The post COVID-19 healthcare landscape and the use of long-acting injectable antipsychotics for individuals with schizophrenia and bipolar I disorder: the importance of an integrated collaborative-care approach

Background Long-acting injectable antipsychotics (LAIs) are an essential maintenance treatment option for individuals with schizophrenia or bipolar I disorder (BP-I). This report summarizes a roundtable discussion on the impact of COVID-19 on the mental healthcare landscape and use of LAIs for individuals with schizophrenia or BP-I. Methods Ten experts and stakeholders from diverse fields of healthcare participated in a roundtable discussion on the impact of the COVID-19 pandemic, treatment challenges, and gaps in healthcare for individuals with schizophrenia or BP-I, informed by a literature search. Results Individuals with schizophrenia or BP-I are at increased risk of COVID-19 infection and increased risk of mortality after COVID-19 diagnosis. LAI prescriptions decreased early on in the pandemic, driven by a decrease in face-to-face consultations. Mental healthcare services are adapting with increased use of telehealth and home-based treatment. Clinical workflows to provide consistent, in-person LAI services include screening for COVID-19 exposure and infection, minimizing contact, and ensuring mask-wearing by individuals and staff. The importance of continued in-person visits for LAIs needs to be discussed so that staff can share that information with patients, their caregivers, and families. A fully integrated, collaborative-care model is the most important aspect of care for individuals with schizophrenia or BP-I during and after the COVID-19 pandemic. Conclusions The COVID-19 pandemic has highlighted the importance of a fully integrated collaborative-care model to ensure regular, routine healthcare contact and access to prescribed treatments and services for individuals with schizophrenia and BP-I.

Project ADAPT: Developing an Academic and Community Practice Collaborative Care Model for Metastatic Breast Cancer Care: A Study Design (Preprint)

BACKGROUND Metastatic breast cancer (MBC) remains incurable despite significant treatment advances. Coordinating care for patients with MBC can be challenging given the various treatment options, available clinical trials, and frequent need for ancillary services. To optimize the care of those with MBC, we designed an academic and community practice collaborative care model based on the Ending Metastatic Breast Cancer for Everyone (EMBRACE) program developed at the Dana Farber Cancer Institute entitled Project ADAPT. OBJECTIVE To describe the implementation science-based study design and innovative components of Project ADAPT. METHODS Project ADAPT utilizes the Dynamic Adaptation Process informed by the Exploration, Preparation, Implementation, and Sustainment framework. Washington University School of Medicine (WUSM) partnered with three community hospitals in the St. Louis region covering rural and urban settings. The Exploration and Preparation phases provide patient and provider feedback on current referral practices to finalize the approach for the Implementation phase. At the Implementation phase, we will enroll patients with MBC at these three community sites to evaluate potential collaborative care at WUSM and assess the impact of this collaborative care model on referral satisfaction and acceptability for patients with MBC and their providers. Patients may then return to their community site for care or continue to receive part of their care at WUSM. We are incorporating virtual and digital health strategies in our approach to improving MBC care coordination to minimize the patient burden. RESULTS The Exploration phase is ongoing. As of August 2021, we have recruited 21 patient and provider participants to complete surveys of the current collaborative care process at WUSM. Throughout this phase and in preparation for the Implementation phase, we have iteratively updated and refined our surveys for the Implementation phase based on testing of our data collection instruments. Our partner sites are in various stages of the single Institutional Review Board (IRB) approval process, which involves a signed reliance agreement between the institutions as well as a site registration and study application process. We have ongoing engagement with all partner sites, which helped solidify our participant recruitment strategies and design patient-friendly recruitment materials. In addition, we have included a patient advocate on the research team. Members of the research team have launched a single IRB Support Network at WUSM to create a repository of the single IRB procedures to streamline partner sites’ onboarding process and facilitate enhanced collaboration across institutions. CONCLUSIONS With this robust model, we expect that patients with MBC will receive optimal care regardless of geographical location and will improve the patient and provider experiences when navigating the health systems

Quantifying the Impact of Phenoconversion on Medications With Actionable Pharmacogenomic Guideline Recommendations in an Acute Aged Persons Mental Health Setting

Introduction: Polypharmacy and genetic variants that strongly influence medication response (pharmacogenomics, PGx) are two well-described risk factors for adverse drug reactions. Complexities arise in interpreting PGx results in the presence of co-administered medications that can cause cytochrome P450 enzyme phenoconversion.Aim: To quantify phenoconversion in a cohort of acute aged persons mental health patients and evaluate its impact on the reporting of medications with actionable PGx guideline recommendations (APRs).Methods: Acute aged persons mental health patients (N = 137) with PGx and medication data at admission and discharge were selected to describe phenoconversion frequencies for CYP2D6, CYP2C19 and CYP2C9 enzymes. The expected impact of phenoconversion was then assessed on the reporting of medications with APRs.Results: Post-phenoconversion, the predicted frequency at admission and discharge increased for CYP2D6 intermediate metabolisers (IMs) by 11.7 and 16.1%, respectively. Similarly, for CYP2C19 IMs, the predicted frequency at admission and discharge increased by 13.1 and 11.7%, respectively. Nineteen medications with APRs were prescribed 120 times at admission, of which 50 (42%) had APRs pre-phenoconversion, increasing to 60 prescriptions (50%) post-phenoconversion. At discharge, 18 medications with APRs were prescribed 122 times, of which 48 (39%) had APRs pre-phenoconversion, increasing to 57 prescriptions (47%) post-phenoconversion.Discussion: Aged persons mental health patients are commonly prescribed medications with APRs, but interpretation of these recommendations must consider the effects of phenoconversion. Adopting a collaborative care model between prescribers and clinical pharmacists should be considered to address phenoconversion and ensure the potential benefits of PGx are maximised.