Informatics Pharmacist VA Center for Medication Safety Department of Veterans Affairs, United States
Background: Clozapine is among the most effective medications for treatment of schizophrenia and is the best treatment for thousands of Veterans enrolled with the Department of Veterans Affairs (VA), despite the risks of severe neutropenia associated with treatment. The VA combines real-time alerting with long-term trending to better understand the aggregate metrics driving policy decisions and their relationship to the real-patient experience.
Objectives: To implement a patient safety application capable of real-time signaling and long-term trending of mild, moderate, and severe neutropenia in our Veteran population.
Methods: Data are extracted, transformed, and loaded into a Power BI (PBI) Application from SQL databases in the VA Corporate Data Warehouse (CDW) and National Clozapine Registry. Data orchestration consists of a daily SQL Server Integration Services job, followed by incremental refreshes to PBI dataflows and datasets driving the application. Power Automate synchronizes the application with new information throughout the day.
The application consists of a series of operational reports and dashboards used by the VA Center for Medication Safety for real-time patient care and long-term tracking and trending.
9,246 Veterans treated with clozapine with Absolute Neutrophil Count (ANC) monitoring since 10/1/1999 are included. This cohort is 90.5% male, 72% white, 18.2% black, and 9.8% other/unknown. 1.24% have a reported special condition affecting ANC monitoring, including Benign Ethnic Neutropenia, Hospice, or Chemotherapy.
A full history of medications, labs, and vitals is extracted from the CDW and continually updated for each clozapine patient. Notifications occur in cases of neutropenia and clinically significant discontinuations of clozapine. Rates of mild, moderate, and severe neutropenia, and number of clinical events are measured.
Results: ANC levels [cells/µL] of 9,246 patients were monitored. Of these patients, 8.85% had an ANC under 1500, 7.77% had an ANC between 1000 and 1500, 2.33% had an ANC between 500 and 1000, and 1.16% had an ANC under 500.
For the 115 patients with special conditions*, 33 (28.7%) had an ANC between 1000 and 1500, 16 (13.91%) had an ANC between 500 and 1000, 3 (2.61%) had an ANC under 500.
A total of 966,948 ANC tests were conducted with 2,574 (0.27%) between 1000 and 1500, 545 (0.06%) between 500 and 1000, and 331 (0.03%) under 500.
The new alert system identified all 278 instances of neutropenia and all 85 clinical discontinuations to date.
*Special condition data limited due to underreporting
Conclusions: The VA leverages a modern informatics infrastructure to track, trend, and intervene upon clozapine induced neutropenia in the Veteran population, both at the individual patient and the national healthcare system levels.
