Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio (Kelleher); PolicyLab at Children's Hospital of Philadelphia, Philadelphia (Rubin); Department of Pediatrics, New York University Langone Health, New York (Hoagwood).
Psychiatr Serv. 2020 Jul 1;71(7):706-712. doi: 10.1176/appi.ps.201900417. Epub 2020 Mar 19.
Psychoactive medications are the most expensive and fastest-growing class of pharmaceutical agents for children. The cost, side effects, and unprecedented growth rate at which these drugs are prescribed have raised alarms from health care clinicians, patient advocates, and agencies about the appropriateness of how these drugs are distributed to parents and their children. This article examines current prescribing of three classes of psychoactive drugs-stimulants, antidepressants, and antipsychotics-and efforts to improve pediatric prescribing of these agents. Federal policy efforts to curb questionable prescribing of psychoactive medications to children have focused particularly on oversight of antipsychotic use among foster care children. The article reviews system-level interventions, including delivery system enhancements, which increase availability of alternatives to medication treatments, employ electronic medical record reminders, and increase cross-sector care coordination; clinician prescribing enhancements, which disseminate best-practice guidelines, create quality and learning collaboratives, and offer "second opinion" psychiatric consultations; and prescriber monitoring programs, which include retrospective review and prospective monitoring of physicians' prescribing to identify patterns suggestive of inappropriate prescribing. Potential interventions to deter inappropriate pediatric prescribing are briefly described, such as transparency in drug prices and incentives among insurers, public agencies, and pharmacy benefit managers; value-based purchasing, specifically value-based payment for medications; and preventive interventions, such as parent training.
精神活性药物是儿童中最昂贵和增长最快的一类药物。这些药物的成本、副作用以及前所未有的开方增长率引起了医疗保健临床医生、患者权益维护者以及各机构对这些药物分发给父母及其子女的适当性的关注。本文研究了三类精神活性药物（兴奋剂、抗抑郁药和抗精神病药）的当前开方情况，并努力改善这些药物在儿科的使用。联邦政策努力遏制对儿童不合理使用精神活性药物，特别侧重于监督寄养儿童的抗精神病药物使用。本文回顾了系统层面的干预措施，包括提高药物治疗替代方案的可及性的医疗服务提供系统增强措施、使用电子病历提醒、增加跨部门护理协调；临床医生开方增强措施，传播最佳实践指南、创建质量和学习合作、提供“第二意见”精神病咨询；以及处方医生监测计划，包括对医生处方的回顾性审查和前瞻性监测，以识别表明不当处方的模式。简要描述了一些可能的干预措施，以阻止不当的儿科处方，如药品价格透明度以及保险公司、公共机构和药品福利管理机构之间的激励措施；基于价值的采购，特别是基于药物的价值支付；以及预防干预措施，如家长培训。
