Implementing Clozapine Point-of-Care Fingerstick Testing in Outpatient Psychiatric Care: A Mixed Methods Study
Catherine Leonard (3), Cheryl Y. S. Foo (1,2,3), Carol Lim (1,2,4), Sarah MacLaurin (1,2,4), Corinne Cather (1,2,3), Abigail L. Donovan (1,2,3,5), Oliver Freudenreich (1,2,3)
1. Psychosis Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA
2. Harvard Medical School, Boston, MA
3. Center of Excellence for Psychosocial and Systemic Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA
4. Freedom Trail Clinic, North Suffolk Mental Health Association, Boston, MA
5. Acute Psychiatry Service, Massachusetts General Hospital, Boston, MA
Background: Despite clozapine's superior efficacy for treatment-resistant schizophrenia, it remains underutilized in part due to the burden from blood work needed to use it safely. While point-of-care fingerstick testing is an option for streamlining blood monitoring, empirical data on implementation in psychiatric settings is lacking. This study assessed its real-world uptake, patient acceptability, and associated implementation factors across two outpatient clinics in Massachusetts.
Methods: We conducted a two-site, mixed-methods study. Clozapine-treated patients receiving venipuncture or point-of-care fingerstick bloodwork were eligible to complete a survey that evaluated patient satisfaction regarding their current blood monitoring method and interest in the point-of-care fingerstick device. Rate and frequency of fingerstick testing use were extracted from electronic health record data. Interviews with clinic staff were conducted to evaluate feasibility and implementation factors impacting the use of a point-of-care fingerstick device.
Results: 28% of survey respondents (n=86) developed psychosis symptoms in the past 10 years. 22% (10/45) of clozapine-treated patients at a specialized psychosis treatment program and 60% (120/199) at a community mental health center used fingerstick testing at least once. Among survey respondents, 36% were infrequent users and 56% were non-users; these groups cited reluctance to change care, and perceived greater pain/inconvenience with fingerstick testing versus venipuncture. Non-users had taken clozapine for about seven years longer than those who tried fingerstick testing. Survey respondents had taken clozapine for a mean of 10.7 years (SD=8.1). Clinic staff cited provider burden, lack of reimbursement mechanisms, and staffing challenges as barriers to implementation; facilitators included having designated personnel for test administration.
Conclusions: When implementing point-of-care fingerstick testing, providers encountered logistical barriers related to patient acceptance, workflow, and reimbursement limitations. Programs seeking to implement point-of-care fingerstick devices should carefully consider patient preferences, duration of clozapine treatment, and staff workflow and develop a systematized patient education and shared decision-making strategy.