Best practices in Tardive Dyskinesia (TD) identification and management among psychiatry and neurology clinicians have historically been suboptimal. The gaps in practice include a lack of awareness of TD coupled with not routinely utilizing diagnostic tools for the monitoring and assessment of at-risk patient populations. With the approval of the first TD pharmacotherapies, vesicular monoamine transporter 2 (VMAT2) inhibitors, there is now an opportunity to substantially improve patient outcomes by educating these same clinicians on appropriate use and therapeutic decision making. This educational curriculum was designed with multiple components, including a TD360 website to be a central hub for all of the educational material and adjunct resources. Other modalities incorporate patient and caregiver videos, a journal club, various live meetings throughout the Psych Congress network in addition to online modules. The TD360 curriculum was launched in 2018 and continues today by reinforcing previous learning with a greater focus on quality of life impacts on TD patients and their caregivers, and addressing COVID-19 challenges in TD patients. Learning outcomes for 2018 and 2019 are the primary focus of this poster with some 2020 data included. Clinician learners have been educated through multiple interventions throughout the curriculum.
The educational curriculum has evolved to include covering the following four objectives. Upon completion of education, clinician learners should be able to implement routine screening tools into practice, such as the AIMS exam to identify TD in patients on atypical antipsychotics. Then, utilize available pharmacotherapies for the treatment of TD. Next, realize quality of life impacts of TD on patients and their families. Finally, adjust care of TD patients via telemedicine as a result of the COVID-19 pandemic.
The curriculum consisted of multiple modalities in order to facilitate various learning styles in addition to optimal targeting of a diverse clinician audience. The live meetings consisted of Elevate by Psych Congress, which is focused on early-career psychiatry clinicians, Psych Congress Regionals Meetings, which are focused on community-based psychiatry and primary care clinicians, Psych Congress, which is focused on the broad spectrum of psychiatry clinicians, Practicing Clinicians Exchange (PCE) regional meetings focused on primary care nurse practitioners and physician assistants, the College of Psychiatric and Neurologic Pharmacists (CPNP) annual meeting, and the American Psychiatric Nurses Association (APNA) annual meeting. There were also multiple online initiatives that were produced within the Psych Congress network as well as in conjunction with other educational partners, such as Medscape.
The targeted audience was broad within the psychiatry, neurology and primary care specialties, which includes physicians, nurse practitioners, physician assistants, nurses and pharmacists.
Increases in Knowledge and Competence
There were significant increases seen across test questions in regard to knowledge and competence in clinician behavior and practice. Five of the learner outcomes’ questions were highlighted and analyzed further. First, clinician learners increased their knowledge surrounding a patient barrier to care and clinician misconception around antipsychotic treatment and initiating VMAT2-inhibitor therapy with an increase of 56 percent in the post-test response. However, this also highlights a remaining deficit to be addressed in future educational programming. Second, clinician learners’ own self report of their ability to address multiple barriers to long-term VMAT2-inhibitor treatment, including barriers related to patient access of treatment, patient adherence to treatment and clinician management of adverse events was significantly increased by 254 percent after the education. Third, clinicians self-reported confidence in their ability to provide successful ongoing management of VMAT2-inhibitor treatment also showed a significant increase of 305 percent after the education. Fourth, clinician learners’ knowledge of the appropriate frequency of conducting an AIMS exam increased 491 percent following the education. Last, clinician learners’ knowledge of the criteria for diagnosis of TD had an increase of 84 percent, indicating a remaining deficit.
Learners Intent to Change
Clinician learners provided insight into what their intended changes to practice would be following the education. First, 67 percent of clinician learners stated they would now consider VMAT2-inhibitor treatments as an option for TD patients. This was an increase from 45 percent the previous year. Second, 63 percent of clinician learners stated they would utilize the AIMS exam as a screening tool to diagnose TD more frequently in their patients on antipsychotics. This was an increase from 52 percent the previous year. Third, 50 percent of clinician learners stated they would engage in patient support and follow-up strategies that would promote long-term VMAT2-inhibitor adherence. Fourth, 49 percent of clinician learners would now monitor patients taking VMAT2 inhibitors for emergent adverse effects at every intervention. Fifth, 46 percent of clinician learners stated they would address patient- and access-related barriers to VMAT2-inhibitor treatment initiation. Last, 42 percent of clinician learners will conduct routine assessment of VMAT2-inhibitor treatment efficacy and tolerability for individualized dose optimization on patient follow-up visits.
Learners Barriers to Change
Clinician leaners identified multiple barriers to implementing their intended practice changes. 62 percent noted insurance, 35 percent noted affordability, 27 percent noted formulary placement, 17 percent noted lack of patient adherence to medications and 13 percent noted lack of time and/or resources.
Future Educational Needs Identified
As a result of this initial learner outcomes analysis of an ongoing educational curriculum, further programming is warranted. First, the American Psychiatric Association (APA) recently issued guidelines in 2020. In this guidance, APA recommends that:
o “Patients who have moderate to severe or disabling tardive dyskinesia associated with antipsychotic therapy be treated with a reversible inhibitor of the vesicular monoamine transporter2 (VMAT2).”
o “Treatment with a VMAT2 inhibitor can also be considered for patients with mild tardive dyskinesia based on factors such as patient preference, associated impairment, or effect on psychosocial functioning.”
o “Deutetrabenazine or valbenazine are preferred over tetrabenazine because of greater evidence base supporting their use.”
o “Anticholinergic medications do not improve and may even worsen tardive dyskinesia in addition to producing significant side effects.”
o “A lower dose of antipsychotic medication can be considered, although evidence for this approach is minimal and the potential for benefit needs to be weighed against the possibility of recurrent symptoms or relapse.”
Next, clinician learners still have remaining questions on which VMAT2 inhibitor to utilize yet there is no specific guidance on this, so it often is decided based on outside factors, such as the patient’s health insurance coverage, treatment costs and formulary placement in addition to ease of use. These barriers are in the top identified by clinician learners. Therefore, education targeted to managed care decision makers is key to overcoming obstacles to long-term VMAT2-inhibitor treatment.
Last, challenges associated with COVID-19 have provided additional barriers to clinicians, particularly in providing an AIMS exam via telemedicine. Education on how to overcome barriers to care is essential; therefore, an additional online series was developed promptly.