1 New York State Office of Mental Health, Albany, New York, and State University of New York at Albany, School of Public Health, Rensselaer, New York.
2 New York State Office of Mental Health, and New York University Langone Health, New York, New York.
J Manag Care Spec Pharm. 2018 Mar;24(3):238-246. doi: 10.18553/jmcp.2018.24.3.238.
Concerns about antipsychotic prescribing for children, particularly those enrolled in Medicaid and with Supplemental Security Income (SSI), continue despite recent calls for selective use within established guidelines.
To (a) examine the application of 6 quality measures for antipsychotic medication prescribing in children and adolescents receiving Medicaid and (b) understand distinctive patterns across eligibility categories in order to inform ongoing quality management efforts to support judicious antipsychotic use.
Using data for 10 states from the 2008 Medicaid Analytic Extract (MAX), a cross-sectional assessment of 144,200 Medicaid beneficiaries aged < 21 years who received antipsychotics was conducted to calculate the prevalence of 6 quality measures for antipsychotic medication management, which were developed in 2012-2014 by the National Collaborative for Innovation in Quality Measurement. These measures addressed antipsychotic polypharmacy, higher-than-recommended doses of antipsychotics, use of psychosocial services before antipsychotic initiation, follow-up after initiation, baseline metabolic screening, and ongoing metabolic monitoring.
Compared with children eligble for income-based Medicaid, children receiving SSI and in foster care were twice as likely to receive higher-than-recommended doses of antipsychotics (adjusted odds ratio [AOR] = 2.4, 95% CI = 2.3-2.6; AOR = 2.5, 95% CI = 2.4-2.6, respectively) and multiple concurrent antipsychotic medications (AOR = 2.2, 95% CI = 2.0-2.4; AOR = 2.2, 95% CI = 2.0-2.4, respectively). However, children receiving SSI and in foster care were more likely to have appropriate management, including psychosocial visits before initiating antipsychotic treatment and ongoing metabolic monitoring. While children in foster care were more likely to experience baseline metabolic screening, SSI children were no more likely than children eligible for income-based aid to receive baseline screening.
While indicators of overuse were more common in SSI and foster care groups, access to follow-up, metabolic monitoring, and psychosocial services was somewhat better for these children. However, substantial quality shortfalls existed for all groups, particularly metabolic screening and monitoring. Renewed efforts are needed to improve antipsychotic medication management for all children.
This project was supported by grant number U18HS020503 from the Agency for Healthcare Research and Quality (AHRQ) and Centers for Medicare & Medicaid Services (CMS). Additional support for Rutgers-based participants was provided from AHRQ grants R18 HS019937 and U19HS021112, as well as the New York State Office of Mental Health. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ, CMS, or the New York State Office of Mental Health. Finnerty has been the principle investigator on research grants/contracts from Bristol Myers Squibb and Sunovion, but her time on these projects is fully supported by the New York State Office of Mental Health. Scholle, Byron, and Morden work for the National Committee for Quality Assurance, a not-for-profit organization that develops and maintains quality measures. Neese-Todd was at Rutgers University at the time of this study and is now employed by the National Committee for Quality Assurance. The other authors have no financial relationships relevant to this article to disclose. Study concept and design were contributed by Finnerty, Neese-Todd, and Crystal, assisted by Scholle, Leckman-Westin, Horowitz, and Hoagwood. Scholle, Byron, Morden, and Hoagwood collected the data, and data interpretation was performed by Pritam, Bilder, Leckman-Westin, and Finnerty, with assistance from Scholle, Byron, Crystal, Kealey, and Neese-Todd. The manuscript was written by Leckman-Westin, Kealey, and Horowitz and revised by Layman, Crystal, Leckman-Westin, Finnerty, Scholle, Neese-Todd, and Horowitz, along with the other authors.
尽管最近有人呼吁在既定准则内有选择性地使用抗精神病药物，但人们仍持续关注儿童，尤其是那些参加医疗补助计划和补充保障收入计划的儿童使用抗精神病药物的问题。
（a）评估在接受医疗补助的儿童和青少年中使用 6 项抗精神病药物管理质量措施的情况；（b）了解不同资格类别之间的独特模式，以便为正在进行的质量管理工作提供信息，以支持合理使用抗精神病药物。
使用来自 2008 年医疗补助分析提取（MAX）的 10 个州的数据，对 144200 名接受抗精神病药物治疗的年龄<21 岁的医疗补助受益人的横断面评估，以计算 6 项抗精神病药物管理质量措施的流行率，这些措施是由国家创新质量测量合作组织于 2012-2014 年制定的。这些措施涉及抗精神病药物的联合使用、抗精神病药物的推荐剂量过高、在开始使用抗精神病药物之前使用心理社会服务、启动后的随访、基线代谢筛查和持续的代谢监测。
与有资格获得基于收入的医疗补助的儿童相比，接受补充保障收入和寄养的儿童接受推荐剂量过高的抗精神病药物的可能性是前者的两倍（调整后的优势比[OR]为 2.4，95%置信区间[CI]为 2.3-2.6；OR 为 2.5，95%CI 为 2.4-2.6），同时也接受了多种同时使用的抗精神病药物（OR 为 2.2，95%CI 为 2.0-2.4；OR 为 2.2，95%CI 为 2.0-2.4）。然而，接受补充保障收入和寄养的儿童更有可能接受适当的管理，包括在开始抗精神病药物治疗前进行心理社会访问和持续的代谢监测。虽然寄养儿童更有可能进行基线代谢筛查，但接受补充保障收入的儿童与有资格获得基于收入的援助的儿童相比，进行基线筛查的可能性并没有更高。
虽然在补充保障收入和寄养群体中更常见的是过度使用的指标，但这些儿童获得随访、代谢监测和心理社会服务的机会要好一些。然而，所有群体都存在相当大的质量缺陷，特别是代谢筛查和监测。需要进一步努力改善所有儿童的抗精神病药物管理。
本项目由美国医疗保健研究与质量局（AHRQ）和医疗保险和医疗补助服务中心（CMS）的拨款号 U18HS020503 资助。罗格斯大学的参与者还得到了 AHRQ 拨款 R18 HS019937 和 U19HS021112 以及纽约州心理健康办公室的支持。本研究的内容完全由作者负责，不一定代表 AHRQ、CMS 或纽约州心理健康办公室的官方观点。芬纳蒂曾是百时美施贵宝和山内信的研究资助/合同的主要研究者，但她在这些项目上的时间完全由纽约州心理健康办公室支持。Scholle、Byron 和 Morden 为国家质量保证委员会工作，该委员会是一个制定和维护质量措施的非营利组织。Neese-Todd 在研究期间在罗格斯大学工作，现在在国家质量保证委员会工作。其他作者与本文无经济关系需要披露。研究概念和设计由 Finnerty、Neese-Todd 和 Crystal 提出，并由 Scholle、Leckman-Westin、Horowitz 和 Hoagwood 协助。Scholle、Byron、Morden 和 Hoagwood 收集了数据，Pritam、Bilder、Leckman-Westin 和 Finnerty 进行了数据解释，并得到了 Scholle、Byron、Crystal、Kealey 和 Neese-Todd 的协助。手稿由 Leckman-Westin、Kealey 和 Horowitz 撰写，并由 Layman、Crystal、Leckman-Westin、Finnerty、Scholle、Neese-Todd 和 Horowitz 以及其他作者进行了修订。
