Article: Elaine H. Morrato, Benjamin Druss, Daniel M. Hartung, Robert J. Valuck, Richard Allen, Elizabeth Campagna, and John W. Newcomer. (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.
I have a sense that people outside of health care have trouble understanding insiders when the latter complain about the quality of health care. After all, the clinics are gleaming, they house big sleek machines, and a single procedure can generate a bill like the sticker on a Lexus. We would seem to be discussing a high end product, no?
This elegant study tells a different story. The study is about metabolic testing of patients receiving second-generation antipsychotic drugs. These drugs (e.g., olanzapine) are used to treat schizophrenia and other dire mental illnesses. They are widely used because first generation drugs (e.g., Haldol) have severe side effects, including restlessness, body tremors, and facial tics. The tragedy of serious mental illness is that part of what you see is actually the side effects of treatment. The second-generation drugs are thought to have less risk of producing these effects. Unfortunately, the second-generation drugs often have a different set of severe side effects: weight gain, hyperglycemia, and increased risk of diabetes. These side effects led the FDA to send a letter warning all physicians and recommending that they order metabolic tests to check for these effects in patients taking second generation antidepressants.
So Morrato et al. set out to see whether the FDA warning led to a change in the rates at which Medicaid patients received metabolic testing. Because the effects serious psychotic illnesses are so disabling, many patients are destitute and have care that is paid for through Medicaid. Therefore, the researchers expected that Medicaid records would show an increase in metabolic testing following the date of the letter. But, essentially nothing happened. Psychiatrists didn't increase their testing. Oddly, however, there was a change in the prescribing practices of psychiatrists. They shifted toward a drug that is thought to have less severe metabolic risks.
Why didn't psychiatrists order metabolic tests? It is not, clearly, that they were unaware of the problem, because it was widely publicized, their patients were rapidly gaining weight right before their eyes, and the FDA notice seemed to cause a modest shift toward a less risky medication. I think the problem is in what psychiatrists do, which is write prescriptions for psychoactive medications -- and apparently, almost nothing else. They can't, in general, run these tests in their offices. They could, of course, have written orders for metabolic tests to be run elsewhere. However, that would require the patients to take them somewhere to get the testing done at a lab that might, or might not, ever let the psychiatrist know the result. It doubtlessly seemed pointless, so the orders were probably rarely written or followed. The systemic problem, then, seems to be that psychiatrists seem to have only one lever in the health care system, psychopharmacology, and can't or won't do anything else. We will need to reengineer the system. A letter from the FDA will not do the trick.