PERSPECTIVES OF NURSE PRACTITIONERS AND PHYSICIAN ASSOCIATES ON PRESENTING LONG-ACTING INJECTABLES TO ADULTS WITH SCHIZOPHRENIA: A DELPHI PANEL STUDY

Purpose

Healthcare providers (HCPs), including nurse practitioners (NPs) and physician associates (PAs), commonly prescribe oral antipsychotics (APs) to treat adults with schizophrenia, but daily administration requirements can present adherence challenges and limit clinical effectiveness. While long-acting injectable (LAI) APs have demonstrated improved AP adherence and clinical outcomes (e.g., reduced hospitalizations and relapses) compared with oral APs, they remain infrequently prescribed due to stigma, patient concerns and misconceptions about LAIs, and reimbursement constraints, along with limited HCP/patient awareness.

Objective

This study aims to achieve consensus on strategies for HCPs to discuss and offer LAIs to adults with schizophrenia, promote acceptance among eligible patients, and accelerate utilization of LAIs earlier in the treatment journey. This study addresses a critical knowledge gap by focusing on NP and PA perspectives, whose central roles in schizophrenia treatment and management have been underrepresented in prior research. Methodology: A 3-round double-blinded modified Delphi panel was convened, composed of NPs and PAs specializing in the treatment of adults with schizophrenia and use of LAIs in the United States. Round 1 was composed of individual 90-minute opinion-based interviews informed by literature review and expert NP, PA, psychiatrist, and patient perspectives. Insights were used to develop preliminary consensus statements for Round 2, which was a 30-minute online survey. Panelists rated their level of agreement on a 5-point Likert scale and provided feedback on the proposed statements. Round 3, in progress at the time of this submission, is a 30-minute online survey where panelists will re-rate modified statements based on Round 2 feedback. Percent agreement was defined as the proportion of panelists who responded “strongly agree” or “agree” to a given statement. Consensus was defined a priori as ≥50% agreement (50-79%: moderate consensus, ≥80%: strong consensus, 100%: unanimous).

Results

12 panelists participated in Rounds 1 and 2 (92% NPs, 83% female, 50% nonWhite). Panelists had experience in inpatient and outpatient settings, providing both in-person and telepsychiatry services, with varied tenure treating adults with schizophrenia (median: 10 years, range: 2-18 years). All 29 statements in Round 2 achieved consensus (26 strong, 7 unanimous, 3 moderate). Key HCP-related barriers to successful LAI offers included limited infrastructure for on-site LAI administration and lack of familiarity with LAIs. Perceived patient-related barriers to timely LAI initiation were concerns and misconceptions about injectable medications, insurance coverage restrictions, and transportation challenges. To address patient-related barriers, there was strong alignment on offering LAIs proactively and often in the schizophrenia treatment journey, centering conversations on patient experience, personal goals, autonomy, and both peer-to-peer and HCP-patient knowledge sharing. Panelists agreed that training on-site staff, investing in LAI inventory, and fostering external partnerships can help to overcome both patient-and HCP-related barriers, in addition to providing education on clinical and logistical aspects of LAI prescribing to HCPs.

Conclusions

These interim results highlight strong alignment among NPs and PAs specializing in the care of adults with schizophrenia on best practices for engaging in patientcentered discussions surrounding LAIs. These insights reflect actionable strategies for overcoming barriers to early LAI prescribing that can be leveraged by HCPs with all levels of experience with LAIs.