of Medicine, Boston University, Boston. Dr. Smith is also with the Department of Psychiatry, University of Massachusetts Medical School, Worcester. Dr. McCullough is also with the School of Public Health, Boston University, Boston. Ms. Engle is with the Center for Healthcare Organization and Implementation Research, U.S. Department of Veterans Affairs Boston Healthcare System, Boston. Dr. Christopher is with the National Pharmacy Benefits Management Academic Detailing Service, U.S. Department of Veterans Affairs, San Diego. Dr. Rickles is with the Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs. Dr. Semla is with the National Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, and the Department of General Internal Medicine, Northwestern University Feinberg School of Medicine, both in Chicago.
Jessica L
JL
Gören
Dr. Gören is with the Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston (e-mail: jgoren@challiance.org ). She is also with the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, where Dr. Rose, Dr. Smith, and Dr. McCullough are affiliated. Dr. Rose is also with the Department of Medicine, Boston University, Boston. Dr. Smith is also with the Department of Psychiatry, University of Massachusetts Medical School, Worcester. Dr. McCullough is also with the School of Public Health, Boston University, Boston. Ms. Engle is with the Center for Healthcare Organization and Implementation Research, U.S. Department of Veterans Affairs Boston Healthcare System, Boston. Dr. Christopher is with the National Pharmacy Benefits Management Academic Detailing Service, U.S. Department of Veterans Affairs, San Diego. Dr. Rickles is with the Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs. Dr. Semla is with the National Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, and the Department of General Internal Medicine, Northwestern University Feinberg School of Medicine, both in Chicago.
Adam J
AJ
Rose
Dr. Gören is with the Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston (e-mail: jgoren@challiance.org ). She is also with the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, where Dr. Rose, Dr. Smith, and Dr. McCullough are affiliated. Dr. Rose is also with the Department of Medicine, Boston University, Boston. Dr. Smith is also with the Department of Psychiatry, University of Massachusetts Medical School, Worcester. Dr. McCullough is also with the School of Public Health, Boston University, Boston. Ms. Engle is with the Center for Healthcare Organization and Implementation Research, U.S. Department of Veterans Affairs Boston Healthcare System, Boston. Dr. Christopher is with the National Pharmacy Benefits Management Academic Detailing Service, U.S. Department of Veterans Affairs, San Diego. Dr. Rickles is with the Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs. Dr. Semla is with the National Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, and the Department of General Internal Medicine, Northwestern University Feinberg School of Medicine, both in Chicago.
Ryann L
RL
Engle
Dr. Gören is with the Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston (e-mail: jgoren@challiance.org ). She is also with the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, where Dr. Rose, Dr. Smith, and Dr. McCullough are affiliated. Dr. Rose is also with the Department of Medicine, Boston University, Boston. Dr. Smith is also with the Department of Psychiatry, University of Massachusetts Medical School, Worcester. Dr. McCullough is also with the School of Public Health, Boston University, Boston. Ms. Engle is with the Center for Healthcare Organization and Implementation Research, U.S. Department of Veterans Affairs Boston Healthcare System, Boston. Dr. Christopher is with the National Pharmacy Benefits Management Academic Detailing Service, U.S. Department of Veterans Affairs, San Diego. Dr. Rickles is with the Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs. Dr. Semla is with the National Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, and the Department of General Internal Medicine, Northwestern University Feinberg School of Medicine, both in Chicago.
Eric G
EG
Smith
Dr. Gören is with the Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston (e-mail: jgoren@challiance.org ). She is also with the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, where Dr. Rose, Dr. Smith, and Dr. McCullough are affiliated. Dr. Rose is also with the Department of Medicine, Boston University, Boston. Dr. Smith is also with the Department of Psychiatry, University of Massachusetts Medical School, Worcester. Dr. McCullough is also with the School of Public Health, Boston University, Boston. Ms. Engle is with the Center for Healthcare Organization and Implementation Research, U.S. Department of Veterans Affairs Boston Healthcare System, Boston. Dr. Christopher is with the National Pharmacy Benefits Management Academic Detailing Service, U.S. Department of Veterans Affairs, San Diego. Dr. Rickles is with the Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs. Dr. Semla is with the National Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, and the Department of General Internal Medicine, Northwestern University Feinberg School of Medicine, both in Chicago.
Melissa L D
ML
Christopher
Dr. Gören is with the Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston (e-mail: jgoren@challiance.org ). She is also with the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, where Dr. Rose, Dr. Smith, and Dr. McCullough are affiliated. Dr. Rose is also with the Department of Medicine, Boston University, Boston. Dr. Smith is also with the Department of Psychiatry, University of Massachusetts Medical School, Worcester. Dr. McCullough is also with the School of Public Health, Boston University, Boston. Ms. Engle is with the Center for Healthcare Organization and Implementation Research, U.S. Department of Veterans Affairs Boston Healthcare System, Boston. Dr. Christopher is with the National Pharmacy Benefits Management Academic Detailing Service, U.S. Department of Veterans Affairs, San Diego. Dr. Rickles is with the Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs. Dr. Semla is with the National Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, and the Department of General Internal Medicine, Northwestern University Feinberg School of Medicine, both in Chicago.
Nathaniel M
NM
Rickles
Dr. Gören is with the Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston (e-mail: jgoren@challiance.org ). She is also with the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, where Dr. Rose, Dr. Smith, and Dr. McCullough are affiliated. Dr. Rose is also with the Department of Medicine, Boston University, Boston. Dr. Smith is also with the Department of Psychiatry, University of Massachusetts Medical School, Worcester. Dr. McCullough is also with the School of Public Health, Boston University, Boston. Ms. Engle is with the Center for Healthcare Organization and Implementation Research, U.S. Department of Veterans Affairs Boston Healthcare System, Boston. Dr. Christopher is with the National Pharmacy Benefits Management Academic Detailing Service, U.S. Department of Veterans Affairs, San Diego. Dr. Rickles is with the Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs. Dr. Semla is with the National Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, and the Department of General Internal Medicine, Northwestern University Feinberg School of Medicine, both in Chicago.
Todd P
TP
Semla
Dr. Gören is with the Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston (e-mail: jgoren@challiance.org ). She is also with the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, where Dr. Rose, Dr. Smith, and Dr. McCullough are affiliated. Dr. Rose is also with the Department of Medicine, Boston University, Boston. Dr. Smith is also with the Department of Psychiatry, University of Massachusetts Medical School, Worcester. Dr. McCullough is also with the School of Public Health, Boston University, Boston. Ms. Engle is with the Center for Healthcare Organization and Implementation Research, U.S. Department of Veterans Affairs Boston Healthcare System, Boston. Dr. Christopher is with the National Pharmacy Benefits Management Academic Detailing Service, U.S. Department of Veterans Affairs, San Diego. Dr. Rickles is with the Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs. Dr. Semla is with the National Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, and the Department of General Internal Medicine, Northwestern University Feinberg School of Medicine, both in Chicago.
Megan B
MB
McCullough
D000554:Ambulatory Care Facilities / Q000706:statistics & numerical data*; D014150:Antipsychotic Agents / Q000627:therapeutic use*; D003024:Clozapine / Q000627:therapeutic use*; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D009722:Nurse Practitioners / Q000706:statistics & numerical data*; D010595:Pharmacists / Q000706:statistics & numerical data*; D011570:Psychiatry / Q000706:statistics & numerical data*; D012559:Schizophrenia / Q000188:drug therapy*; D014481:United States; D014493:United States Department of Veterans Affairs / Q000706:statistics & numerical data*
D014150:Antipsychotic Agents; D003024:Clozapine