Trends and Intervention Results for Unusual Antipsychotic Polypharmacy Prescribing Patterns for Florida Adult and Child Medicaid Population: 2007-2013
Abstract
Background: The rapid growth in the use of antipsychotic medications has created challenges for Medicaid programs in many states. One area of particular concern has been and continues to be unusual antipsychotic polypharmacy prescribing patterns (UAPPPs) for adults and children. Our project has monitored 24 quarters of antipsychotic prescribing patterns for adults and children written by all Florida Medicaid prescribers over the July 2007 through June 2013 period and intervened with selected prescribers with UAPPPs patterns against a set of psychotherapeutic medication guidelines developed and updated in a series of meetings with national experts. This study reports our 6-year findings.
Methods: The Medicaid Drug Therapy Management Program for Behavioral Health (MDTMP) at the University of South Florida analyzed the Florida Medicaid prescription patterns for adult and child patients using three measures of UAPPP developed by our expert consensus panels: (1) two antipsychotics for 90 or more days (2AP90), (2) three antipsychotics for 60 days (3AP60), and (3) three antipsychotics for 90 days (3AP90). We report the trends for any prescriber for adult and child Medicaid patients that incurred a UAPPP as well as the results of 250 prescribers that received an intervention.
Results: In FY 2012/13, the number of unique adult-patient prescribers hitting one or more UAPPPs had risen to 10,822 prescribers; a 27.3% increase from six years earlier. For children, over the same period, Florida Medicaid prescribers that wrote at least one UAPPP script grew 4.8% to 3,025 prescribers. Overall, for prescribers that wrote one or more UAPPP scripts for both adult and child Medicaid patients, over the 6-year period, the number of scripts per patient and the number of scripts per provider declined ranging from -4.2% to -15.1%. While the group of adult-patient prescribers that wrote one or more UAPPPs showed mixed results on the three UAPPP measures, the group of child-patient prescribers that wrote one or more UAPPPs showed substantial declines in their numbers of patients, numbers of scripts, and number of scripts per prescriber ranging from -22.4% to -100% for each of these three measures. The 250 prescribers, who were among the highest adult- and child-patient prescribers, and experienced an intervention by MDTMP representatives, showed even greater declines in their UAPPP practice patterns and measures.
Conclusions: We found that over the six-year study period there were substantial declines in most UAPPP measures of child patients for any prescribers that had one or more UAPPPs and the declining trend was even more substantial when the prescribers were targeted for an intervention by the MDTMP program. For adult patients, the MDTMP interventions for prescribers that incurred an UAPPP also appeared successful for many measures, but for those prescribers that did not experience an intervention the results were mixed.
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Horacek, J., Bubenikova-Valeova, V., Kopecek, M., Palenicek, T., Dockery, C., Mohr, P. & Höschl, C. (2006) Mechanism of Action of Atypical Antipsychotic Drugs and the Neurobiology of Schizophrenia, CNS Drugs 20(5) 389-405
Buchanan, R. W., J. Kreyenbuhl, et al. "The 2009 Schizophrenia PORT Psychopharmacological Treatment Recommendations and Summary Statements." Schizophrenia Bulletin 36(1): 71-93.
Tandon R, MS Keshavan, HA Nasrallah, Schizophrenia, "just the facts" what we know in 2008. 2. Epidemiology and etiology. Schizophr Res. 2008 Jul;102 (1-3):1-18. Epub 2008 Jun 2.
Tandon R, Belmaker RH, Gattaz WF, Lopez-Ibor JJ Jr, Okasha A, Singh B, Stein DJ, Olie JP, Fleischhacker WW, Moeller HJ; Section of Pharmacopsychiatry, World Psychiatric Association. World Psychiatric Association Pharmacopsychiatry Section statement on comparative effectiveness of antipsychotics in the treatment of schizophrenia. Schizophr Res. 2008 Mar;100(1-3):20-38. Epub 2008 Feb 19.
TA Ketter, A Handbook of Diagnosis and Treatment for Bipolar Disorder, Washington, DC: American Psychiatric Publishing, 2010.
Allison, D.B., Newcomer, J.W., Dunn, A.L., Blumenthal, J.A., Fabricatore, A.N., Daumit, G.K., Cope, M.B., Riley, W.T., Vreeland, B., Hibbeln, J.R., Alpert, J.E. (2009). Obesity Among Those with Mental Disorders A National Institute of Mental Health Meeting Report. Am J of Preventive Med. Apr;36(4): 341-350.
Connolly, K. R. and M. E. Thase "If at First You Don't Succeed: A Review of the Evidence for Antidepressant Augmentation, Combination and Switching Strategies." Drugs 71(1): 43-64.
Fedorowicz VJ, Fombonne E, Metabolic side effects of atypical antipsychotics in children: a literature review. J Psychopharmacol. 2005 Sep;19(5):533-50.
Crystal, S., M. Olfson, et al. (2009). "Broadened Use Of Atypical Antipsychotics: Safety, Effectiveness, And Policy Challenges." Health Affairs 28(5): w770-w781.
Lewis, S. n. and J. Lieberman (2008). "CATIE and CUtLASS: can we handle the truth?" The British Journal of Psychiatry 192(3): 161-163.
J Clin Psychiatry. 2011;72 Suppl 1:4-8. doi: 10.4088/JCP.10075su1.01.
Antipsychotics in the treatment of schizophrenia: an overview.
Tandon R
A Systematic Review of Combination and High-Dose Atypical Antipsychotic Therapy in Patients with Schizophrenia [CADTH Optimal Use Report; Volume 1, Issue 1B]. Ottawa: Canadian Agency for Drugs and Technologies in Health; 2011.For more information on this project, visit
http://www.cadth.ca/en/products/op
Stagnitti, M. N. Trends in the Use and Expenditures for the Therapeutic Class Prescribed Psychotherapeutic Agents and All Subclasses, 1997 and 2004. Statistical Brief #163. February 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/ datafiles/publications/st163/stat163.shtml
Crowley, M. J., et al. (2014). "Prioritization of Research Addressing Antipsychotics for Adolescents and Young Adults With Bipolar Disorder." Annals of Internal Medicine 160(7): 492-498.
Botts S, Hines H, Littrell R. Antipsychotic polypharmacy in the ambulatory care setting, 1993-2000. Psychiatr Serv. 2003;54(8):1086.
Gilmer TP, Dolder CR, Folsom DP, Mastin W, Jeste DV. Antipsychotic polypharmacy trends among Medicaid beneficiaries with schizophrenia in San Diego County, 1999-2004. Psychiatr Serv. 2007;58(7):1007-1010.
Stahl SM, Grady MM. A critical review of atypical antipsychotic utilization: comparing monotherapy with polypharmacy and augmentation. Curr Med Chem. 2004; 11(3):313-327.
Stahl SM. Antipsychotic polypharmacy, part 1: therapeutic option or dirty little secret? J Clin Psychiatry. 1999;60(7):425-426.
Freudenreich O, Goff DC. Antipsychotic combination therapy in schizophrenia: a review of efficacy and risks of current combinations. Acta Psychiatr Scand. 2002; 106(5):323-330.
Honer WG, Thornton AE, Chen EY, Chan RC, Wong JO, Bergmann A, Falkai P, Pomarol-Clotet E, McKenna PJ, Stip E, Williams R,MacEwan GW,Wasan K, Procyshyn R; Clozapine and Risperidone Enhancement (CARE) Study Group. Clozapine alone versus clozapine and risperidone with refractory schizophrenia. N Engl J Med. 2006;354(5):472-482.
Suzuki T, Uchida H, Watanabe K, Nakajima S, Nomura K, Takeuchi H, Tanabe A, Yagi G, Kashima H. Effectiveness of antipsychotic polypharmacy for patients with treatment refractory schizophrenia: an open-label trial of olanzapine plus risperidone for those who failed to respond to a sequential treatment with olanzapine, quetiapine and risperidone. Hum Psychopharmacol. 2008;23(6):455-463.
Tranulis C, Skalli L, Lalonde P, Nicole L, Stip E. Benefits and risks of antipsychotic polypharmacy: an evidence-based review of the literature. Drug Saf. 2008; 31(1):7-20.
Clark RE, Bartels SJ, Mellman TA, Peacock WJ. Recent trends in antipsychotic combination therapy of schizophrenia and schizoaffective disorder: implications for state mental health policy. Schizophr Bull. 2002;28(1):75-84.
Gilmer TP, Dolder CR, Folsom DP, Mastin W, Jeste DV. Antipsychotic polypharmacy
trends among Medicaid beneficiaries with schizophrenia in San Diego County,
-2004. Psychiatr Serv. 2007;58(7):1007-1010.
Frye MA, Ketter TA, Leverich GS, Huggins T, Lantz C, Denicoff KD, Post RM. The increasing use of polypharmacotherapy for refractory mood disorders: 22 years of study. J Clin Psychiatry. 2000;61(1):9-15.
McIntyre RS, Jerrell JM. Polypharmacy in children and adolescents treated for major depressive disorder: a claims database study. J Clin Psychiatry. 2009; 70(2):240-246.
Glezer A, Byatt N, Cook R Jr, Rothschild AJ. Polypharmacy prevalence rates in the treatment of unipolar depression in an outpatient clinic. J Affect Disord. 2009; 117(1-2):18-23.
Kotzan JA, Maclean R, Wade W, Martin BC, Lami H, Tadlock G, Gottlieb M. Prevalence and patterns of concomitant use of selective serotonin reuptake inhibitors and other antidepressants in a high-cost polypharmacy cohort. Clin Ther. 2002;24(2):237-248.
Frye MA, Ketter TA, Leverich GS, Huggins T, Lantz C, Denicoff KD, Post RM. The increasing use of polypharmacotherapy for refractory mood disorders: 22 years of study. J Clin Psychiatry. 2000;61(1):9-15.
Stahl SM, Grady MM. A critical review of atypical antipsychotic utilization: comparing monotherapy with polypharmacy and augmentation. Curr Med Chem. 2004; 11(3):313-327.
Freudenreich O, Goff DC. Antipsychotic combination therapy in schizophrenia: a review of efficacy and risks of current combinations. Acta Psychiatr Scand. 2002; 106(5):323-330.
Honer WG, Thornton AE, Chen EY, Chan RC, Wong JO, Bergmann A, Falkai P, Pomarol-Clotet E, McKenna PJ, Stip E, Williams R,MacEwan GW,Wasan K, Procyshyn R; Clozapine and Risperidone Enhancement (CARE) Study Group. Clozapine alone versus clozapine and risperidone with refractory schizophrenia. N Engl J Med. 2006;354(5):472-482.
Constantine R, Tandon R. Changing Trends in Pediatric Antipsychotic Use in Florida's Medicaid Program. Psychiatr Serv 2008;59:1162-8.
Constantine R, Richard S, Surles R, et al: Optimizing pharmacotherapy of schizophrenia: tools for the psychiatrist. Current Psychosis and Therapeutics Reports 4:6–11, 2006
Tandon R, Dewan N, Constantine R, et al: Best pharmacologic treatment of schizophrenia: applying principles of evidence based medicine. Current Psychosis and Therapeutic Reports 3:53–60, 2005
Constantine RJ, Tandon R, McPherson M, et al.: Early diagnoses and psychotherapeutic medication treatment experiences of a cohort of children under 6 years old who received antipsychotic treatment in Florida’s Medicaid program. J Child Adolesc Psychopharm 2011; 21:79–84.
Florida Statewide Advocacy Council, Psychotropic Drug Use in Foster Care, Red Item Report, July 2003, p. 3.
Constantine, R, Boaz, T, Tandon, R. Antipsychotic Polypharmacy in the Treatment of Children and Adolescents in the Fee for Service Component of a Large State Medicaid Program. Clinical Therapeutics, 2010, 32:5, 949-959.
Constantine, R., Andel, R., Tandon, R. Trends in Antipsychotic Polypharmacy: Progress and Challenges in Florida’s Medicaid Program. Community Mental Health Journal 2010, 46:523-530.
Bero, L., & Rennie, D. (1995). The Cochrane Collaboration:Preparing, maintaining, and disseminating systematic reviews of the effects of health care. Journal of the American Medical Association, 274, 1935-1938.
Clark, N. M., Gong, M., Schork, M. A., Evans, D., Roloff, D., Hurwitz, M., et al. (1998). Impact of education for physicians on patient outcomes. Pediatrics, 101(5), 831-836.
Club, A. (1996). Systematic practice-based interventions are better than conferences for improving professional practice. ACP Journal Club, 124, 22.
Cohen, S. J. (1994). Changing physician behavior to improve disease prevention. Preventive Medicine, 23, 284-291.
Conrad, P. (2004). Prescribing more psychotropic medications for children: What does the increase mean? Archives of Perdiatrics & Adolescent Medicine, 158, 829-830.
Elson, R. B., & Connelly, D. P. (1995). Computerized patient records in primary care: Their role in mediating guideline-driven physician behavior. Archives of Family Medicine, 4(8), 698-705.
Farmer, A. P., Legare, F., Turcot, L., Grimshaw, J., Harvey, E., McGowan, J. L., et al. (2009). Printed educational materials:effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2008(3).
Finkelstein, J. A., Huang, S. S., Kleinman, K., Rifas-Shiman, S. L., Stille, C. J., Daniel, J., et al. (2008). Impact of a 16-community trial to promote judicious antibiotic use in Massachusetts. Pediatrics, 121(1), 15-23.
Fraser, G. L., Wennberg, D. E., Dickens, J. D. J., & Lambrew, C. T. (1996). Changing physician behavior in ordering digoxin assays. Annals of Pharmacotherapy, 30(5), 449-454.
Freemantle, N., Harvey, E., Wolf, F., Grimshaw, J., Grilli, R., & Bero, L. (1997). Printed educational materials: Effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 1997(2).
Jamtvedt, G., Young, J. M., Kristofferson, D. T., O'Brien, M. A., & Oxman, A. (2006). Audit and feedback: Effects on professinal practice and health care outcomes. Cochrane Database of Systematic Reviews 2006(2).
Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: a conceptual framework. Quality in Health care : QHC, 7(3), 149-158.
Kleijnen, J., & Chalmers, I. (1997). How to practice and teach evidence based medicine:Role of the Cochrane Collaboration. Acta Anaesthesiologica Scandinavica Supplementum, 41 (supplement 111)(1), 231-233.
Koyanagi, C., Forquer, S., & Alfano, E. (2005). Medicaid policies to contain psychiatric drug costs. Health Affairs, 24(2), 536-544.
Lundberg, G. D. (1998). Changing physician behavior in ordering diagnostic tests. Journal of the American Medical Association, 280, 2036-2037.
Macfarlane, J., Holmes, W., Gard, P., Thornhill, D., Macfarlane, R., & Hubbard, R. (2002). Reducing antibiotic use for acute bronchitis in primary care: Blind, randomised controlled trial of patient information leaflet. British Medical Journal 324, 1-6.
Morrato, E. H., Dodd, S., Oderda, G., Haxby, D. G., Allen, R., & Valuck, R. J. (2007). Prevalence, Utilization Patterns, and Predictors of Antipsychotic Polypharmacy: Experience in a Multistate Medicaid Population, 1998-2003. Clinical Therapeutics: The International Peer-Reviewed Journal of Drug Therapy, 29(1), 183-195.
O'Brien, M. A., Freemantle, N., Oxman, A., Wolf, F., Davis, D., & Herrin, J. (2001). Continuing education meetings and workshops: effects on professional practice and health care Cochrane Database of Systematic Reviews (1).
O'Brien, M. A., Rogers, S., Jamtvedt, G., Oxman, A., Odgaard-Jensen, J., Kristofferson, D. T., et al. (2007). Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews(4).
Oxman, A. D., Thomson, M. A., Davis, D. A., & Haynes, R. B. (1995). No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. Canadian Medical Association Journal, 153(10), 1423-1431.
Pazirandeh, M. (2002). Does patient partnership in continuing medical education (CME) improve the outcome in osteoporosis management? Journal of Continuing Education in the Health Professions, 22, 142-151.
Solomon, D. H., Hashimoto, H., Daltroy, L., & Liang, M. H. (1998). Techniques to improve physicians' use of diagnostic tests: A new conceptual framework. Journal of the American Medical Association, 280(23), 2020-2027.
Sommers, L. S., Sholtz, R., Sheperd, R. M., & Starkweather, D. B. (1984). Physician involvement in quality assurance. Medical Care, 22(12), 1115-1138.
Soumerai, S. B., McLaughlin, T. J., & Avron, J. (1989). Improving drug prescribing in primary care: A critical analysis of the experimental literature. The Milbank Quarterly, 67(2), 268-317.
Soumerai, S. B., McLaughlin, T. J., Ross-Degnan, D., Casteris, C. S., & Bollini, P. (1994). Effects of limiting Medicaid drug-reimbursement benefits on the use of psychotropic agenst and acute mental health services by patients with schizophrenia. New England Journal of Medicine, 331, 650-655.
Steiner, J. F. (2005). A series of evidence-based drug therapy letters improved prescribing behaviour. Evidence Based Medicine, 10, 91-97.
Sullivan, S. D., Lee, T. A., Blough, D. K., Finkelstein, J. A., Lozano, P., Inui, T. S., et al. (2005). A multisite randomized trial of the effects of physician education and organizational change in chronic asthma care: Cost-effectiveness analysis of the pediatric asthma care patient outcomes research team II (PAC-PORT II). Archives of Perdiatrics & Adolescent Medicine, 159, 428-434.
Tu, K., & Davis, D. (2002). Can we alter physician behavior by educational methods? Lessons learned from studies of the management and follow-up of hypertension. Journal of Continuing Education in the Health Professions, 22, 11.
Weiss, K. B., Lozano, P., Finkelstein, J. A., Carey, V. J., Sullivan, S. D., Fuhlbrigge, A. L., et al. (2003). A randomized controlled clinical trial to improve asthma care for children through provider education and health systems change: A description of the pediatric asthma care patient outcome research team (PAC-PORT II) study design. Health Services and Outcomes Research Methodology, 4(4), 265-282.
Constantine R, MA Bengtson, T Murphy, M McPherson, R Andel, ME Jones, C Donaldson-Guenther, (2012). "Impact of the Florida Medicaid Prior-Authorization Program on Use of Antipsychotics by Children Under Age Six." Psychiatric Services 63(12): 1257-1260.
Constantine R, Tandon R. Changing Trends in Pediatric Antipsychotic Use in Florida's Medicaid Program. Psychiatr Serv 2008;59:1162-8.
Constantine R, Richard S, Surles R, et al: Optimizing pharmacotherapy of schizophrenia: tools for the psychiatrist. Current Psychosis and Therapeutics Reports 4:6–11, 2006
Tandon R, Dewan N, Constantine R, et al: Best pharmacologic treatment of schizophrenia: applying principles of evidence based medicine. Current Psychosis and Therapeutic Reports 3:53–60, 2005
Constantine RJ, Tandon R, McPherson M, et al.: Early diagnoses and psychotherapeutic medication treatment experiences of a cohort of children under 6 years old who received antipsychotic treatment in Florida’s Medicaid program. J Child Adolesc Psychopharm 2011; 21:79–84.
Florida Statewide Advocacy Council, Psychotropic Drug Use in Foster Care, Red Item Report, July 2003, p. 3.
Constantine, R, Boaz, T, Tandon, R. Antipsychotic Polypharmacy in the Treatment of Children and Adolescents in the Fee for Service Component of a Large State Medicaid Program. Clinical Therapeutics, 2010, 32:5, 949-959.
Constantine, R., Andel, R., Tandon, R. Trends in Antipsychotic Polypharmacy: Progress and Challenges in Florida’s Medicaid Program. Community Mental Health Journal 2010, 46:523-530.
CM Miller, Numerous red flags did not save Miami 12-year-old from prescription drug death, The Palm Beach Post, April 19, 2010.
CM Miller, Lawsuit blames Miami psychiatrist in death of boy with autism, The Palm Beach Post, Wednesday, May 20, 2009
K Kramer, Suicides of Young Persons in Florida Associated with Psychotropic Drugs – A Five-Year Study, Citizens Commission on Human Rights of Florida, February 2006.
Citizens Commission on Human Rights of Florida, The Psychotropic Drugging of Florida’s Medicaid Children, 2006.
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