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Audit GP practice records of patients prescribed clozapine

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It is important for mentally ill patients to be managed appropriately within both primary and secondary care, as many patients are at a higher risk of physical health problems. In its advice for ‘promoting and maintaining recover y’, the updated National Institute for Health and Clinical Excellence (NICE) Clinical Guideline for Schizophrenia1 states that primary care is best placed to monitor the physical health of this population. The National Service Framework (NSF) for Mental Health2 stated its aim was to deliver better primar y health care, ensuring consistent advice and help for people with mental health needs including primary care services for individuals with severe mental illness. In addition, the Quality and Outcomes Framework (QOF)3 of the General Medical Services contract supports aims aspired to in previous policy and guidance such as the NSF for Mental Health2 and NICE guideline.1 The evidence demonstrating increased health needs of people with severe mental illnesses applies in the main to people with schizophrenia and other psychoses and bipolar disorder. The association between schizophrenia and poor physical health is well established.4 Poor health results in higher standardised mortality rates (SMR) and increased morbidity for individuals with schizophrenia.5 SMRs for people with a severe mental illness are twice as high as in the general population. Research has shown that it is common for GPs to overlook assessment for known risk factors in these patients.6 One study of 101 patients with severe and enduring mental illness living in the community found that their physical health was poorer than the general population. This study also reported that while GPs noted these problem areas in patient notes, few attempts to intervene were apparent.7 www.progressnp.com

Audit of GP practice records of patients prescribed clozapine Patients prescribed clozapine have associated physical health risks because of both use of the drug itself and their underlying mental illness. It is therefore important that primary and secondary care work closely together to optimise patient care. Here, the authors describe their audit of patients prescribed clozapine in secondary care to identify whether they were registered on their GP practice’s severe mental illness register and whether the practice had a record that they were taking clozapine. Most people with a diagnosis of schizophrenia in the care of the NHS are treated by secondary care mental health ser vices. Sur veys suggest that about 10-20 per cent of patients are managed in primary care: this includes monitoring, treatment and suppor t for their mental health problems in collaboration with secondar y care ser vices. 8-10 It is therefore essential that there is good communication between the two sectors regarding the prescribing of medicines, and in par ticular antipsychotics, for these patients. Primar y care provides a vital service for people with schizophrenia, who may consult GPs more frequently11 and are in contact with primary care services for a longer cumulative time than patients without mental health problems.12-14 Although most GPs regard themselves as being involved in the monitoring and treatment of physical illness and prescribing for physical health problems, only a minority of GPs regard themselves as being involved in the monitoring and treatment of mental health difficulties in patients with schizophrenia.15,16 One of the key priorities of the NICE Clinical Guideline for Schizophrenia 1 is that GPs and other health care professionals should monitor the physical health of people with schizophrenia at

least once a year. The focus is on cardiovascular disease, as people with schizophrenia are at higher risk of cardiovascular disease than the general population. The government recommends that patients with a severe mental illness (SMI) should be listed on a GP practice SMI register. Mental health indicator 8 in the QOF 3 states that ‘the practice can produce a register of people with schizophrenia, bipolar disorder and other psychoses’. SMI registers can support a structured care approach, which includes regular assessments of needs that impact upon physical health and well-being.1 This audit focused on records of the use of the antipsychotic drug clozapine, which is usually prescribed for treatment-resistant schizophrenia. In the local strategic health authority, clozapine can only be prescribed by secondar y care. Clozapine has the potential to cause cer tain serious sideeffects, notably neutropenia and agranulocytosis; and in common with some other antipsychotics, clozapine can cause significant weight gain and increase the risk of developing diabetes and cardiovascular disease.17 Therefore it is impor tant for primar y care providers to have clear documentation in their medical notes of patients prescribed clozapine from

Caroline Parker MRPharmS, MCMHP, Portia Somasunderam MPharm

Progress in Neurology and Psychiatry 11


Patients prescribed clozapine n=157

Consultants prescribing clozapine n=18

GP practices n=47

Table 1. Number of patients prescribed clozapine, consultants prescribing clozapine and GP practices identified in the audit

Patients registered with a GP n=112 (71.3%)

Patients not registered with a GP n=19 (12.1%)

Unknown n=26 (16.6%)

Table 2. GP practice registration status of patients prescribed clozapine (n=157)

secondar y care. Fur thermore, clozapine is associated with a number of significant and common drug interactions, eg nicotine in cigarettes decreases patients’ blood levels of clozapine. Therefore the physical health of patients prescribed clozapine needs to be monitored closely.

Methods An audit was designed to investigate whether GP practices knew which of their patients are prescribed clozapine by consultant psychiatrists, and whether these patients were identified on their SMI registers. Data collection was undertaken at St Charles’ Hospital, par t of Central and Nor th West London NHS Foundation Trust, by one of the authors as part of her pharmacy preregistration training programme. Data were collected for all patients who received their supplies of clozapine through the St Charles’ Hospital pharmacy services. The audit was based on one previously conducted in Derbyshire Mental Health Ser vices Trust. 18 The following questions were asked: • Is this patient on your SMI register? • Is there a record that the patient is taking clozapine, which is prominent and obvious at each consultation? • Is the GP aware that the patient

is receiving supplies of clozapine from the local hospital pharmacy? Audit standards There is no national standard for recording clozapine in patients’ primar y care notes so the standard was agreed locally, as follows: • 100% of patients prescribed clozapine must be listed on their GP practices SMI register. • 100% of these patients must have clozapine documented in their medical notes. Procedure All patients prescribed clozapine from the local mental health unit were identified from the mandatory clozapine monitoring service database. GP contact details for all these patients were retrieved from the Trust’s electronic medical records database. Questionnaires were faxed to the identified GP practices for completion, and these were returned by fax.

Results A total of 157 patients were identified as being prescribed clozapine, by 18 consultant psychiatrists (see Table 1). The youngest patient was 20 years old and the oldest was 84 years old. Questionnaires were faxed to 47 GP surgeries, of which 41 responded, giving a response rate

12 Progress in Neurology and Psychiatry

of 87 per cent. GP practices had between one and seven patients each. A total of 10 patients were admitted as in-patients at the time of the audit. Data were collected for 131 of the 157 patients, and it was not possible to identify a GP for the remaining 26 patients via the routine source (the Trust’s electronic patient records system). Of the 131 patients for whom a GP could be identified, 112 (85 per cent) patients were currently registered with the GP, and 19 (15 per cent) were not registered with the named GP (see Table 2). GP practice responses to the three questions are described in Table 3. The majority of patients registered with a GP (100/112, 89 per cent) were listed on the practice’s SMI register, although a number of patients (12/112, 11 per cent) were not. Just over half (62/112, 55 per cent) of the patients had documentation in their medical notes indicating that they were prescribed clozapine, and the remainder (50/112, 45 per cent) did not have documentation. Of the patients who had documentation in their notes that they were prescribed clozapine, nearly all (59/62, 95 per cent) were known to be getting these supplies of clozapine from the named local hospital pharmacy department.

Discussion It would be expected that all patients would be registered with a GP; however, in some cases (17 per cent) this could not be established. These patients may have been registered with a GP, but details were not documented and readily available on the electronic patient record system. A further 12 per cent of patients were known not to be registered with a GP. However, the majority (89 per cent) of patients who were known to be www.progressnp.com


Is the patient on the GP’s SMI register?

Yes

No

100 (89.3%)

12 (10.7%)

Is there documentation in the medical notes that the patient is prescribed clozapine?

62 (55.4%)

50 (44.6%)

Is the GP aware that clozapine supplies are from the local hospital pharmacy?

59 (52.7%)

53 (47.3%)

Table 3. GP practice records of patients prescribed clozapine (n=112)

registered with a GP, were listed on their practice’s SMI register. This was a good rate of recording, however it does not meet the audit standard of 100 per cent. Although just over half (55 per cent) of the patients had clear documentation in their GP notes that they were prescribed clozapine, nearly half did not. This suggests that there is poor communication between secondary and primary care, and that GPs may be unaware of the physical health risks associated with prescribing clozapine, and the potential for interactions. The ‘Yes’ response rate to the question ‘Is the GP aware that clozapine supplies are from the local hospital pharmacy?’ was very similar to that of the question ‘Is there documentation in the medical notes that the patient is prescribed clozapine?’ suggesting that once a GP was aware that a patient was prescribed clozapine, they also knew the pharmacy supplying it, in this case St Charles’ Hospital pharmacy. Given the high response rate to the questionnaire (87 per cent), and the fact that the results were consistent with those found in the original audit conducted in Derby,18 it is likely that these findings are a true reflection of rates of recording throughout our Trust, and probably nationally. Study limitations Although there was a good response rate from GP surgeries,

a few practice managers refused to disclose information about patients, as they felt mental illness was a sensitive topic and that the patient had the right to confidentiality unless the information needed was clinically necessar y specific to the individual’s care. This is not in keeping with the NHS Code of Practice on Confidentiality,19 and limited data collection.

Conclusions Patients who are prescribed clozapine have a significant and severe mental illness (usually treatmentresistant schizophrenia) and have significant physical health risks due numerous factors including their diagnosis and the use of clozapine.17 Their care requires close liaison and communication between primar y and secondar y care services. In our audit, nearly all patients prescribed clozapine were listed on their GP practice’s SMI register. However, 45 per cent of patients did not have clear documentation in the GP records that they were prescribed clozapine – this could potentially have significant implications for the management and monitoring of their physical and mental health. Efforts need to be made by both secondar y and primar y care to ensure effective communication about the prescription of clozapine in order


to optimise patient safety, and to minimise risks.

Further work In response to these findings, a local action plan has been drawn up to ensure that: • Consultant psychiatrists and care co-ordinators inform GPs of all patients currently prescribed clozapine • During CPA reviews, the prescription of clozapine is highlighted, and clearly documented in the CPA record • All patients who have been prescribed clozapine have this clearly documented in their GP medical records, in a manner that is prominent and obvious and at every consultation • All patients prescribed clozapine are listed on their GP practice’s SMI register, as per the QOF standard3 • Patients’ full GP details are correctly recorded on the Trust’s electronic patient record system. Following implementation of these actions, we plan to re-audit in approximately a year’s time, to complete the audit cycle.

Acknowledgments Many thanks to Dave Branford, Chief Pharmacist and Rebecca Potter, Specialist Clinical Pharmacist, Derbyshire Mental Health Services Trust (DMHST), for devising the original audit.18 Portia Somasunderam is a Pre-registration Pharmacist, St Charles Hospital, Central and North West London NHS Foundation Trust and Caroline Parker is a Consultant Pharmacist of Adult Mental Health, Central and North West London NHS Foundation Trust

Conflicts of interest None. www.progressnp.com

Letters References 1. National Institute for Health and Clinical Excellence. Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care (update). National Clinical Practice Guideline Number 82. London: NICE, March 2009. 2. National Service Framework for Mental Health. London: Department of Health, 1999. 3. Quality and Outcomes Framework guidance for GMS contract 2009/10. GMS Contract, March 2009. http://www.wales.nhs.uk/sites3/page.cfm?orgid=480& pid=6063 4. Marder SR, Wirshing DA. Maintenance treatment. In Schizophrenia. 2nd edn. SR Hirsch, DR Weinberger, eds. Oxford: Blackwell, 2003. 5. Saha S, Chant D, Mcgrath J. Meta-analyses of the incidence and prevalence of schizophrenia: conceptual and methodological issues. Int J Methods Psychiatr Res 2008;17:55-61. 6. Burns T, Cohen A. Item-of-service payments for general practitioner care of severely mentally ill persons: does the money matter? Br J Gen Pract 1998; 48(432):1415-6. 7. Kendrick T, Burns T, Freeling P. Randomised controlled trial of teaching general practitioners to carry

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Importance of diagnosing sleep disorders In his article ‘Errors in the recognition and diagnosis of sleep disorders’ in the November December issue of Progress,1 Professor Stores discusses an important topic of relevance to clinical practice in psychiatr y. We were particularly interested in the section on risk of misdiagnosis of obstructive sleep apnoea (OSA). A variety of psychiatric disorders such as delirium, psychosis,

out structured assessments of their long term mentally ill patients. BMJ 1995;31:93-8. 8. Jeffreys SE, Harvey CA, McNaught AS, et al. The Hampstead Schizophrenia Survey 1991. I: Prevalence and service use comparisons in an inner London health authority, 1986-1991. Br J Psychiatry 1997; 170:301-6. 9. Kendrick T, Burns T, Garland C, et al. Are specialist mental health services being targeted on the most needy patients? The effects of setting up specialist services in general practice. Br J Gen Practice 2000;50:121-6. 10. Rodgers J, Black G, Stobbart A, et al. Audit of primary care of people schizophrenia in general practice in Lothian. Quality in Primary Care 2003;11:133-40 11. Nazareth I, King M, Haines A, et al. Accuracy of diagnosis of psychosis on a general practice computer system. Br Med J 1993;307:32-4. 12. Lang FH, Forbes JF, Murray GD, et al. Service provision for people with schizophrenia. Clinical and economic perspective. Br J Psychiatry 1997;171:159-64. 13. Lang F, Johnstone E, Murray D. Service provision for people with schizophrenia. Role of the general practitioner. Br J Psychiatry 1997;171:165-8. 14. Kai J, Crosland A, Drinkwater C. Prevalence of

enduring and disabling mental illness in the inner city. Br J Gen Practice 2000;50:922-4. 15. Bindman J, Johnson S, Wright S, et al. Integration between primary and secondary services in the care of the severely mentally ill: patients’ and general practitioners’ views. Br J Psychiatry 1997;171: 169-74. 16. Burns T, Greenwood N, Kendrick T, et al.Attitudes of general practitioners and community mental health team staff towards the locus of care for people with chronic psychotic disorders. Primary Care Psychiatry 2000;6:67-71. 17. Marder S, et al. Physical health monitoring of patients with schizophrenia. Am J Psychiatry 2004; 161:1334-49. 18. Potter R,Titterton J,Tuplin L, et al. Interface Audit: GP practice recording of clozapine and SMI registers. Joint working between Derby City PCT, Derbyshire County PCT and Derbyshire Mental Health Services Trust (DMHST). 10 September 2008. 19. Confidentiality - NHS Code of Practice. London: Department of Health, November 2003.. http://www.dh.gov.uk/prod_consum_dh/groups/ dh_digitalassets/@dh/@en/documents/digitalasset/ dh_4069254.pdf

depression and cognitive impairment are known to be associated with OSA.2-5 Sometimes, the primar y presentation of people with OSA to health care services is with a psychiatric disorder. We refer to a case report6 of a patient with an unusual presentation of OSA. Over many years, he was assessed and treated by a GP, a physician, a psychologist and a psychiatric nurse at different points in time. His main symptoms were irritability, anger outbursts, clumsiness and short-term memory deficits. He was given a variety of differential diagnoses including early frontal lobe dementia, organic personality disorder and anxiety disorder. The patient’s wife eventually provided a histor y of her husband exhibiting motor and verbal agitation during sleep. The patient also complained of excessive daytime drowsiness. Onward referral and further assessment at the local Sleep Disorders Clinic confirmed the diagnosis of OSA. Following treatment with continuous positive air ways pressure (CPAP), he showed a remarkable improvement. Often, assumptions are made that sleep disturbance is due to an

underlying psychiatric condition or a side-effect of psychotropic medication. We therefore agree with Professor Stores’ recommendation to clinicians that obtaining a detailed sleep history and other relevant information would reduce the risk of misdiagnosis of sleep disorders.


Dr Sanjana Nyatsanza, Consultant Psychiatrist and Dr Vinay Sudhindra Rao, ST6 Psychiatrist, Older People’s Mental Health Services, Peterborough, Cambridgeshire and Peterborough Foundation Trust References 1. Stores G. Errors in the recognition and diagnosis of sleep disorders. Progress in Neurology and Psychiatry 2009;13(6):24-33. 2. Munoz X, Marti S, Sumalla J, et al. Acute delirium as a manifestation of obstructive sleep apnoea syndrome. Am J Respiratory Critical Care Med 1998;158 (4):1306-7. 3. Berrettini WH. Paranoid psychosis and sleep apnoea syndrome. Am J Psychiatry 1980;137(4):493. 4. Schroder CM, O’Hara R. Depression and obstructive sleep apnea (OSA). Ann Gen Psychiatry 2005;4-13. 5. Findley LJ, Barth JT, Powers DC, et al. Cognitive impairment in patients with obstructive sleep apnoea and associated hypoxemia. Chest 1986;90:686-90. 6. Nyatsanza S, Ganapathy K, Menon V, Smith I. An unusual presentation of obstructive sleep apnoeas. BMJ Case Reports 2009;doi:10.1136/bcr.12.2008.1336. ( w w w. c a s e re p o r t s . b m j . c o m / c o n t e n t / 2 0 0 9 / bcr.12.2008.1336.abstract) www.progressnp.com