Perceived Barriers and Facilitators of Clozapine Use: A National Survey of Veterans Affairs Prescribers

Methods

This study was conducted as a national survey of mental health providers within the VHA who had a scope of practice that allowed clozapine prescribing. Any HCP in a solely administrative role was excluded. The survey tool was reviewed by clinical pharmacy specialists at the Lexington VA Health Care System for content and ease of administration. Following appropriate institutional review board approval, the survey was submitted to the organizational assessment subcommittee and the 5 national VA unions for approval per VA policy. The survey tool was built and administered through REDCap (Nashville, Tennessee) software. An electronic link was sent out to the national VA psychiatric pharmacist and national psychiatry chief listservs for dissemination to the psychiatric providers at each facility with weekly reminders sent out during the 4-week study period to maximize participation. The 29-item survey was developed to assess demographic information, HCP characteristics, perceived barriers and facilitators of clozapine use, and general clozapine knowledge. Knowledge-based questions included appropriate indications, starting dose, baseline ANC requirement, ANC monitoring requirements, and possible AEs.

Primary outcomes assessed were perceived barriers to clozapine prescribing, opinions of potential interventions to facilitate clozapine prescribing, knowledge regarding clozapine, and the impact of medication management clinics on clozapine prescribing. For the purposes of this study, a clozapine clinic was defined as an interdisciplinary team dedicated to clozapine prescribing and monitoring.

Secondary outcomes included a comparison of clozapine prescribing rates among different subgroups of HCPs. Subgroups included HCP discipline, geographic region, presence of academic affiliation, level of comfort or familiarity with clozapine, and percentage of time spent in direct patient care. The regional Veterans Integrated Service Networks (VISN) were used to evaluate the effect of geographic region on prescribing practices.

Results of the survey were analyzed using descriptive statistics. The Mann-Whitney U test was utilized to compare ordinal data from questions that were scored on a Likert scale, and nominal data was compared utilizing the χ² test. For all objectives, an α of < .05 was considered significant.

Results

Ninety-eight HCPs from 17 VISNs responded during the 4-week survey period. One participant was excluded due to a solely administrative role. HCP characteristics and demographics are described in Table 1. The majority of respondents practice in an outpatient mental health setting either at the main VA campus or at a community-based outpatient clinic (CBOC).

Primary Outcomes

Perceived Barriers to Prescribing

The majority of survey respondents rated all factors listed as at least somewhat of a barrier to prescribing. Table 2 describes the perception of these various factors as barriers to clozapine prescribing. Along with prespecified variables, a free text box was available to participants to identify other perceived barriers not listed. Among other concerns listed in this text box were patient buy-in (11.3%), process/coordination of prescribing (8.2%), time restrictions (7.2%), prescriber restrictions (7.2%), access (3.1%), credentialing problems (2.1%), and lack of clear education materials (1%).

Perceived Facilitators to Prescribing

When asked to consider the potential for increased prescribing with various interventions, most participants reported that all identified facilitators would be at least somewhat likely to increase their clozapine utilization. Table 3 describes the perception of these various factors as facilitators to clozapine prescribing. Other identified facilitators included nursing or pharmacy support for follow-ups (4.1%), advanced practice registered nurse credentialing for VHA prescribing (3.1%), utilization of national REMS program without the NCCC (3.1%), outside pharmacy use during titration phase (2.1%), prespecified coverage for HCPs while on leave (1%), and increased access to specialty consults for AEs (1%).