1
|
Candon M, Shen S, Rothbard A, Reed A, Everett M, Demp N, Weingartner M, Fadeyibi O. Incorporating clinician insight and care plans into an audit and feedback initiative for antipsychotic prescribing to Medicaid-enrolled youth in Philadelphia. BMC Health Serv Res 2024; 24:574. [PMID: 38702737 PMCID: PMC11067128 DOI: 10.1186/s12913-024-11029-5] [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] [Received: 08/03/2023] [Accepted: 04/22/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Audit and feedback (A/F), which include initiatives like report cards, have an inconsistent impact on clinicians' prescribing behavior. This may be attributable to their focus on aggregate prescribing measures, a one-size-fits-all approach, and the fact that A/F initiatives rarely engage with the clinicians they target. METHODS In this study, we describe the development and delivery of a report card that summarized antipsychotic prescribing to publicly-insured youth in Philadelphia, which was introduced by a Medicaid managed care organization in 2020. In addition to measuring aggregate prescribing behavior, the report card included different elements of care plans, including whether youth were receiving polypharmacy, proper medication management, and the concurrent use of behavioral health outpatient services. The A/F initiative elicited feedback from clinicians, which we refer to as an "audit and feedback loop." We also evaluate the impact of the report card by comparing pre-post differences in prescribing measures for clinicians who received the report card with a group of clinicians who did not receive the report card. RESULTS Report cards indicated that many youth who were prescribed antipsychotics were not receiving proper medication management or using behavioral health outpatient services alongside the antipsychotic prescription, but that polypharmacy was rare. In their feedback, clinicians who received report cards cited several challenges related to antipsychotic prescribing, such as the logistical difficulties of entering lab orders and family members' hesitancy to change care plans. The impact of the report card was mixed: there was a modest reduction in the share of youth receiving polypharmacy following the receipt of the report card, while other measures did not change. However, we documented a large reduction in the number of youth with one or more antipsychotic prescription fill among clinicians who received a report card. CONCLUSIONS A/F initiatives are a common approach to improving the quality of care, and often target specific practices such as antipsychotic prescribing. Report cards are a low-cost and feasible intervention but there is room for quality improvement, such as adding measures that track medication management or eliciting feedback from clinicians who receive report cards. To ensure that the benefits of antipsychotic prescribing outweigh its risks, it is important to promote quality and safety of antipsychotic prescribing within a broader care plan.
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
| | - 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
| | - Abigail Reed
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mia Everett
- Community Behavioral Health, Philadelphia, PA, USA
| | - Neal Demp
- Community Behavioral Health, Philadelphia, PA, USA
| | | | | |
Collapse
|
2
|
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
|
3
|
Mackie TI, Cook S, Crystal S, Olfson M, Akincigil A. Antipsychotic Use Among Youth in Foster Care Enrolled in a Specialized Managed Care Organization Intervention. J Am Acad Child Adolesc Psychiatry 2020; 59:166-176.e3. [PMID: 31071384 DOI: 10.1016/j.jaac.2019.04.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 03/28/2019] [Accepted: 04/29/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Little is known about whether interventions implemented by specialized Medicaid managed care organizations (MMCOs) contributed to recent stabilization of antipsychotic prescribing to youths in foster care. This study examined a multimodal antipsychotic intervention implemented by a specialized MMCO for youths in foster care with routine mental health screening, health passports, elective psychiatric consultation line, and retrospective drug utilization reviews to determine whether this multimodal intervention significantly reduced antipsychotic dispensing for youths with conditions without US Food and Drug Administration (FDA)-approved indications. METHOD Employing a difference-in-differences design, intervention effectiveness for youths in foster care (age 6-17 years) compared with adopted youthss was examined. Analyses were stratified by FDA-indicated conditions, other externalizing conditions, and other internalizing conditions. Outcomes included predicted annual probabilities of any antipsychotic dispensed, antipsychotic dispensed for ≥90 consecutive days, and glucose and lipid testing. RESULTS Intervention-enrolled youths with FDA-indicated conditions, relative to comparison youths, experienced a 0.6% reduction in any antipsychotic dispensed and 3.1% increase for ≥90 consecutive days dispensed in the 2 years following implementation, both nonsignificant differences. Youths with other externalizing disorders experienced significant reductions, relative to comparison youths, in any antipsychotic dispensed (-6.3%, p < .001) and in ≥90 consecutive days dispensed (-5.5%, p < .001). Youths with other internalizing disorders experienced a significant reduction, relative to comparison youths, in any antipsychotic dispensed (-7.6%, p < .001) and in ≥90 consecutive days dispensed (-5.1%, p < .001). Glucose and lipid testing increased at statistically comparable rates for both groups. CONCLUSION MMCO implementation significantly reduced antipsychotic medications without FDA-indicated conditions prescribed to youths, while not significantly affecting antipsychotic medications prescribed to youths with FDA-indicated conditions.
Collapse
Affiliation(s)
- Thomas I Mackie
- School of Public Health, Rutgers University, Piscataway, NJ; Institute for Health, Health Care Policy, and Aging Research, Rutgers University.
| | - Sharon Cook
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University
| | - Stephen Crystal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University; School of Social Work, Rutgers University
| | - Mark Olfson
- College of Physicians and Surgeons, Columbia University, and the New York State Psychiatric Institute, New York, NY
| | - Ayse Akincigil
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University; School of Social Work, Rutgers University
| |
Collapse
|
4
|
Prior Authorization Policies and Preferred Drug Lists in Medicaid Plans: Stakeholder Perspectives on the Implications for Youth with ADHD. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2019; 46:580-595. [PMID: 30993569 DOI: 10.1007/s10488-019-00937-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This qualitative study describes how Medicaid policies create challenges for the delivery and receipt of mental health treatment for low-income youth in Georgia. We conducted focus groups with caregivers of Medicaid-enrolled children with ADHD and semi-structured interviews with providers and administrators at four safety net clinics that provided mental health care to these youth. Stakeholders reported that prior authorization policies for psychosocial services, restrictiveness of preferred drug lists, and changes in preferred drug lists in Medicaid plans created barriers to treatment continuity and quality for youth with ADHD and led to more administrative burden for safety-net clinics serving these youth.
Collapse
|
5
|
Goldberg SG, Wagner K. American Psychological Association practice guidelines for psychopharmacology: Ethical practice considerations for psychologists involving psychotropic use with children and adolescents. J Clin Psychol 2018; 75:344-363. [PMID: 30368810 DOI: 10.1002/jclp.22705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES This study discusses the implications of the American Psychological Association's 2011 Practice Guidelines for Pharmacology as they apply to psychologists working with juvenile clients. Special considerations apply due to concerns about the developmental side effects that occur when psychotropic medications are prescribed to children and adolescents. METHODS OR DESIGN This study provides recommendations for implementing each of the Practice Guidelines. Constructive criticism of the Practice Guidelines is also discussed with the aim of improving service delivery. RESULTS This study provides specific recommendations for psychologists regarding obtaining adequate knowledge about psychopharmacology to inform clients or consult with physicians. Suggestions are made for continuing education requirements for psychologists who work with juveniles. CONCLUSIONS Recommendations are made for psychologists working with juveniles to increase their knowledge of psychotropic medications for a more ethical and informed voice regarding the prescribing of such medications.
Collapse
Affiliation(s)
- Susan G Goldberg
- Department of Psychology, Duquesne University, Pittsburgh, Pennsylvania
| | - Kathryn Wagner
- VA Medical Center Mental Health Clinic, Washington, District of Columbia
| |
Collapse
|
6
|
Lee H, Song DH, Kwon JW, Han E, Chang MJ, Kang HY. Assessing the risk of type 2 diabetes mellitus among children and adolescents with psychiatric disorders treated with atypical antipsychotics: a population-based nested case-control study. Eur Child Adolesc Psychiatry 2018; 27:1321-1334. [PMID: 29460164 DOI: 10.1007/s00787-018-1123-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 02/09/2018] [Indexed: 11/26/2022]
Abstract
To examine the associations between atypical antipsychotic (AAP) exposure and the development of type 2 diabetes mellitus (T2DM) in Korean pediatric patients with psychiatric disorders, we conducted a nested case-control study using the claims data of the National Health Insurance system of Korea between 2010 and 2014. A cohort of patients with psychiatric disorders was identified, and enrollment was taken as the date of the first psychiatric diagnosis. Cases involved patients with a diagnosis of T2DM or prescriptions for glucose lowering drugs after enrollment, and the identification of T2DM was defined as the index date. We performed a conditional logistic regression analysis for matched case-control data to assess associations between AAP exposure and T2DM, and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) are presented. From 1,092,019 patients aged 2-19 years, we identified 20,263 cases with T2DM and 80,043 controls, matched by sex, age, enrollment date, and primary psychiatric diagnosis. After adjusting for comorbidities, psychotropic medication history, and the healthcare institution characteristics, the aOR of having T2DM was significantly higher in multi-AAP users compared with non-users (aOR 1.89; 95% CI 1.63-2.20). Particularly high ORs for T2DM were observed in clozapine users compared with non-users (aOR 3.47; 95% CI 1.88-6.41). We observed a linear relationship between the increase in risperidone dose and the increase in the risk of developing T2DM. Our findings suggest a significantly increased risk of developing T2DM in child or adolescent patients with psychiatric disorders exposed to AAPs compared with those not exposed to AAPs.
Collapse
Affiliation(s)
- Hankil Lee
- College of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, 85 Songdogwahak-ro, Incheon, 21983, Republic of Korea
| | - Dong-Ho Song
- Department of Psychiatry and Institute of Behavioral Science in Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Jin-Won Kwon
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, Republic of Korea
| | - Euna Han
- College of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, 85 Songdogwahak-ro, Incheon, 21983, Republic of Korea
| | - Min-Jung Chang
- College of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, 85 Songdogwahak-ro, Incheon, 21983, Republic of Korea
| | - Hye-Young Kang
- College of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, 85 Songdogwahak-ro, Incheon, 21983, Republic of Korea.
| |
Collapse
|
7
|
Lee H, Song DH, Han E, Kang HY. Nationwide Epidemiologic Study of Atypical Antipsychotic Use Among Pediatric Population with Mental Illness in Korea. J Child Adolesc Psychopharmacol 2018; 28:205-215. [PMID: 29641236 DOI: 10.1089/cap.2017.0111] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective: This population-based epidemiologic study aimed to analyze the prevalence and trends of atypical antipsychotic (AAP) use and identify factors associated with AAP prescribing among children and adolescents in Korea. Methods: Using the Health Insurance Review and Assessment Service-Pediatric Patients Sample data between 2010 and 2014, we assessed the prevalence of and secular trends in AAP use; utilization of individual AAP drug based on the type of healthcare services, healthcare institutions, and health security programs; and factors associated with AAP use. Results: The average annual prevalence of AAP use was 417 per 100,000 children and adolescents, which increased by 40% from 2010 to 2014. The major AAP drug of choice has shifted from risperidone (72.70% and 49.29% in 2010 and 2014, respectively) to aripiprazole (11.31% and 34.64% in 2010 and 2014, respectively). Quetiapine was mainly prescribed for inpatients. Therefore, hospitals have 2-3 times higher proportion of quetiapine use than clinics. A prominent difference exists in the prescribing rates and AAP drug of choice based on income level. Patients enrolled in the Medical Aid (MA) program had a higher AAP prescription rate than those enrolled in the National Health Insurance (NHI) program (adjusted odds ratio: 7.78). Moreover, MA recipients were more frequently prescribed with cheaper alternatives, such as risperidone, compared with NHI recipients. Conclusion: AAP has been increasingly used among the pediatric population in Korea. Future studies are needed to identify the causes of this increase and establish evidence on appropriate AAP use. In addition, relevant policies should be developed to ensure that low-income mentally ill children could take advantage of the best available therapy.
Collapse
Affiliation(s)
- Hankil Lee
- Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Republic of Korea
| | - Dong-Ho Song
- Department of Psychiatry and Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Euna Han
- Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Republic of Korea
| | - Hye-Young Kang
- Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Republic of Korea
| |
Collapse
|
8
|
Deutsch SA, Lynch A, Zlotnik S, Matone M, Kreider A, Noonan K. Mental Health, Behavioral and Developmental Issues for Youth in Foster Care. Curr Probl Pediatr Adolesc Health Care 2015; 45:292-7. [PMID: 26409926 DOI: 10.1016/j.cppeds.2015.08.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Youth in foster care represent a unique population with complex mental and behavioral health, social-emotional, and developmental needs. For this population with special healthcare needs, the risk for adverse long-term outcomes great if needs go unaddressed or inadequately addressed while in placement. Although outcomes are malleable and effective interventions exist, there are barriers to optimal healthcare delivery. The general pediatrician as advocate is paramount to improve long-term outcomes.
Collapse
Affiliation(s)
- Stephanie A Deutsch
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; Division of General Pediatrics, Safe Place: Center for Child Protection and Health, The Children's Hospital of Philadelphia, PA.
| | - Amy Lynch
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sarah Zlotnik
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Meredith Matone
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Amanda Kreider
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kathleen Noonan
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA
| |
Collapse
|