BRIEF
Peer
Review
of Prescribing
BY HERBERT DIAMOND, M.D., AND KARL RICKELS, M.D.
Patterns
RICHARD
in a CMHC
TISLOW,
M.D.,
has
been
developed,
studied,
must
take
in order
to dovetail
more
treatment.
More
JR.,
M.D.,
specifically,
a
of the primary antipsychotic In the course of a regular
and
introduced into clinical psychiatric practice. For the first time psychiatric clinicians have available some uniquely therapeutic medications. Out of a massive clinical experience a number of authors have identified some ubiquitous problems in the use of these medications that point to new directions prescription practices
SNYDER,
appropriately
with the state of the art (1-3). The major problems highlighted in the literature indude drug overuse and polyphanmacy-combining multiple antipsychotic on antidepressant agents, excessive pairing of antipsychotic with antidepressant agents, and overuse of antiparkinson drugs. DiMascio (4) examined prescription practices in hospital settings and discussed the “folly of polyphanmacy,” as well as many instances of inappropriate use of individual drugs. Menlis and associates (5) also studied polyphanmacy and concluded that it was not an adequate form Presented
at the
Anaheim,
annual
Calif.
meeting ,
May
of the American 5-9, 1975.
Psychiatric
Asso-
Ms. Lenore J. Diamond for tabulation for preparation of the manuscript.
au-
written by staff psychiatrists in a lange urban community mental health center (CMHC), one of us (H.D.) observed the perpetuation of practices that were incneasingly being questioned by leading clinical psychophanmacologists. Monitoring of the prescribing patterns of our dispensed staff of psychiatrists not only met some needs of managerial accountability but also aimed at an optimum and consistent use of psychotropic medications throughout the center’s service delivery system. This was an ambitious undertaking since the West Philadelphia Community Mental Health Consortium,
Inc. , is a complex, decentralized CMHC that veloped a comprehensive system of mental
of
has dehealth!
mental retardation (MH/MR) services now consisting of 18 programs in 29 facilities. The Consortium represents its community by coordinating the activities of a local planning agency and the major health and educational institutions in the catchment area. It has brought together I I institutions and their communities in a collabonative MH/MR venture in southwest Philadelphia.
Four
general
sponsibility work of
physicians
for services
and
chemotherapy that has
group
of 7 neighborhood
ization ice.
program,
and
16 psychiatrists in been
change member
components
assistance cists, who
Welfare. yet been scniptions
are are
filled then
not
the
medical
ne-
hospital-
been
central for
senv-
practices with the
of an intramural issued free
of
pharmacy in one patients on public by local pharmathe Department of
because this information had not these medical assistance preavailable
to the
Two years ago, the monthly began to be reviewed regularly by
prescription were consistent
in Pennsylvania reimbursed by
However, computerized, were
a partial of an aftercane
development that had
by the Consortium’s hospital. Prescriptions
have
the outpatient netdeveloped around a
clinics,
state of the art led to the review of prescriptions
Dr. Diamond is Medical Director, Dr. Tislow was Director of Emergency Services, Dr. Snyder is Staff Psychiatrist, and Dr. Rickels is Consultant in Psychopharmacology, West Philadelphia Community Mental Health Consortium, Inc. , P.O. Box 8076, Philadelphia, Pa. 19101. Dr. Rickels is also Director of Psychopharmacology, Philadelphia General Hospital. The authors are also with the University of Pennsylvania School of Medicine, where Dr. Diamond is Associate Professor of Psychiatry and Associate Director of the Division ofCommunity Psychiatry, Drs. Tislow and Snyder are Associates in Psychiatry, and Dr. Rickels is Professor of Psychiatry and Pharmacology. The authors wish to thank data and Ms. June Walker
of
medication. review of prescriptions
The goal of developing throughout the system that ciation,
number
thons (6-9) have investigated the use of antiparkinson with antipsychotic agents and have presented data indicating that 70% to 90% ofall patients so treated were given unnecessary prophylactic antipankinson agents to reduce on eliminate extrapynamidal-like side effects
THE MODERN ERA of psychopharmacology has evolved oven the last two decades. In this relatively short period of time a new armamentarium of effective agents
THOBURN
of
Monitoring the prescribing patterns ofpsychiatrists is a challenging and now necessary professional responsibility. The authors describe a peer review and feedback system in a decentralized CMHC, linked to continuing education in psychopharmacology, that made staffpsychiatristsfamiliar with the state of the art and accountableforpractice within its guidelines. Data are presented that confirm shifts from polypharmacy toward more appropriate use of psychotropic medications.
psychoactive
COMMUNICATIONS
director
and
Am J Psychiatry
project.
prescription summaries in a conference setting psychiatric 133:6,
staff June
1976
for
nele697
BRIEF
COMMUNICATIONS
vance
to diagnosis,
the current
treatment
literature.
of target
symptoms,
The conference
became
and
an ongo-
ing
seminar in psychopharmacology. Since monitoring the professional performance of psychiatric colleagues presented a delicate although necessary responsibility, great care was taken to cxplain the purposes of the review, i.e. , to improve prescribing skills, upgrade cane, reduce costs where possible, and enhance continuing education. The last goal was particularly emphasized and consistently reinforced, and the psychiatric group coalesced around this important educational experience. Many in the
ben of different drugs prescribed per patient and compared the results in April and May of 1973 with both April and May of 1974 and October and November of 1974. Because of staff turnover a number of physicians on the staff in 1973 were only available for the April and May comparison in 1974; we therefore chose to study
only
were square
analyses
RESULTS
process in the CMHC. considerable resistance threatening professional
Although we had anticipated to this unfamiliar and possibly exposure, we found that mi-
1973
tial reservations
gave
readily
way
to a spirited
accept-
dated to review all prescriptions on a continuing basis and to question the individual practitioners about their rationale for polypharmacy, duplication of antipsychotic or antidepressant agents, or prescription of long-term
antipankinson
back mechanism was threatening statement
medication.
A monthly
feed-
periodically
them
reviewed
physicians in the psychopharmacologist
regular
with
seminar (K.R.).
the
entire
a restaff then
group
led by our
of
consultant
METHOD
In order to study the impact of our peer review system on psychotropic medication prescription patterns, comparisons were made of two 2-month periods, one in 1973 and one cation regimens
in 1974. prescribed
We
compared in April
the and
daily mcdiMay of 1973
with those in October and November of 1974; these two periods, 18 months apart, adequately covered the implementation of the review and seminar process through its initial phase. We simply counted how many medications
were
prescribed
once,
twice,
three
times,
or four times a day, omitting all prescriptions tiepileptics and for minor tranquilizers (such pam) that could have been given appropriately
for anas diazeseveral
times
been
a day
and
therefore
would
not
have
Am J Psychiatry
133:6,
June
1976
Table
physicians
of 1973 and
then
applied
daily
medication
I summarizes
and
1974.
to
the
who
1974. Chicollected
Since
the
1973
daily
regimens dosage
for
schedules
were not routinely recorded on the early prescription summaries on readily available, many original clinical records had to be reviewed. The differences in sample size
between
1973
and
1974
can
be attributed
primarily
to an increased patient caseload in 1974 and also to some 1973 data that were not readily available. As can be seen in the table, there was a decrease in the daily frequency of drug administration, with significantly more patients prescribed once-a-day medication compared with divided-dose regimens. The shift is highly significant
three
when
times,
on
compared
four
with
times
the
a day
former
twice,
dosage
patterns
Table 2 summarizes the multiple-drug study and presents the number of drugs prescribed to individual patients during two comparable periods. As can be seen, a significant decrease in polyphanmacy had occurred-mone patients in 1974 than in 1973 were given only I or at the most 2 medications. When we examined the use of antiparkinson drugs during the same two periods, we found that of 205 patients in 1973, 138 (67%) were treated with a combination of antipsychotic and antipankinson agents, while in 1974 only 103 of 195 patients (53%) were so treated. These data indicate a significant decrease in the use of antiparkinson agents as a result of the peer review
(x28.l7,
dfl,
p
Peer
Review
of Prescribing
BY HERBERT DIAMOND, M.D., AND KARL RICKELS, M.D.
Patterns
RICHARD
in a CMHC
TISLOW,
M.D.,
has
been
developed,
studied,
must
take
in order
to dovetail
more
treatment.
More
JR.,
M.D.,
specifically,
a
of the primary antipsychotic In the course of a regular
and
introduced into clinical psychiatric practice. For the first time psychiatric clinicians have available some uniquely therapeutic medications. Out of a massive clinical experience a number of authors have identified some ubiquitous problems in the use of these medications that point to new directions prescription practices
SNYDER,
appropriately
with the state of the art (1-3). The major problems highlighted in the literature indude drug overuse and polyphanmacy-combining multiple antipsychotic on antidepressant agents, excessive pairing of antipsychotic with antidepressant agents, and overuse of antiparkinson drugs. DiMascio (4) examined prescription practices in hospital settings and discussed the “folly of polyphanmacy,” as well as many instances of inappropriate use of individual drugs. Menlis and associates (5) also studied polyphanmacy and concluded that it was not an adequate form Presented
at the
Anaheim,
annual
Calif.
meeting ,
May
of the American 5-9, 1975.
Psychiatric
Asso-
Ms. Lenore J. Diamond for tabulation for preparation of the manuscript.
au-
written by staff psychiatrists in a lange urban community mental health center (CMHC), one of us (H.D.) observed the perpetuation of practices that were incneasingly being questioned by leading clinical psychophanmacologists. Monitoring of the prescribing patterns of our dispensed staff of psychiatrists not only met some needs of managerial accountability but also aimed at an optimum and consistent use of psychotropic medications throughout the center’s service delivery system. This was an ambitious undertaking since the West Philadelphia Community Mental Health Consortium,
Inc. , is a complex, decentralized CMHC that veloped a comprehensive system of mental
of
has dehealth!
mental retardation (MH/MR) services now consisting of 18 programs in 29 facilities. The Consortium represents its community by coordinating the activities of a local planning agency and the major health and educational institutions in the catchment area. It has brought together I I institutions and their communities in a collabonative MH/MR venture in southwest Philadelphia.
Four
general
sponsibility work of
physicians
for services
and
chemotherapy that has
group
of 7 neighborhood
ization ice.
program,
and
16 psychiatrists in been
change member
components
assistance cists, who
Welfare. yet been scniptions
are are
filled then
not
the
medical
ne-
hospital-
been
central for
senv-
practices with the
of an intramural issued free
of
pharmacy in one patients on public by local pharmathe Department of
because this information had not these medical assistance preavailable
to the
Two years ago, the monthly began to be reviewed regularly by
prescription were consistent
in Pennsylvania reimbursed by
However, computerized, were
a partial of an aftercane
development that had
by the Consortium’s hospital. Prescriptions
have
the outpatient netdeveloped around a
clinics,
state of the art led to the review of prescriptions
Dr. Diamond is Medical Director, Dr. Tislow was Director of Emergency Services, Dr. Snyder is Staff Psychiatrist, and Dr. Rickels is Consultant in Psychopharmacology, West Philadelphia Community Mental Health Consortium, Inc. , P.O. Box 8076, Philadelphia, Pa. 19101. Dr. Rickels is also Director of Psychopharmacology, Philadelphia General Hospital. The authors are also with the University of Pennsylvania School of Medicine, where Dr. Diamond is Associate Professor of Psychiatry and Associate Director of the Division ofCommunity Psychiatry, Drs. Tislow and Snyder are Associates in Psychiatry, and Dr. Rickels is Professor of Psychiatry and Pharmacology. The authors wish to thank data and Ms. June Walker
of
medication. review of prescriptions
The goal of developing throughout the system that ciation,
number
thons (6-9) have investigated the use of antiparkinson with antipsychotic agents and have presented data indicating that 70% to 90% ofall patients so treated were given unnecessary prophylactic antipankinson agents to reduce on eliminate extrapynamidal-like side effects
THE MODERN ERA of psychopharmacology has evolved oven the last two decades. In this relatively short period of time a new armamentarium of effective agents
THOBURN
of
Monitoring the prescribing patterns ofpsychiatrists is a challenging and now necessary professional responsibility. The authors describe a peer review and feedback system in a decentralized CMHC, linked to continuing education in psychopharmacology, that made staffpsychiatristsfamiliar with the state of the art and accountableforpractice within its guidelines. Data are presented that confirm shifts from polypharmacy toward more appropriate use of psychotropic medications.
psychoactive
COMMUNICATIONS
director
and
Am J Psychiatry
project.
prescription summaries in a conference setting psychiatric 133:6,
staff June
1976
for
nele697
BRIEF
COMMUNICATIONS
vance
to diagnosis,
the current
treatment
literature.
of target
symptoms,
The conference
became
and
an ongo-
ing
seminar in psychopharmacology. Since monitoring the professional performance of psychiatric colleagues presented a delicate although necessary responsibility, great care was taken to cxplain the purposes of the review, i.e. , to improve prescribing skills, upgrade cane, reduce costs where possible, and enhance continuing education. The last goal was particularly emphasized and consistently reinforced, and the psychiatric group coalesced around this important educational experience. Many in the
ben of different drugs prescribed per patient and compared the results in April and May of 1973 with both April and May of 1974 and October and November of 1974. Because of staff turnover a number of physicians on the staff in 1973 were only available for the April and May comparison in 1974; we therefore chose to study
only
were square
analyses
RESULTS
process in the CMHC. considerable resistance threatening professional
Although we had anticipated to this unfamiliar and possibly exposure, we found that mi-
1973
tial reservations
gave
readily
way
to a spirited
accept-
dated to review all prescriptions on a continuing basis and to question the individual practitioners about their rationale for polypharmacy, duplication of antipsychotic or antidepressant agents, or prescription of long-term
antipankinson
back mechanism was threatening statement
medication.
A monthly
feed-
periodically
them
reviewed
physicians in the psychopharmacologist
regular
with
seminar (K.R.).
the
entire
a restaff then
group
led by our
of
consultant
METHOD
In order to study the impact of our peer review system on psychotropic medication prescription patterns, comparisons were made of two 2-month periods, one in 1973 and one cation regimens
in 1974. prescribed
We
compared in April
the and
daily mcdiMay of 1973
with those in October and November of 1974; these two periods, 18 months apart, adequately covered the implementation of the review and seminar process through its initial phase. We simply counted how many medications
were
prescribed
once,
twice,
three
times,
or four times a day, omitting all prescriptions tiepileptics and for minor tranquilizers (such pam) that could have been given appropriately
for anas diazeseveral
times
been
a day
and
therefore
would
not
have
Am J Psychiatry
133:6,
June
1976
Table
physicians
of 1973 and
then
applied
daily
medication
I summarizes
and
1974.
to
the
who
1974. Chicollected
Since
the
1973
daily
regimens dosage
for
schedules
were not routinely recorded on the early prescription summaries on readily available, many original clinical records had to be reviewed. The differences in sample size
between
1973
and
1974
can
be attributed
primarily
to an increased patient caseload in 1974 and also to some 1973 data that were not readily available. As can be seen in the table, there was a decrease in the daily frequency of drug administration, with significantly more patients prescribed once-a-day medication compared with divided-dose regimens. The shift is highly significant
three
when
times,
on
compared
four
with
times
the
a day
former
twice,
dosage
patterns
Table 2 summarizes the multiple-drug study and presents the number of drugs prescribed to individual patients during two comparable periods. As can be seen, a significant decrease in polyphanmacy had occurred-mone patients in 1974 than in 1973 were given only I or at the most 2 medications. When we examined the use of antiparkinson drugs during the same two periods, we found that of 205 patients in 1973, 138 (67%) were treated with a combination of antipsychotic and antipankinson agents, while in 1974 only 103 of 195 patients (53%) were so treated. These data indicate a significant decrease in the use of antiparkinson agents as a result of the peer review
(x28.l7,
dfl,
p
