The TOP (Treatment Optimization of Psychosis) Collaborative is a quality improvement (QI) project that aims to systematically implement, measure, and share best practices in the treatment of psychosis. Teams from across the VCH region will come together to achieve similar goals over the course of 12 months – connecting people living with psychosis with the best possible treatment, care, and monitoring in their community.
The goal of the TOP Collaborative is to improve outcomes for our clients with schizophrenia/schizoaffective disorder by connecting them with the best treatment options, alongside follow-up care and monitoring in the community.
Treatment optimization of psychosis (TOP) has the potential to improve the health of individuals and their quality of life, in addition to decreasing acute health care utilization, risk to self, and encounters with the legal system. Research has shown that clozapine, for instance, is associated with 18.6 fewer inpatient days per year per client treated.
In VCH, psychosis is a leading cause of readmission to acute psychiatry within 30 days of discharge, a standard metric for quality care. Treatment of psychosis in community settings is primed for a quality improvement project of this type that will introduce new standardized approaches to monitoring adherence and retention in treatment, with increased use of compliance aids, long-acting antipsychotic medications and, when necessary, clozapine.
The TOP Collaborative will follow the Breakthrough Series (BTS) Collaborative methodology developed by the Institute of Healthcare Improvement (IHI).
The TOP Collaborative will create a community of learning in which teams collaborate with each other to discuss common issues, share ideas and common challenges, and spread best practices to offer the best possible treatment and care to people living with psychosis. Throughout the Collaborative, team participants will maintain contact with each other and the TOP project team through monthly meetings, quarterly in-person learning sessions, teleconference calls, electronic mailing list, emails, webinars, and website access.
The safety profile of clozapine is well known. Serious adverse reactions such as agranulocytosis and cardiomyopathy have led to early recommendations of hospital admission when initiating clozapine. However, such severe adverse reactions are very rare (at 0.3% for agranulocytosis and 1-3% for cardiomyopathy) and early recognition and treatment has improved significantly since they were first recognized.
Data from the 1990s to today proves clozapine can be safely implemented in the community through careful selection of clients and with close monitoring and support. In VCH, clozapine is still mostly initiated in acute care settings (e.g., hospital) or subacute care settings (e.g., facilities such as Venture), which creates unnecessary barriers to appropriate treatment of psychosis, as well as being more costly to the health-care system.
Evidence from other jurisdictions in the world including the United Kingdom, Australia, New Zealand, and the US suggest that it is often safe and appropriate to initiate treatment with clozapine in community settings. In fact, overall mortality is lower for those on clozapine than in schizophrenia as a whole.
Anyone living with schizophrenia whose psychosis has not adequately responded to treatment and who is diagnosed with a treatment-resistant disorder. 100% of clients whose psychosis failed to respond to an adequate trial of >=2 antipsychotics should be offered clozapine. Of the clients who are eligible for a clozapine start in the community and who accept the treatment, the goal is >90% will undergo titration in the community and >70% of those will reach a therapeutic dose.
Clozapine is the only treatment approved by Health Canada for people who live with treatment-resistant psychosis. However, some people may have side effects to this medication and require extra supports to succeed with it. TOP is designed to help teams develop the expertise to offer this treatment to all clients who could benefit from it. Compared with other medications, clozapine is about twice as likely to succeed in reducing symptoms and it also protects them from suicidal thoughts and early death from all causes including medical.
The goal of the TOP Collaborative is to improve outcomes for our clients with schizophrenia/ schizoaffective disorder. By June of 2022, we aim to have at least 45% of clients undergoing clozapine treatment show an improvement in their functioning as assessed by HONOS score and at least 45% of clients undergoing clozapine treatment have a 20% or more improvement in symptoms, as assessed by standardized rating instruments.
TOP will focus on optimizing schizophrenia treatment and on improving management of Treatment Resistant Schizophrenia (TRS) by shifting clozapine initiation from hospital to community settings by building capacity at each community mental health team.
You’re right, the aims are focused on clozapine goals. However, how we get there is not all about clozapine. The process we take to meet these goals involves making sure that our clients are screened appropriately and accurately: as having treatment resistant schizophrenia and having been offered an adequate treatment of other antipsychotic medications, such as depot medications. We do have clozapine focused goals because the data tells us that this is a treatment option which is underutilized in B.C. For example, in Australia and New Zealand clozapine usage is estimated to be about 30% in TRS, but only 17% in B.C.
We want to be ambitious with our targets. When we look at our goals of 100%, they simply indicate that we are offering treatment options which are appropriate for those individuals in our care. As a team, we think it is a reasonable aim to offer appropriate treatment options to 100% of clients. We chose a goal of 70% of clients to be retained on clozapine because generally that is the rate of acceptance for this medication. Since our clients will be closely supervised for the duration of titration, we should aim high. For the goals involving improvement in symptoms, we estimate that 45% will improve based on research that indicates between 30% and 60% of clients with TRS see improvement in symptoms when treated with clozapine.
There are many layers that enable teams to choose which of their clients will be part of the Collaborative. The TOP team is working with data analysts to get a list of clients from each team who we think might be the right fit for the Population of Focus (POF) for this Collaborative. We have also developed a stepwise process that clinicians can use to review their clients, and find those who will benefit from optimized psychosis treatment.
Alongside this, we are working with the PARIS team to develop clinical support tools in PARIS that will help clinicians screen clients to see who to include in the POF for their TOP Collaborative work. While this tool is being developed in PARIS, we will provide a paper version for TOP participating clinicians to use, which is a certified legal paper chart.
Clozapine is considered the standard of care for patients with TRS. It can be initiated in hospital, transitional settings, or in community, but elective admissions just for this are not the best use of resources and may be impossible to arrange. Postponing treatment until a patient requires admission is also risky as patients with uncontrolled psychosis may suffer psychosocial deterioration, loss of housing, and suicide. All clinical guidelines call for clozapine when indicated, and the CMPA has provided an opinion that clozapine can be initiated in community with a documented oral consent from the client