Department of Population Medicine, Harvard Medical School, 133 Brookline Ave., 6th Floor, Boston, MA 02215, USA.
Psychiatr Serv. 2011 Feb;62(2):186-93. doi: 10.1176/ps.62.2.pss6202_0186.
This study examined the association between a Medicaid prior-authorization policy for second-generation antipsychotic and anticonvulsant agents and medication discontinuation and health service use by patients with bipolar disorder.
A pre-post design with a historical comparison group was used to analyze Maine Medicaid and Medicare claims data. A total of 946 newly treated patients were identified during the eight-month policy (July 2003-February 2004), and a comparison group of 1,014 was identified from the prepolicy period (July 2002-February 2003). Patients were stratified by number of visits to community mental health centers (CMHCs) before medication initiation (proxy for illness severity): CMHC attenders, at least two visits; nonattenders, fewer than two. Changes in rates of medication discontinuation and outpatient, emergency room, and hospital visits were estimated.
Compared with nonattenders, at baseline CMHC attenders had substantially higher rates of comorbid mental disorders and use of medications and health services. The policy was associated with increased medication discontinuation among attenders and nonattenders, reductions in mental health visits after discontinuation among attenders (-.64 per patient per month; p<.05), and increases in emergency room visits after discontinuation among nonattenders (.16 per patient per month; p<.05). During the eight-month policy period, the policy had no detectable impact on hospitalization risk.
The prior-authorization policy was associated with increased medication discontinuation and subsequent changes in health service use. Although small, these unintended effects raise concerns about quality of care for a group of vulnerable patients. Long-term consequences of prior-authorization policies on patient outcomes warrant further investigation.
本研究考察了医疗补助计划（Medicaid）针对第二代抗精神病药和抗惊厥药的预先授权政策与双相情感障碍患者药物停用和卫生服务使用之间的关联。
采用前后设计并结合历史对照组分析了缅因州医疗补助计划和医疗保险索赔数据。在 8 个月的政策期间（2003 年 7 月至 2004 年 2 月）共确定了 946 名新接受治疗的患者，在政策前期间（2002 年 7 月至 2003 年 2 月）确定了 1014 名对照患者。根据开始用药前（代表疾病严重程度）前往社区心理健康中心（CMHC）就诊的次数将患者分层：CMHC 就诊者，至少就诊两次；非就诊者，就诊次数少于两次。估计了药物停用率以及门诊、急诊和住院就诊次数的变化。
与非就诊者相比，CMHC 就诊者在基线时有更高的合并精神障碍和用药及卫生服务使用率。该政策与就诊者和非就诊者的药物停用率增加相关，在就诊者中，停药后的心理健康就诊次数减少（每月每名患者减少 0.64 次；p<0.05），而非就诊者的停药后急诊就诊次数增加（每月每名患者增加 0.16 次；p<0.05）。在 8 个月的政策期间，该政策未对住院风险产生可察觉的影响。
预先授权政策与药物停用率增加以及随后卫生服务使用的变化有关。尽管这些影响较小，但引起了对一组弱势患者的护理质量的关注。预先授权政策对患者结局的长期影响值得进一步研究。
