Tang Yan, Horvitz-Lennon Marcela, Gellad Walid F, Lave Judith R, Chang Chung-Chou H, Normand Sharon-Lise, Donohue Julie M
Dr. Tang, who was a doctoral student at the University of Pittsburgh when this work was conducted, is with RTI International, Research Triangle Park, North Carolina (e-mail:
Psychiatr Serv. 2017 Jun 1;68(6):579-586. doi: 10.1176/appi.ps.201600041. Epub 2017 Feb 15.
Underuse of clozapine and overuse of antipsychotic polypharmacy are both indicators of poor quality of care. This study examined variation in prescribing clozapine and antipsychotic polypharmacy across providers, as well as factors associated with these practices.
Using 2010-2012 Pennsylvania Medicaid data, prescribers were identified if they wrote antipsychotic prescriptions for ten or more nonelderly adult patients with schizophrenia annually. Generalized linear mixed models with a binomial distribution and a logit link were used to examine prescriber-level annual percentages of patients with clozapine use and with long-term (≥90 days) antipsychotic polypharmacy and associated characteristics of prescribers' patient caseloads, prescriber characteristics, and Medicaid payer (fee-for-service versus managed care plans).
The study cohort included 645 prescribers in 2010, 632 in 2011, and 650 in 2012. In 2012, the mean prescriber-level annual percentage of patients with any clozapine use was 7% (range 0%-89%), and the mean percentage of patients with any long-term antipsychotic polypharmacy was 7% (range 0%-45%) (similar rates were found during 2010-2012). Prescribers with high prescription volume, a smaller percentage of patients from racial or ethnic minority groups, and a larger percentage of patients eligible for Supplemental Security Income were more likely to use both clozapine and antipsychotic polypharmacy for treating schizophrenia. Prescriber specialty and Medicaid payer were also associated with prescribers' practices.
Considerable variation was found in clozapine and antipsychotic polypharmacy practices across prescribers in their treatment of schizophrenia. Targeting efforts to selected prescribers holds promise as an approach to promote evidence-based antipsychotic prescribing.
氯氮平使用不足和抗精神病药物联合使用过度均表明医疗质量较差。本研究调查了不同医疗服务提供者在氯氮平处方和抗精神病药物联合使用方面的差异，以及与这些做法相关的因素。
利用2010 - 2012年宾夕法尼亚州医疗补助数据，确定每年为10名或更多非老年成年精神分裂症患者开具抗精神病药物处方的开处方者。采用具有二项分布和logit链接的广义线性混合模型，研究开处方者层面使用氯氮平患者的年度百分比、长期（≥90天）使用抗精神病药物联合治疗患者的年度百分比，以及开处方者患者病例数量的相关特征、开处方者特征和医疗补助支付方（按服务收费与管理式医疗计划）。
研究队列在2010年包括645名开处方者，2011年为632名，2012年为650名。2012年，开处方者层面使用任何氯氮平的患者年度平均百分比为7%（范围为0% - 89%），长期使用任何抗精神病药物联合治疗的患者平均百分比为7%（范围为0% - 45%）（2010 - 2012年期间发现类似比例）。处方量高、来自种族或少数民族群体的患者比例较小、符合补充保障收入条件的患者比例较大的开处方者，更有可能使用氯氮平和抗精神病药物联合治疗精神分裂症。开处方者的专业和医疗补助支付方也与开处方者的做法有关。
在精神分裂症治疗中，不同开处方者在氯氮平和抗精神病药物联合使用方面存在相当大的差异。针对选定的开处方者开展工作有望成为促进循证抗精神病药物处方的一种方法。
