Patients with schizophrenia commonly receive more than one antipsychotic concurrently despite little evidence to support this practice. The Joint Commission has recently implemented Hospital-Based Inpatient Psychiatric Services (HBIPS) quality measures to monitor and reduce inappropriate antipsychotic polypharmacy in patients. Pharmacists need to have a clear understanding of these quality measures and consider their role in improving appropriate antipsychotic use.

Practice guidelines for the treatment of schizophrenia recommend monotherapy with antipsychotics as the mainstay of treatment.1–3 However, 10–30% of patients are treatment resistant and have little or no response to antipsychotic medications.3 Up to an additional 30% of patients have partial responses to treatment, defined as exhibiting residual hallucinations or delusions.3 Practice guidelines recommend treatment with multiple antipsychotics (polypharmacy) only for patients who have failed multiple trials of monotherapy.2,3 The best available evidence to support the use of multiple antipsychotics comes from studies that examined combining clozapine with another antipsychotic.4–6 Despite consensus recommendations for monotherapy, antipsychotic polypharmacy routinely occurs. Faires and colleagues conducted a multiple site, retrospective review of antipsychotic use in 796 adult inpatients and outpatients with schizophrenia over a one year period. Their study found that 57.5% of patients received more than one antipsychotic concurrently, for greater than 60 of 365 days of therapy.7 

In addition to limited evidence supporting the effectiveness of antipsychotic polypharmacy, there is also a growing body of evidence that some combinations may increase adverse effects. Antipsychotic polypharmacy may be associated with increases in extrapyramidal symptoms (EPS), hyperprolactinemia, sexual dysfunction, sedation, cognitive impairment, hyperlipidemia and metabolic syndrome.8,9 

In response to these concerns, the Joint Commission, in cooperation with the National Association of Psychiatric Health Systems, the National Association of State Mental Health Program Directors (NASMHPD) and the NASMHPD Research Institute, developed a set of quality measures that specifically targeted patients who are discharged from inpatient facilities on more than one scheduled antipsychotic.10,11 These core performance measures specifically target Hospital-Based Inpatient Psychiatric Services (HBIPS) performed at free-standing psychiatric hospitals and psychiatric units within acute care hospitals. These measures were implemented in October 2008 and made mandatory for free-standing psychiatric hospitals in 2011. Hospitals that utilize these quality measures meet the Joint Commission's ORYX® (Outcomes Research Yields eXcellence) reporting requirements.12 ORYX® is the Joint Commission's performance measurement and improvement initiative, first implemented in 1997. ORYX® integrates outcomes and other performance measure data into the accreditation process. ORYX® measurement requirements are intended to support Joint Commission accredited organizations in their quality improvement efforts, and the data are publicly reported on the Joint Commission website at Quality Check®, www.qualitycheck.org. The public availability of performance measure data permits comparisons of hospital performance at state and national levels.12 Two HBIPS measures specifically address antipsychotic polypharmacy and are entitled, “HBIPS-4: patients discharged on more than one antipsychotic” and “HBIPS-5: patients discharged on more than one antipsychotic with appropriate justification.”10 

HBIPS measures allow psychiatric hospitals to benchmark their performance against national averages. Performances on these quality measures are also available to the general public through the Joint Commission's QualityCheck® website. The Centers for Medicare and Medicaid Services (CMS) has plans to present HBIPS results on its Hospital Compare website starting in 2014.

Details of the measurement sets for HBIPS-4 and HBIPS-5 are presented in Table 1 and Table 2. Notice the data are stratified by age. Table 3 describes specific appropriate justifications for multiple antipsychotic use as defined by the Joint Commission.

Table 1:

HBIPS-4 Patients discharged on multiple antipsychotic medications

HBIPS-4 Patients discharged on multiple antipsychotic medications
HBIPS-4 Patients discharged on multiple antipsychotic medications
Table 2:

HBIPS-5 Patients discharged on multiple antipsychotic medications with appropriate justification

HBIPS-5 Patients discharged on multiple antipsychotic medications with appropriate justification
HBIPS-5 Patients discharged on multiple antipsychotic medications with appropriate justification
Table 3:

Appropriate Justification for Multiple Antipsychotic Medications

Appropriate Justification for Multiple Antipsychotic Medications
Appropriate Justification for Multiple Antipsychotic Medications

Hospital performance on these quality measures will have a direct impact on accreditation status. Psychiatric pharmacists play an important role in optimizing outcomes for patients taking antipsychotic medications. Pharmacist education of prescribers has demonstrated a reduction in the prevalence of antipsychotic polypharmacy from a baseline level of 18.3% to 6.6% following interventions.13 Pharmacists need to evaluate the evolving literature on the risks and benefits of antipsychotic polypharmacy and assist prescribers in appropriate use. One method of doing so is by monitoring patients who receive multiple, scheduled antipsychotics, and making recommendations for meeting the Joint Commission HBIPS documentation requirements when patients are discharged on more than one antipsychotic. Pharmacist need to consider these quality measures when monitoring, modifying and recommending antipsychotic medication therapies for patients.

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