A Randomized Controlled Trial of an Extension for Community Healthcare Outcomes (ECHO) Tele-mentoring Program to Increase Clozapine Utilization

Background and Hypothesis To determine whether a tele-mentoring program increases clozapine utilization by improving prescriber knowledge and perceived competence in clozapine management. Study Design In a cluster-randomized controlled design, we tested the effectiveness of an Extension for Community Healthcare Outcomes (ECHO) model-based intervention, consisting of 26 biweekly didactic and case-based tele-mentoring sessions, vs enhanced treatment as usual (eTAU), in which both conditions received access to a consultation phone line and a point of care device for on-site hematologic monitoring. Prescribers completed baseline and 12-month assessments of clozapine knowledge and competence, and prescription records were used to evaluate the effects of ECHO on prescribing and treatment persistence. Study Results 266 prescribers from 43 mental health treatment settings throughout Maryland were enrolled. Prescribers randomized to ECHO demonstrated a significant increase in clozapine knowledge compared to eTAU (P < .001), and competence increased significantly in those who attended 14 or more tele-mentoring sessions (P = .017). ECHO did not increase the likelihood of clozapine prescribing during follow-up (P = .70). While there was a 17% lower hazard of clozapine discontinuation among patients of prescribers randomized to ECHO, this did not reach statistical significance (P = .72). Conclusions A statewide tele-mentoring program increased prescriber knowledge and competence in clozapine prescribing among those attending most ECHO sessions. Median time to clozapine discontinuation was double in the ECHO group, however, neither this nor rates of prescribing were statistically significantly different from control. Additional support is needed to motivate clozapine prescribing beyond providing education and increasing confidence in clozapine management.