Is Metabolic Syndrome on the Radar?
Kingwai Lui DO, Gagandeep Randhawa, Vicken Totten MD, MS, Adam Smith, Joachim Raese MD
Kaweah Delta Health Care District
Discussion
Abstract
Phase 2
Objectives: Metabolic syndrome (MS) is a common, but underdiagnosed comorbid
condition in psychiatric patients and is exacerbated by second-generation
antipsychotics (SGAs). This study was performed to 1) to compare the detection rate
of MS at Kaweah Delta Mental Health Hospital (KDHMHH) before and after
implementation of an automated scan of the electronic medical record (EMR) for the
criteria of MS, (2) to assess psychiatrists’ response to notification of the presence of
MS in their patients, (3) to monitor acute changes in metabolic profile with SGAs.
Methods: A 3 phase study first queried the EMRs of 9100 consecutive admissions for
compliance with recommended testing and diagnosis of MS. Mandatory testing was
initiated. Phase 2 identified patients with MS, notified treating psychiatrists that the
patient met criteria. Phase 3 examined the change in therapy and discharge diagnoses
made as a result of the notification.
Results: 323 of 1178 consecutively admitted patients were diagnosed with MS.
Notification of psychiatrists of the diagnosis of MS increased the rate of noting "MS" on
the discharge summary from 0% to 38.9%. However, psychiatrist did not switch
patients with MS to drugs with a more benign metabolic profile, nor was treatment of
the components of MS improved. A subgroup of MS patients experienced a rapid
increase in triglycerides after only 3 to 17 days of continued treatment with SGAs.
Conclusions: Electronic alerts of the diagnosis of MS have limited impact on
physician’s decision making. Significant opportunities exist for the improvement of
psychiatric physician's awareness of MS and improvement of their prescribing
practices.
The following data were derived from the patient database: age,
gender, blood pressure, BMI, glucose, HDL, triglycerides, and
abdominal girth (in cm). Cases of MS were further examined for
admitting diagnosis, use of SGAs, use of medications to treat MS,
and the presence of a discharge diagnosis of metabolic syndrome
under Axis III.
Phase 3
In addition to data collection, the following changes were
implemented to increase psychiatrists’ awareness of MS:
•Secure email to inform psychiatrists that a patient met criteria for MS
•Personalized email alerts were sent to psychiatrists attending
patients with newly diagnosed MS.
•Progress note template prompting for documentation of presence of
MS, change in antipsychotic use, and /or treatment with
antihypertensive or lipid/glucose lowering drugs
Continued use of clozapine, risperidone, olanzapine, or quetiapine
after the diagnosis of MS prompted a second lipid panel and glucose
level
Methods
Electronic medical records (EMR) of 1178 patients at Kaweah Delta
Mental Health Hospital were queried between July 1st, 2014 and
January 31st, 2015. De-identified patient data was abstracted. Data
included age, gender, systolic and diastolic blood pressure, abdominal
girth (cm), body mass (BMI), fasting serum glucose, HDL, and
triglycerides.
Patients who met criteria for metabolic syndrome (MS) were classified
by DSM-IV diagnoses of psychotic disorders, bipolar disorder,
depressive disorders, and other psychiatric disorders, by treatment
status with four secondary generation antipsychotics (clozapine,
olanzapine, risperidone, and quetiapine), by a severity rating based on
the number of criteria met for MS (3 to 5), and by treatment status for
the components of MS (antihypertensive drugs, lipid lowering agents,
and hypoglycemic agents). The following criteria were used for
diagnosis of metabolic syndrome:
1) Hypertension: systolic > 130 and diastolic > 85
2) Body Mass Index (BMI) >25 or waist circumference (female > 88cm,
male >
102)
3) Fasting Glucose >110 mg/dl;
4) Fasting HDL <40 mg/dl (<50 mg/dl in females), and
5) Fasting Triglycerides >150 mg/dl.
Phase 1
The EMR of 9100 consecutive admissions were screened for tests
ordered for required for the diagnosis of MS (lipid panel, blood
glucose, and vital signs). Patients diagnosed with MS were evaluated
for completeness of treatment (1 = no treatment; 2 = partial treatment;
3 = complete treatment) of the components of metabolic syndrome
(hypertension, elevated glucose, decreased HDL, increased
triglycerides).
Results
N
Percentage
148
45.8
54
16.7
91
30
28.2
9.3
Number of MSb
criterion met
● 3
● 4
● 5
161
133
30
49.8
41.2
9.3
SGAc prescribed
on admission (n =
151)
● Clozapine
● Olanzapine
● Quetiapine
● Risperidone
6
56
37
52
4.0
37.1
24.5
34.4
SGAc prescribed
on discharge (n =
145)
● Clozapine
● Olanzapine
● Quetiapine
● Risperidone
7
52
34
52
4.8
35.9
23.4
35.9
Axis I diagnosis
on Admission
●
●
●
Psychotic
Disorders
Bipolar
Disorder
Depression
Othersa
Conclusion
Diagnosing and treating MS is of critical importance in psychiatric patients. This study
shows that metabolic syndrome is often under-diagnosed; and even when diagnosed is
rarely completely treated. Switching antipsychotic medications from SGAs to FGAs
will decrease the prevalence of MS, yet psychiatrists seem reluctant to use this
strategy. More troubling is the reluctance of psychiatrists to acknowledge and
document the diagnosis of MS. More intensive education of both psychiatrists and
consulting internists may be helpful in changing prescribing behavior, but incorporating
forcing functions into the EMR are more likely to have immediate effects.
In addition, future quality measures such as the Hospital Based Inpatient Psychiatric
Services (HBIPS) (Specification Manual for National Quality Core Measures version
2015A) may require psychiatrists to document MS. These measures may incentivize
physicians to change their prescribing choices.
References
Inpatient with MS (n=323) treated with SGAs
●
Fiver barriers may contribute to psychiatrists’ passivity in diagnosing and
treating metabolic syndrome related to antipsychotic use
-Lack of urgency
-Lack of knowledge
-Lack of familiarity
-Lack of agreement
-Cognitive dissonance
a
Others (Mood disorder NOS, adjustment disorder)
Metabolic syndrome with following criteria: 1) Hypertension: systolic > 130 and diastolic
> 85, 2) Body Mass Index (BMI) > 25, 3) Fasting Glucose > 110 mg/dL, 4) Fasting HDL
< 40 mg/dL in males (< 50 mg/dL in females), and 5) Fasting Triglycerides > 150 mg/dL
c
SGA - Second Generation Antipsychotics
b
References:
Cabana MD, Rand CS, Powe NR, et al. Why Don't Physicians Follow Clinical
Practice Guidelines? A Framework for Improvement. JAMA. 1999; 282(15):
1458-1465.
Cohn TA, Sernyak MJ (2006) Metabolic monitoring for patients treated with
antipsychotic medications. Can J Psychiatry 51: 492-501.
Grundy, S., Brewer, H., Cleeman, J., Smith, S., Lenfant, C., Association, A., &
Heart, L. (2004) Definition of Metabolic Syndrome Report of the National Heart,
Lung, and Blood Institute/American Heart Association Conference on Scientific
Issues Related to Definition. Circulation, 109: 433–438
Lett TA, Wallace TJM, Chowdury NI, Tiwari AK, Kennedy JL, Muller DJ (2012).
Pharmacogenetics of antipsychotic-induced weight gain: review and clinical
implications. Mol Psychiatry 17: 242-266.
Morrato EH, Druss B, Hartung DM, Valuck, RJ, Allen R, Campagna, E, and
Newcomer JW (2010) Metabolic testing rates in 3 state Medicaid programs after
FDA warnings and ADA/APA recommendations for second-generation
antipsychotic drugs. Archives of General Psychiatry, 67: 17-24.
Newcomer JW, Nasrallah HA, Loebel AD (2004) The atypical antipsychotic
therapy and metabolic issues national survey: practice patterns and knowledge
of psychiatrists. J Clin Psychopharmacol 24 Suppl 1: S1- S6.
Rosenheck R, Perlick D, Bingham S, Liu-Mares W, Collins J, Warren S, et all
(2003) Department of Veterans Affairs Cooperative Study Group on the CostEffectiveness of Olanzapine. Effectiveness and cost of olanzapine and
haloperidol in the treatment of schizophrenia: a randomized controlled trial
JAMA 290: 2693-2702.
Stroup TS, McEvoy JP, Swartz MS, Byerly MJ, Glick ID, Canive JM, McGee MF,
Simpson GM, Stevens MC, Lieberman JA (2003). The National Institute of
Mental Health Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE)
Project: schizophrenia trial design and protocol development. Schizophrenia
Bulletin, 29:15-31.
Sugawara N, Yasui-Furukori N, Yamazaki M, et al. Psychiatrists’ Attitudes
toward Metabolic Adverse Events in Patients with Schizophrenia. PLoS ONE
2014;9.
Walker, E., McGee, R., & Druss, B. (2015). Mortality in Mental Disorders and
Global Disease Burden Implications. JAMA Psychiatry. Doi:
10.1001/jamapsychiatry.2014.2502
Tips for Inserting Graphs or Images
Note: Skip the following procedure if your graphs were created in PowerPoint®, Illustrator (eps file) or Excel.
Insert Footer or Copyright Information Here
Image checking procedure: After you insert the image (72 dpi screen resolution) and resize* to fit, right click on it
Printed by