How to Audit LAI and Clozapine Use in Coordinated Specialty Care
How should a coordinated specialty care program review its own use of long-acting injectable antipsychotics and clozapine?
Patients with early phase schizophrenia and related disorders remain at high risk for relapse and hospitalization even in coordinated specialty care. This article shows that use of long-acting injectable antipsychotics and clozapine varies markedly across otherwise similar clinics, suggesting that some programs should treat low use as an implementation problem rather than a patient-mix issue.
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Measure the proportion of patients who receive each medication type
Calculate the proportion of your coordinated specialty care population with any antipsychotic prescription data who received an LAI at any point in treatment and the proportion who received clozapine at any point. This matches the article's approach, in which patients were counted as receiving these treatments if they received them at any point during care.
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Benchmark your rates against the EPINET ranges
Compare your program's rates with the ranges reported in EPINET. Across 8 hubs, LAI use ranged from 5.0% to 37.5% and clozapine use from 1.7% to 9.0%; across 113 clinics, LAI use ranged from 0.024 to 0.60 and clozapine from 0.005 to 0.33.
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Do not assume demographic mix explains low use
Interpret unusually low or highly variable rates cautiously because the article found that clinic-level variation in both LAI and clozapine prescribing remained significant after adjustment for sex, ethnicity, and race. That means demographics alone should not be used to dismiss a possible implementation gap.
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Review equity patterns in prescribing discussions
Examine whether prescribing discussions and access appear equitable across patient groups. In EPINET, males had higher rates than females for both LAIs and clozapine, and Black participants had higher LAI rates than White participants, while Hispanic versus non-Hispanic differences were not significant.
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Map clinic-level barriers to medication delivery
If use is low, identify local barriers the article names, including clinician attitudes and training, communication skills, supportive leadership, support services, insurance coverage, clinic resources, and prescriber expertise. For clozapine specifically, review whether mandatory hematological monitoring and intensive side-effect management create workflow barriers.
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Use implementation strategies to improve appropriate uptake
The article recommends an implementation science approach beginning with an implementation science logic model to identify clinic- and hub-level barriers and facilitators. It also highlights practice facilitation, staff education about advantages and disadvantages of LAIs, skill-building for informed discussions with patients and families, clinic reorientation to support delivery, network influence strategies, and leadership implementation strategies.
Clinical Considerations
- The article states that there are no consensus guidelines on reasonable utilization standards for LAI and clozapine use in coordinated specialty care-eligible patients.
- Variation in treatment rates can be desirable when driven by patient choice, so higher or lower rates are not automatically better.
- The dataset did not include patient, clinician, or family treatment preferences, which limits interpretation of why a given clinic's rates are low or high.
- Medication data were captured at Core Assessment Battery assessments, so prescriptions started and stopped between assessments were not included.
Bottom Line
A coordinated specialty care clinic should routinely measure its own LAI and clozapine use, compare it with EPINET variation ranges, and investigate clinic workflow barriers when evidence-based treatments appear underused.
