1
|
Ray WA, Fuchs DC, Olfson M, Patrick SW, Stein CM, Murray KT, Daugherty J, Cooper WO. Antipsychotic Medications and Mortality in Children and Young Adults. JAMA Psychiatry 2024; 81:260-269. [PMID: 38019523 PMCID: PMC10687711 DOI: 10.1001/jamapsychiatry.2023.4573] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 10/05/2023] [Indexed: 11/30/2023]
Abstract
Importance Dose-related effects of antipsychotic medications may increase mortality in children and young adults. Objective To compare mortality for patients aged 5 to 24 years beginning treatment with antipsychotic vs control psychiatric medications. Design, Setting, and Participants This was a US national retrospective cohort study of Medicaid patients with no severe somatic illness or schizophrenia or related psychoses who initiated study medication treatment. Study data were analyzed from November 2022 to September 2023. Exposures Current use of second-generation antipsychotic agents in daily doses of less than or equal to 100-mg chlorpromazine equivalents or greater than 100-mg chlorpromazine equivalents vs that for control medications (α agonists, atomoxetine, antidepressants, and mood stabilizers). Main Outcome and Measures Total mortality, classified by underlying cause of death. Rate differences (RDs) and hazard ratios (HRs) adjusted for potential confounders with propensity score-based overlap weights. Results The 2 067 507 patients (mean [SD] age, 13.1 [5.3] years; 1 060 194 male [51.3%]) beginning study medication treatment filled 21 749 825 prescriptions during follow-up with 5 415 054 for antipsychotic doses of 100 mg or less, 2 813 796 for doses greater than 100 mg, and 13 520 975 for control medications. Mortality was not associated with antipsychotic doses of 100 mg or less (RD, 3.3; 95% CI, -5.1 to 11.7 per 100 000 person-years; HR, 1.08; 95% CI, 0.89-1.32) but was associated with doses greater than 100 mg (RD, 22.4; 95% CI, 6.6-38.2; HR, 1.37; 95% CI, 1.11-1.70). For higher doses, antipsychotic treatment was significantly associated with overdose deaths (RD, 8.3; 95% CI, 0-16.6; HR, 1.57; 95% CI, 1.02-2.42) and other unintentional injury deaths (RD, 12.3; 95% CI, 2.4-22.2; HR, 1.57; 95% CI, 1.12-2.22) but was not associated with nonoverdose suicide deaths or cardiovascular/metabolic deaths. Mortality for children aged 5 to 17 years was not significantly associated with either antipsychotic dose, whereas young adults aged 18 to 24 years had increased risk for doses greater than 100 mg (RD, 127.5; 95% CI, 44.8-210.2; HR, 1.68; 95% CI, 1.23-2.29). Conclusions and Relevance In this cohort study of more than 2 million children and young adults without severe somatic disease or diagnosed psychosis, antipsychotic treatment in doses of 100 mg or less of chlorpromazine equivalents or in children aged 5 to 17 years was not associated with increased risk of death. For doses greater than 100 mg, young adults aged 18 to 24 years had significantly increased risk of death, with 127.5 additional deaths per 100 000 person-years.
Collapse
Affiliation(s)
- Wayne A. Ray
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - D. Catherine Fuchs
- Department of Psychiatry and Behavioral Science, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mark Olfson
- Columbia University Irving Medical Center, New York, New York
| | - Stephen W. Patrick
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
- Vanderbilt Center for Child Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - C. Michael Stein
- Division of Rheumatology, Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
- Division of Clinical Pharmacology, Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Katherine T. Murray
- Division of Clinical Pharmacology, Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
- Division of Cardiovascular Medicine, Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - James Daugherty
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - William O. Cooper
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
- Vanderbilt Center for Child Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| |
Collapse
|
2
|
Cosme CG, Rudig NO, Borsellino PJ, Chea D, Krider RI, Durette L. Prescribed psychotropic medication patterns among treated Foster Care enrollees: a single institution study. Front Psychiatry 2024; 14:1278233. [PMID: 38274418 PMCID: PMC10808658 DOI: 10.3389/fpsyt.2023.1278233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
Background While several state-based studies have shown that children in foster care are more likely to be prescribed psychotropic medications and experience concomitant medication use both within and among medication class, these patterns have not been explored in the state of Nevada, which lacks state mandated oversight of psychotropic prescribing for foster care enrolled youth. Methods Data from an electronic medical record system from a single institution were analyzed to examine the prevalence of psychotropic prescribing and concomitant medication use in children ages 2 to 19 who were enrolled and received psychotropic prescriptions between July 2019 to June 2022. Results Out of 569 distinct psychotropic medication treatment episodes within this cohort, the most frequent psychotropic classes prescribed were non-stimulant ADHD medications (alpha-agonists and atomoxetine, 31.5%), atypical antipsychotics (22.1%), antidepressants (20.6%), and stimulants (16.0%). The use of stimulants and non-stimulant ADHD medications decreased in older age groups while the use of antidepressants and antipsychotics increased in older age groups. During the three-year period studied, 24.0% of psychotropic medications prescriptions increased in dosage. Treatments were prescribed for only one month in 43.8% of youth. In children prescribed psychotropic medications, concomitant medication use for at least 60 days occurred in 28.0% of children who had any psychotropic medication prescribed. Conclusion Within the cohort of 273 foster care enrolled subjects aged 2 to 19 years old who received psychotropic medication prescriptions, non-stimulant ADHD medications (both alpha-agonists and atomoxetine) and atypical antipsychotics were more commonly co-prescribed additional psychotropic medication compared to other co-prescribed medication categories. This study illustrates prescribing patterns in a community mental health clinic focused on judicious prescribing of psychotropic medications in foster care enrolled youth. Despite this, 41% of the youth treated in this clinic received at least one prescription for psychotropic medication, and of those, 27.8% were prescribed more than one psychotropic medication at the same time. More studies are necessary to understand the underlying causes of high prevalence of concomitant medication use and prescribing practices of psychotropic medications use in foster care involved pediatric populations.
Collapse
Affiliation(s)
- Celica Glenn Cosme
- Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, NV, United States
| | - Nathan O. Rudig
- Center for Community Solutions, Las Vegas, NV, United States
| | - Philip J. Borsellino
- Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, NV, United States
| | - Deanna Chea
- Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, NV, United States
| | - Reese I. Krider
- Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, NV, United States
| | - Lisa Durette
- Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, NV, United States
| |
Collapse
|
3
|
Monson ET, Shastri S, Chen D, Madden SL, Keeshin BR. The Utah psychotropic oversight program: collaboratively addressing antipsychotic use within youth in foster care without prior authorization. Front Psychiatry 2023; 14:1271165. [PMID: 38025462 PMCID: PMC10654962 DOI: 10.3389/fpsyt.2023.1271165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives Fostered youth have increased risk of exposure to trauma. Antipsychotic medications are often utilized within the foster care system, potentially to address problematic behaviors that may be associated with trauma. The Utah Psychotropic Oversight Program (UPOP) was formed to support prescribers and encourage evidence-based treatment approaches for fostered youth. However, it is unclear what impact an oversight program can have on a high turnover population and without tools such as prior authorization. This study evaluates 4 years of collected data from the UPOP program for efficacy and to identify future intervention targets. Methods Deidentified data were collected as a routine function of the oversight program over 4 years (01/2019-12/2022), from individuals aged 0-18 years old (total N = 8,523, 48.3% female). UPOP oversight criteria: ≤6yo + any psychotropic medication, ≥7yo + 2 or more psychotropic medications. For this analysis, youth were divided by UPOP individuals ever receiving an antipsychotic (AP) prescription (UPOP_AP; N = 755, 42.3% female) or not (UPOP_NAP, N = 1,006, 48.3% female) and non-UPOP fostered (N = 6,762, 48.9% female). Comparisons were made across demographic and clinical variables via ANOVA, Chi-square, unpaired t-test, and logistic regression. Results UPOP_AP more likely to be older males with behavioral diagnoses, increased polypharmacy, longer duration of fostering, and higher care level. AP prescription rates dropped from 52.8 to 39.1% for males and 43.3 to 38.2% in females with unchanged number of psychotropic prescriptions and care level across 2019-2022. UPOP_AP that discontinued AP treatment had fewer average psychotropic medications, but increased antidepressant and sleep prescriptions, as compared with individuals that remained on AP. Conclusion Youth within the foster care system receive antipsychotics at high rates and in an uneven distribution. Prescribing practices can change in the context of supportive oversight programs without components such as prior authorization, and without increasing the need for higher levels of care. Specific emphasis on the treatment of mood, anxiety, and sleep issues may also lead to greater success in discontinuing AP treatment. Oversight may support treatment providers while reducing exposure to medications with considerable side effect burden that could cause future comorbidity.
Collapse
Affiliation(s)
- Eric T. Monson
- Department of Psychiatry, University of Utah, Salt Lake City, UT, United States
| | - Sachi Shastri
- Medical Scholars Program, Augusta University/University of Georgia Medical Partnership, Athens, GA, United States
| | - Danli Chen
- Department of Psychiatry, University of Utah, Salt Lake City, UT, United States
- Study Design and Biostatistics Center, University of Utah, Salt Lake City, UT, United States
| | - Stacy L. Madden
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Brooks R. Keeshin
- Department of Psychiatry, University of Utah, Salt Lake City, UT, United States
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| |
Collapse
|
4
|
Chavez LJ, Richards JE, Fishman P, Yeung K, Renz A, Quintana LM, Massimino S, Penfold RB. Cost of Implementing an Evidence-Based Intervention to Support Safer Use of Antipsychotics in Youth. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:725-733. [PMID: 37261566 DOI: 10.1007/s10488-023-01273-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2023] [Indexed: 06/02/2023]
Abstract
To estimate the cost of implementing a clinical program designed to support safer use of antipsychotics in children and adolescents (youth) age 3-17 years at the time of initiating an antipsychotic medication. We calculate the costs of implementing a psychiatric consultation and navigation program for youth prescribed antipsychotic medications across 4 health systems, which included an electronic health record (EHR) decision support tool, consultation with a child and adolescent psychiatrist, and up to 6 months of behavioral health care navigation, as well as telemental health for patients (n = 348). Cost data were collected for both start-up and ongoing intervention phases and are estimated over a 1-year period. Data sources included study records and time-in-motion reports, analyzed from a health system perspective. Costs included both labor and nonlabor costs (2019 US dollars). The average total start-up and ongoing costs per health system were $34,007 and $185,174, respectively. The average total cost per patient was $2,128. The highest average ongoing labor cost components were telemental health ($901 per patient), followed by child and adolescent psychiatrist consultation ($659), and the lowest cost component was primary care/behavioral health provider time to review/respond to the EHR decision support tool and case consultation ($24). For health systems considering programs to promote safer and targeted use of antipsychotics among youth, this study provides estimates of the full start-up and ongoing costs of an EHR decision support tool, psychiatric consultation service, and psychotherapeutic services for patients and families.Trial registration: Clinicaltrials.gov, NCT03448575.
Collapse
Affiliation(s)
- Laura J Chavez
- Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Julie E Richards
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Paul Fishman
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Kai Yeung
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Anne Renz
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - LeeAnn M Quintana
- Kaiser Permanente Colorado Institute for Health Research, Aurora, CO, USA
| | | | - Robert B Penfold
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| |
Collapse
|
5
|
Ratheesh A, McGorry P. Trends in antipsychotic prescribing in children and adolescents: more is not necessarily better. Lancet Psychiatry 2023; 10:75-76. [PMID: 36638817 DOI: 10.1016/s2215-0366(23)00003-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 01/12/2023]
Affiliation(s)
- Aswin Ratheesh
- Orygen, Parkville, VIC 3052, Australia; Centre for Youth Mental Health, The University of Melbourne, Parkville, VIC, Australia.
| | - Patrick McGorry
- Orygen, Parkville, VIC 3052, Australia; Centre for Youth Mental Health, The University of Melbourne, Parkville, VIC, Australia
| |
Collapse
|
6
|
Minding the complexities of psychotropic medication management for children and youth in the foster care system: Paper 1: The facilitators and barriers to learning about trauma-informed medication management. Arch Psychiatr Nurs 2022; 41:35-42. [PMID: 36428071 DOI: 10.1016/j.apnu.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 06/24/2022] [Accepted: 07/02/2022] [Indexed: 11/20/2022]
Abstract
The phenomenon of inappropriate polypharmacy among the foster care population arises in part due to the challenges related to integrating trauma-informed principles into service delivery. It is further exacerbated by the complexity of intersecting systems in which child welfare case workers need to communicate, including foster and biological parents, social service agencies, and advocates. Yet, there is limited research about trauma-informed psychotropic medication management interventions for child welfare staff. This pilot study was conducted to evaluate a trauma-informed psychotropic medication management intervention and is reported in two manuscripts, pertaining respectively to the facilitators and barriers to learning, and perceived individual and institutional trauma responsiveness. The intervention comprised of a 2-hour-long training session for child welfare staff and a 3-month web-based curriculum for leadership personnel, aiming to increase their understanding of trauma-informed psychotropic medication management. In the first paper, we report on the facilitators and barriers to learning, grouped into three categories: teacher attributes, learner attributes, and situational factors. In the second paper, in addition to trauma responsiveness ratings, we also provide a detailed account of one participant's life experience and perceptions of the intervention provided, as an exemplar of the psychosocial facets of resilience. The ABC Medication Scale scores that measured staff knowledge, attitudes, and behaviors associated with medications used to treat mental health symptoms showed a significant change in scores following training. Based on these findings, we provide practical solutions to address situational factors that are worth considering when providing training for child welfare staff. PAPER 1 ABSTRACT: THE FACILITATORS AND BARRIERS TO LEARNING ABOUT TRAUMA-INFORMED MEDICATION MANAGEMENT: Given that foster care children experience many challenges that threaten their well-being, their physical and mental health needs tend to be greater than those of their peers who are not in foster care. However, owing to the transient nature of the foster care placements, as well as continuous changes in medical providers and counselors, the screenings, supportive interventions, and treatments they receive may be fragmented. This is particularly problematic when considering that many of these children are medicated as a means of managing their behavior. Moreover, children in foster care are also more vulnerable to having the medications and diagnoses accumulate due to frequent placement changes and lack of treatment continuity. Our research was guided by the question "What are the facilitators and barriers to learning about trauma-informed psychotropic medication management?" We developed an intervention to address the issue of inappropriate polypharmacy and examined the facilitators and barriers to learning using a mixed methods design. The facilitators to learning were instructor-specific (e.g., reputation, teaching style, capacity for selecting and implementing relevant resources), learner-specific (altruism, capacity to see personal relevance in the learning situation, desire for knowledge/competence, career advancement/recognition-seeking), and situational (immediacy/on-demand resources, reinforcement of pleasant learning experience). Barriers were largely situational (workload and family demands). Based on these findings, we provide practical strategies for addressing situational factors that are worth considering when designing training curricula aimed at child welfare staff.
Collapse
|
7
|
Bertram JE, McKanry J. Minding the complexities of psychotropic medication management for children and youth in the foster care system: Paper 2: Levels of trauma responsiveness among child welfare staff. Arch Psychiatr Nurs 2022; 41:68-73. [PMID: 36428077 DOI: 10.1016/j.apnu.2022.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Foster care children tend to have greater physical and mental health needs compared to those of their peers who are not in foster care due to many challenges that threaten their well-being. Yet, owing to frequent placement changes, their treatment may be fragmented. Moreover, if foster children are unable to provide important information about their own health status, and the same cannot be obtained from their families of origin, the resulting incomplete and/or inconsistent health history puts them at risk for unrecognized problems and conflicting diagnoses. Paradoxically, foster parents and resource providers often request psychotropic medications for children and youth in their care as a means of managing their behaviors. The phenomenon of inappropriate polypharmacy arises due in part to the difficulties related to integrating trauma-informed principles into the care process. It is further exacerbated by the complexity of intersecting systems in which child welfare case workers need to communicate including foster and biological parents, social service agencies, and advocates. In this second paper, we report on the same intervention as that discussed in the first paper, focusing on the effectiveness of the live 2-hour face-to-face training for child welfare staff and the 3-month web-based curriculum for leadership personnel in improving the participants' trauma responsiveness. RESEARCH QUESTIONS 1. What are the child welfare staff's perceptions of their own knowledge, attitudes, and communication behaviors associated with medications used to treat mental health symptoms and monitoring for side-effects of psychotropic medication use in children? 2. What is the level of trauma responsiveness among child welfare staff? METHODOLOGY AND PARTICIPANTS The ABC Medication Scale was employed to measure staff knowledge, attitudes, and behaviors associated with medications used to treat mental health symptoms before and after the intervention to determine if the training resulted in any improvements. Individual- and organizational-level trauma responsiveness was rated on a continuum of the Missouri Model: A Developmental Framework for Trauma-Informed Approaches. Artifacts of the web-based curriculum and qualitative interview data were analyzed by applying grounded theory methods. FINDINGS/RESULTS There was a significant increase in The ABC Medication Scale scores following the training. The qualitative findings further revealed that majority of the participants rated themselves as "trauma aware" or "trauma responsive" on the Missouri Model, while indicating that their agencies could work harder to become more fully trauma-informed. As trauma-informed child welfare workforce that understands the complexity and advocacy requirements of psychotropic medication management is needed, further longitudinal research is required is to assess the training effects over time. In particular, the aim should be to establish (a) how knowledge and attitude shifts correlate with greater degrees of trauma responsiveness, and (b) if and how such trainings translate into improved systems of support.
Collapse
|
8
|
Mackie TI, Schaefer AJ, Palatucci JS, Leslie LK, Crystal S, Gusmano M, Karpman HE. The Role of Formal Policy to Promote Informed Consent of Psychotropic Medications for Youth in Child Welfare Custody: A National Examination. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2022; 49:986-1003. [PMID: 35932357 PMCID: PMC9616785 DOI: 10.1007/s10488-022-01212-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 01/25/2023]
Abstract
Active participation of youth and surrogate decision-makers in providing informed consent and assent for mental health treatment is critical. However, the procedural elements of an informed consent process, particularly for youth in child welfare custody, are not well defined. Given calls for psychotropic medication oversight for youth in child welfare custody, this study proposes a taxonomy for the procedural elements of informed consent policies based upon formal and informal child welfare policies and then examines whether enacted state formal policies across the United States endorsed these elements. A sequential multi-method study design included: (1) semi-structured interviews with key informants (n = 58) primarily from state child welfare agencies to identify a taxonomy of procedural elements for informed consent of psychotropic medications and then (2) a legislative review of the 50 states and D.C. to characterize whether formal policies endorsed each procedural element through February 2022. Key informants reported five procedural elements in policy, including how to: (1) gather social and medical history, (2) prescribe the medication, (3) authorize its use through consent and youth assent, (4) notify relevant stakeholders, and (5) routinely review the consenting decision. Twenty-three states endorsed relevant legislation; however, only two states specified all five procedural elements. Additionally, the content of a procedural element, when included, varied substantively across policies. Further research and expert consensus are needed to set best practices and guide policymakers in setting policies to advance transparency and accountability for informed consent of mental health treatment among youth in child welfare custody.
Collapse
Affiliation(s)
- Thomas I Mackie
- Department of Health Policy and Management, SUNY Downstate Health Sciences University School of Public Health, 450 Clarkson Ave, Brooklyn, NY, 11203, USA.
| | - Ana J Schaefer
- Department of Health Policy and Management, SUNY Downstate Health Sciences University School of Public Health, 450 Clarkson Ave, Brooklyn, NY, 11203, USA
| | - John S Palatucci
- Rutgers School of Public Health, 683 Hoes Lane W, Piscataway, NJ, 08854, USA
| | - Laurel K Leslie
- American Board of Pediatrics, Chapel Hill, NC, USA
- Tufts University School of Medicine, 136 Harrison Ave, Boston, MA, 02111, USA
| | - Stephen Crystal
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, 112 Paterson Street, New Brunswick, NJ, 08901, USA
| | - Michael Gusmano
- College of Health, Lehigh University, 27 Memorial Drive, Bethlehem, PA, 18015, USA
| | - Hannah E Karpman
- Smith College, North Hampton, MA, 01062, USA
- University of Massachusetts Chan Medical School, Shiver Center, 55 N Lake Ave, Worcester, 01655, USA
| |
Collapse
|
9
|
Preliminary findings on the effects of medication advocacy and daily behavior ratings on prescriber behavior. BEHAVIORAL INTERVENTIONS 2021. [DOI: 10.1002/bin.1859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
10
|
Stutzman DL. Long-term use of antidepressants, mood stabilizers, and antipsychotics in pediatric patients with a focus on appropriate deprescribing. Ment Health Clin 2021; 11:320-333. [PMID: 34824957 PMCID: PMC8582767 DOI: 10.9740/mhc.2021.11.320] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/09/2021] [Indexed: 11/13/2022] Open
Abstract
It is estimated that 8% to 12% of youth are prescribed psychotropic medications. Those in foster care, juvenile justice systems, residential treatment facilities, and with developmental or intellectual disabilities are more likely to be prescribed high-risk regimens. The use of psychotropic medications in this age group is often off-label and can be associated with significant risk, warranting critical evaluation of their role. Landmark trials, pediatric-specific guidelines, and state-driven initiatives play critical roles in supporting evidence-based use of psychotropic medications in children. Overall, there is a lack of literature describing the long-term use of psychotropic medications in youth—particularly with regard to neurobiological, physical, and social changes that occur throughout development. Deprescribing is an important practice in child and adolescent psychiatry, given concerns for over-prescribing, inappropriate polytherapy, and the importance of reevaluating the role of psychotropic medications as children develop.
Collapse
|
11
|
Candon M, Shen S, Fadeyibi O, Smith JL, Rothbard A. Trends in antipsychotic prescribing for approved and unapproved indications to Medicaid-enrolled youth in Philadelphia, Pennsylvania between 2014 and 2018. BMC Psychiatry 2021; 21:524. [PMID: 34686159 PMCID: PMC8540198 DOI: 10.1186/s12888-021-03533-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/05/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Antipsychotic prescribing to Medicaid-enrolled youth has been the target of numerous policy initiatives, including prior authorization and quality monitoring programs, which often target specific populations. Whether these efforts have changed the level or composition of antipsychotic prescribing is unclear. METHODS Using 2014-2018 administrative claims data for Medicaid enrollees aged 21 years and under in Philadelphia, Pennsylvania, we measured antipsychotic prescription fills overall and for youth without an approved indication (autism, bipolar disorder, or psychosis). We then assessed whether trends differed for populations that have been targeted by policy initiatives, including younger children and foster care-enrolled youth. We also identified the most common approved and unapproved indications and examined whether the treatment duration of antipsychotic prescriptions differed based on whether the youth had an approved or unapproved indication. RESULTS Overall, the number of Medicaid youth with an antipsychotic prescription fill halved between 2014 and 2018. Youth aged 17 years and under and foster care-enrolled youth, who were targeted by prior authorization and quality improvement efforts, experienced larger declines. Roughly half of prescriptions were for unapproved indications in both 2014 and 2018; the most common unapproved indication was ADHD, and the treatment duration was shorter for unapproved indications compared to approved indications. CONCLUSIONS Antipsychotic prescribing to Medicaid-enrolled youth is declining, particularly among populations that have been targeted by policy initiatives like prior authorization and quality monitoring programs. Despite the fact that these initiatives often assess diagnostic criteria, half of antipsychotic prescriptions were for unapproved indications in both 2014 and 2018. More research is needed to gauge whether this prescribing is appropriate.
Collapse
Affiliation(s)
- Molly Candon
- Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Siyuan Shen
- Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA
| | | | - Joseph L Smith
- Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA
- HealthCore, Inc., Wilmington, DE, USA
| | - Aileen Rothbard
- Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 3rd Floor, Philadelphia, PA, 19104, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
12
|
Sheldrick RC, Cruden G, Schaefer AJ, Mackie TI. Rapid-cycle systems modeling to support evidence-informed decision-making during system-wide implementation. Implement Sci Commun 2021; 2:116. [PMID: 34627399 PMCID: PMC8502394 DOI: 10.1186/s43058-021-00218-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 09/23/2021] [Indexed: 11/10/2022] Open
Abstract
Background To “model and simulate change” is an accepted strategy to support implementation at scale. Much like a power analysis can inform decisions about study design, simulation models offer an analytic strategy to synthesize evidence that informs decisions regarding implementation of evidence-based interventions. However, simulation modeling is under-utilized in implementation science. To realize the potential of simulation modeling as an implementation strategy, additional methods are required to assist stakeholders to use models to examine underlying assumptions, consider alternative strategies, and anticipate downstream consequences of implementation. To this end, we propose Rapid-cycle Systems Modeling (RCSM)—a form of group modeling designed to promote engagement with evidence to support implementation. To demonstrate its utility, we provide an illustrative case study with mid-level administrators developing system-wide interventions that aim to identify and treat trauma among children entering foster care. Methods RCSM is an iterative method that includes three steps per cycle: (1) identify and prioritize stakeholder questions, (2) develop or refine a simulation model, and (3) engage in dialogue regarding model relevance, insights, and utility for implementation. For the case study, 31 key informants were engaged in step 1, a prior simulation model was adapted for step 2, and six member-checking group interviews (n = 16) were conducted for step 3. Results Step 1 engaged qualitative methods to identify and prioritize stakeholder questions, specifically identifying a set of inter-related decisions to promote implementing trauma-informed screening. In step 2, the research team created a presentation to communicate key findings from the simulation model that addressed decisions about programmatic reach, optimal screening thresholds to balance demand for treatment with supply, capacity to start-up and sustain screening, and availability of downstream capacity to provide treatment for those with indicated need. In step 3, member-checking group interviews with stakeholders documented the relevance of the model results to implementation decisions, insight regarding opportunities to improve system performance, and potential to inform conversations regarding anticipated implications of implementation choices. Conclusions By embedding simulation modeling in a process of stakeholder engagement, RCSM offers guidance to realize the potential of modeling not only as an analytic strategy, but also as an implementation strategy.
Collapse
Affiliation(s)
- R Christopher Sheldrick
- Department of Health Law, Policy and Management, School of Public Health, Boston University, One Silber Way, Boston, MA, USA.
| | - Gracelyn Cruden
- Oregon Social Learning Center, 10 Shelton McMurphey Blvd, Eugene, OR, USA
| | - Ana J Schaefer
- SUNY Downstate Health Sciences University, 450 Clarkson Ave, Brooklyn, NY, USA
| | - Thomas I Mackie
- SUNY Downstate Health Sciences University, 450 Clarkson Ave, Brooklyn, NY, USA
| |
Collapse
|
13
|
Cruz‐Khalili A, Rapp JT. Initiating the process of providing behavioral services to foster children in inpatient facilities. BEHAVIORAL INTERVENTIONS 2021. [DOI: 10.1002/bin.1829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Amir Cruz‐Khalili
- Department of Psychological Sciences Auburn University Auburn Alabama USA
| | - John T. Rapp
- Department of Psychological Sciences Auburn University Auburn Alabama USA
| |
Collapse
|
14
|
Mead L, Ayres A, Blake JA, Scott JG. Monitoring of metabolic side-effects in children and adolescents prescribed antipsychotic medication: A systematic review. Aust N Z J Psychiatry 2021; 55:763-771. [PMID: 33951933 DOI: 10.1177/00048674211009620] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Prescribing antipsychotic medications to children and adolescents with severe mental and developmental disorders is common; however, there is a lack of consensus on appropriate metabolic monitoring for this population. This review systematically evaluates studies examining metabolic monitoring of children and adolescents prescribed antipsychotic medication to understand the clinical practice of metabolic monitoring and identify opportunities to improve the safety of antipsychotic prescribing in this population. METHODS A systematic search for original research on metabolic monitoring in children and adolescents prescribed antipsychotics was conducted in six databases (PubMed, EMBASE, PsycINFO, The Cochrane Library [Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CENTRAL], Cochrane Methodology Register and Web of Science [Science and Social Science Citation Index]) from inception to February 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were assessed for quality and findings summarised using narrative synthesis. RESULTS Fifteen papers were identified. Studies agreed on the need for metabolic monitoring; however, there was a gap between guideline-recommended practice and clinical practice. Variable rates of baseline and subsequent monitoring were reported for both physical and biochemical parameters, with particularly low rates for monitoring requiring venesection. Younger age was also associated with lower monitoring rates. Implementation of quality improvement activities (new guidelines, staff education and checklists) improved monitoring rates although the measurement of biochemical parameters still occurred in only a minority of children. CONCLUSION Despite widespread awareness and concern regarding metabolic side-effects, monitoring occurred inconsistently and infrequently, particularly for biochemical parameters requiring venesection. Monitoring of anthropometric measures (weight, body mass index and waist circumference) with escalation to more laboratory testing where metabolic concerns are identified may improve monitoring. Minimising iatrogenic harm, through reduced antipsychotic prescription where possible, is a clinical priority in this population.
Collapse
Affiliation(s)
- Laura Mead
- Metro North Mental Health, Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,Children's Health Queensland Hospital and Health Service, South Brisbane, QLD, Australia
| | - Alice Ayres
- Children's Health Queensland Hospital and Health Service, South Brisbane, QLD, Australia
| | - Julie A Blake
- Metro North Mental Health, Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - James G Scott
- Metro North Mental Health, Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,QIMR Berghofer Medical Research Institute, Herston, QLD, Australia.,Queensland Centre for Mental Health Research, Wacol, QLD, Australia
| |
Collapse
|
15
|
Davis DW, Lohr WD, Feygin Y, Creel L, Jawad K, Jones VF, Williams PG, Le J, Trace M, Pasquenza N. High-level psychotropic polypharmacy: a retrospective comparison of children in foster care to their peers on Medicaid. BMC Psychiatry 2021; 21:303. [PMID: 34112146 PMCID: PMC8194140 DOI: 10.1186/s12888-021-03309-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of antipsychotic medication and psychotropic polypharmacy has increased in the United States over the last two decades especially for children from low-income families and those in foster care. Although attention has been paid to providing greater insight, prescribing patterns remain concerning since there is a lack of evidence related to safety and efficacy. High-level psychotropic polypharmacy has not been described. We aim to compare the use of HLPP for children receiving Medicaid services and those in foster care and identify factors associated with the duration of use of high-level psychotropic polypharmacy. Additionally, we will examine the frequency of laboratory metabolic screening and emergency department, inpatient, and outpatient visits. METHODS A cross-sectional, secondary analysis of statewide data describes trends in high-level psychotropic polypharmacy from 2012 to 2017 and the prevalence and predictors of high-level psychotropic polypharmacy duration and resource use in 2017 for all children on Medicaid and those in foster care. High-level psychotropic polypharmacy included concurrent use, at least four classes of medications including an antipsychotic, and at least 30 days duration. RESULTS High-level psychotropic polypharmacy increased from 2012 to 2014 for both groups but stabilized in 2015-2016. Children in foster care showed a slight increase compared to their peers in 2017. There was no association between duration and demographic characteristics or foster care status. Diagnoses predicted duration. Neither group received metabolic monitoring at an acceptable rate. CONCLUSIONS Concerning patterns of high-level psychotropic polypharmacy and metabolic monitoring were identified. Cautious use of high-level psychotropic polypharmacy and greater oversight to ensure that these children are receiving comprehensive services like behavioral health, primary care, and primary prevention.
Collapse
Affiliation(s)
- Deborah Winders Davis
- Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY, 40202, Louisville, USA.
| | - W. David Lohr
- grid.266623.50000 0001 2113 1622Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY 40202 Louisville, USA
| | - Yana Feygin
- grid.266623.50000 0001 2113 1622Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY 40202 Louisville, USA
| | - Liza Creel
- grid.266623.50000 0001 2113 1622Department of Health Management & System Sciences, University of Louisville School of Public Health and Information Science, 485 E. Gray Street, Louisville, KY 40202 USA
| | - Kahir Jawad
- grid.266623.50000 0001 2113 1622Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY 40202 Louisville, USA
| | - V. Faye Jones
- grid.266623.50000 0001 2113 1622Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY 40202 Louisville, USA
| | - P. Gail Williams
- grid.266623.50000 0001 2113 1622Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY 40202 Louisville, USA
| | - Jennifer Le
- grid.266623.50000 0001 2113 1622Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY 40202 Louisville, USA
| | - Marie Trace
- grid.266623.50000 0001 2113 1622Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY 40202 Louisville, USA
| | - Natalie Pasquenza
- grid.266623.50000 0001 2113 1622Department of Pediatrics, Child and Adolescent Health Research Design and Support Unit, University of Louisville, 571 S. Floyd Street, KY 40202 Louisville, USA
| |
Collapse
|
16
|
Chavez LJ, Kelleher KJ, Beck A, Clarke GN, Penfold RB. Trends Over Time in Antipsychotic Initiation at a Large Children's Health Care System. J Child Adolesc Psychopharmacol 2021; 31:381-386. [PMID: 34143677 PMCID: PMC8233217 DOI: 10.1089/cap.2020.0190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objectives: Antipsychotic prescribing in children and adolescents increased sharply beginning in the 1990s, but recent reports among Medicaid enrollees suggest declining trends. However, few studies have included both commercially and publicly insured patients or focused on trends in new antipsychotic medications in children without documented psychotic disorders or other indicated conditions. The objective of the study was to report trends in new antipsychotic prescribing for pediatric patients (age 3-17 years) in a large children's health care system. Methods: Data were abstracted from electronic medical records (January 1, 2013 to December 31, 2017). New antipsychotic medication orders were defined as antipsychotic orders for patients without an order in the 180 days prior. Patients were excluded if the order was initiated in an emergency department or inpatient setting; they were diagnosed with psychotic disorder, mania, autism spectrum disorder, or intellectual disability; or the order was for prochlorperazine. The crude rate of new antipsychotic prescribing is reported quarterly with Poisson 95% confidence intervals in the total sample and by demographic subgroups (child vs. adolescent, female vs. male, public vs. private insurance, and white vs. nonwhite). Results: Antipsychotic orders decreased from 54.9 prescriptions per 10,000 person months in the first quarter of 2013 to 34.1 per 10,000 person months in the last quarter of 2017. Rates of antipsychotic prescribing were significantly higher for adolescents compared with children, patients who were commercially insured compared with Medicaid insured, and at most time points for white compared with non-white patients. However, prescribing rates did not differ significantly based on gender. Conclusions: Antipsychotic prescribing declined for both commercially and Medicaid-insured children in a pediatric hospital-based system, although white and commercially insured patients were more likely to be prescribed antipsychotics. More attention may be needed for reducing potentially avoidable prescribing of antipsychotics in previously understudied subgroups, such as commercially insured patients. Clinical Trial Registration Number: NCT03448575.
Collapse
Affiliation(s)
- Laura J. Chavez
- Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA.,Address correspondence to: Laura J. Chavez, PhD, MPH, Center for Innovation in Pediatric Practice, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Kelly J. Kelleher
- Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Arne Beck
- Kaiser Permanente Colorado, Institute for Health Research, Denver, Colorado, USA
| | - Gregory N. Clarke
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon, USA
| | - Robert B. Penfold
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| |
Collapse
|
17
|
Raballo A, Poletti M, Preti A. Negative Prognostic Effect of Baseline Antipsychotic Exposure in Clinical High Risk for Psychosis (CHR-P): Is Pre-Test Risk Enrichment the Hidden Culprit? Int J Neuropsychopharmacol 2021; 24:710-720. [PMID: 34036323 PMCID: PMC8453273 DOI: 10.1093/ijnp/pyab030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/19/2021] [Accepted: 05/21/2021] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Sample enrichment is a key factor in contemporary early-detection strategies aimed at the identification of help-seekers at increased risk of imminent transition to psychosis. We undertook a meta-analytic investigation to ascertain the role of sample enrichment in the recently highlighted negative prognostic effect of baseline antipsychotic (AP) exposure in clinical high-risk (CHR-P) of psychosis individuals. METHODS Systematic review and meta-analysis of all published studies on CHR-P were identified according to a validated diagnostic procedure. The outcome was the proportion of transition to psychosis, which was calculated according to the Freeman-Tukey double arcsine transformation. RESULTS Thirty-three eligible studies were identified, including 16 samples with details on AP exposure at baseline and 17 samples with baseline AP exposure as exclusion criterion for enrollment. Those with baseline exposure to AP (n = 395) had higher transition rates (29.9%; 95% CI: 25.1%-34.8%) than those without baseline exposure to AP in the same study (n = 1289; 17.2%; 15.1%-19.4%) and those coming from samples that did not include people who were exposed to AP at baseline (n = 2073; 16.2%; 14.6%-17.8%; P < .05 in both the fixed-effects and the random-effects models). Heterogeneity within studies was substantial, with values above 75% in all comparisons. CONCLUSIONS Sample enrichment is not a plausible explanation for the higher risk of transition to psychosis of CHR-P individuals who were already exposed to AP at the enrollment in specialized early-detection programs. Baseline exposure to AP at CHR-P assessment is a major index of enhanced, imminent risk of psychosis.
Collapse
Affiliation(s)
- Andrea Raballo
- Section of Psychiatry, Clinical Psychology and Rehabilitation, Department of Medicine, University of Perugia, Perugia, Italy,Center for Translational, Phenomenological and Developmental Psychopathology (CTPDP), Perugia University Hospital, Perugia, Italy,Correspondence: Andrea Raballo, MD, PhD, Section of Psychiatry, Clinical Psychology and Rehabilitation, Department of Medicine, University of Perugia Piazzale Lucio Severi 1, 06132, Perugia, Italy ()
| | - Michele Poletti
- Department of Mental Health and Pathological Addiction, Child and Adolescent Neuropsychiatry Service, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Antonio Preti
- Department of Neuroscience, University of Turin, Turin, Italy
| |
Collapse
|
18
|
Mackie TI, Schaefer AJ, Hyde JK, Leslie LK, Bosk EA, Fishman B, Sheldrick RC. The decision sampling framework: a methodological approach to investigate evidence use in policy and programmatic innovation. Implement Sci 2021; 16:24. [PMID: 33706785 PMCID: PMC7953669 DOI: 10.1186/s13012-021-01084-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 01/18/2021] [Indexed: 11/10/2022] Open
Abstract
Background Calls have been made for greater application of the decision sciences to investigate and improve use of research evidence in mental health policy and practice. This article proposes a novel method, “decision sampling,” to improve the study of decision-making and research evidence use in policy and programmatic innovation. An illustrative case study applies the decision sampling framework to investigate the decisions made by mid-level administrators when developing system-wide interventions to identify and treat the trauma of children entering foster care. Methods Decision sampling grounds qualitative inquiry in decision analysis to elicit information about the decision-making process. Our case study engaged mid-level managers in public sector agencies (n = 32) from 12 states, anchoring responses on a recent index decision regarding universal trauma screening for children entering foster care. Qualitative semi-structured interviews inquired on questions aligned with key components of decision analysis, systematically collecting information on the index decisions, choices considered, information synthesized, expertise accessed, and ultimately the values expressed when selecting among available alternatives. Results Findings resulted in identification of a case-specific decision set, gaps in available evidence across the decision set, and an understanding of the values that guided decision-making. Specifically, respondents described 14 inter-related decision points summarized in five domains for adoption of universal trauma screening protocols, including (1) reach of the screening protocol, (2) content of the screening tool, (3) threshold for referral, (4) resources for screening startup and sustainment, and (5) system capacity to respond to identified needs. Respondents engaged a continuum of information that ranged from anecdote to research evidence, synthesizing multiple types of knowledge with their expertise. Policy, clinical, and delivery system experts were consulted to help address gaps in available information, prioritize specific information, and assess “fit to context.” The role of values was revealed as participants evaluated potential trade-offs and selected among policy alternatives. Conclusions The decision sampling framework is a novel methodological approach to investigate the decision-making process and ultimately aims to inform the development of future dissemination and implementation strategies by identifying the evidence gaps and values expressed by the decision-makers, themselves. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-021-01084-5.
Collapse
Affiliation(s)
- Thomas I Mackie
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ, USA. .,Institute for Health, Health Care Policy and Aging Research, 112 Paterson Ave, New Brunswick, NJ, USA.
| | - Ana J Schaefer
- Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ, USA
| | - Justeen K Hyde
- VA Center for HealthCare Organization and Implementation Research, Boston University School of Medicine, 72 East Concord St, Boston, MA, USA
| | - Laurel K Leslie
- American Board of Pediatrics, 111 Silver Cedar Court, Chapel Hill, NC, USA.,Tufts School of Medicine, 35 Kneeland Street, Boston, MA, USA
| | - Emily A Bosk
- Rutgers School of Social Work, 390 George Street, New Brunswick, NJ, USA
| | - Brittany Fishman
- Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ, USA
| | - R Christopher Sheldrick
- Department of Health Law, Policy and Management, School of Public Health, Boston University, One Silber Way, Boston, MA, USA
| |
Collapse
|
19
|
Hilt RJ. Editorial: Best Practices in Child Antipsychotic Use Monitoring. J Am Acad Child Adolesc Psychiatry 2021; 60:24-25. [PMID: 33176169 DOI: 10.1016/j.jaac.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 11/02/2020] [Indexed: 11/16/2022]
Abstract
One major change in our field over the past 20 years has been the rapid increase and acceptance of antipsychotic use for children. Pediatric use of antipsychotics was quite rare as recently as the early 1990s, though this was followed by a roughly 6-fold increase in antipsychotic prescribing from 1996 to 2004 with continued higher use rates.1 There is, of course, nothing inherently wrong with rapidly increasing use of a drug class, particularly when it yields significant clinical results. However, alarm was raised for several reasons, such as use variations (eg, children in foster care having much higher rates of use), a majority of antipsychotic use for off-label indications, and significant cardio/metabolic medical complications from their use.2,3 Cost was another concern before generics were available; for instance, all-ages antipsychotic use at one time accounted for nearly one-third of my state's entire Medicaid pharmacy budget. These factors together drove health systems to devise and implement strategies to ensure that youth receiving antipsychotic medications were receiving them appropriately.
Collapse
Affiliation(s)
- Robert J Hilt
- Seattle Children's Hospital, University of Washington, Seattle.
| |
Collapse
|
20
|
Mackie TI, Kovacs KM, Simmel C, Crystal S, Neese-Todd S, Akincigil A. A best-worst scaling experiment to identify patient-centered claims-based outcomes for evaluation of pediatric antipsychotic monitoring programs. Health Serv Res 2020; 56:418-431. [PMID: 33369739 PMCID: PMC8143685 DOI: 10.1111/1475-6773.13610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Objective This article employs a best‐worst scaling (BWS) experiment to identify the claims‐based outcomes that matter most to patients and other relevant parties when evaluating pediatric antipsychotic monitoring programs in the United States. Data Sources Patients and relevant parties, with pediatric antipsychotic oversight and treatment experience, completed a BWS experiment, including policymakers (n = 31), foster care alumni (n = 28), caseworkers (n = 23), prescribing clinicians (n = 32), and caregivers (n = 18). Study Design Respondents received surveys with a scenario on antipsychotic monitoring programs and ranked 11 candidate claims‐based outcomes as most and least important for program evaluation. Data Analysis Stratified by respondent group, best‐worst scores were calculated to identify the relative importance of the claims‐based outcomes. A conditional logit examined whether candidate outcomes for safety, quality, and unintended consequences were preferred over reduction in antipsychotic treatment, the outcome used most often to evaluate antipsychotic monitoring programs. Principal Findings Safety indicators (eg, antipsychotic co‐pharmacy, cross‐class polypharmacy, higher than recommended doses) ranked among the top three candidate outcomes across respondent groups and were an important complement to antipsychotic treatment reduction. Foster care alumni prioritized “antipsychotic treatment reduction” and “increased psychosocial treatment.” Caseworkers, prescribers, and caregivers prioritized “increased follow‐up after treatment initiation.” Potential unintended consequences of an antipsychotic monitoring program ranked lowest, including increased use of other psychotropic medication classes (as a substitute), increased psychiatric hospital stays, and increased emergency room utilization. Results of the conditional logit model found only caregivers significantly preferred other indicators over antipsychotic treatment reduction, preferring improvements in follow‐up care (5.78) and psychosocial treatment (4.53) and reduction in prescriptions of higher than recommended doses (3.64). Conclusions The BWS experiment supported rank ordering of candidate claims‐based outcomes demonstrating the opportunity for future studies to align outcomes used in antipsychotic monitoring program evaluations with community preferences, specifically by diversifying metrics to include safety and quality indicators.
Collapse
Affiliation(s)
- Thomas I Mackie
- School of Public Health, Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, Piscataway, New Jersey, USA
| | - Katherine M Kovacs
- School of Public Health, Rutgers, The State University of New Jersey, Piscataway, New Jersey, USA
| | - Cassandra Simmel
- School of Social Work, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Stephen Crystal
- School of Social Work, Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Sheree Neese-Todd
- Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Ayse Akincigil
- School of Social Work, Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| |
Collapse
|