Antipsychotic Medication Use in Children and Adolescents: A Resource Guide and Workbook

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Antipsychotic Medication Use in Children
andAdolescents A Resource Guide and Workbook

• Jeffery Thompson, MD, MPH
• Washington State Medicaid
• Chief Medical Officer

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How States Worked Together on this Project The
search for truth or something close.

• MMDLN invited a small number of States to discuss
  AP medication management and whether comparing
  systems and policies was possible between June of
  2007 and August of 2009
• A series of informal discussions which generated
  the Project Plan
• A shared discussion among a subset of State
  participants to develop a standardized Data
  Dictionary
• An informal data sharing agreement between 16
  States to pull and share utilization and
  demographic data
• A survey of State programs and practices to
  categorize polices, statutes, and utilization
  controls related to mental health medications
• A process to share State practices based on a
  systematic process (best, promising, emerging,
  and unknown)
• A publication committee to write a Resource Guide
• Close connections with AHRQ, NASMD and NASMHD

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What were project challenges? The search for
truth or something close.

• Distributed Model
• Some issues arises (political, budget or other)
  that has a common theme across states
• Consensus building defines the project plan
• Common data dictionary and data pull at each
  state
• Discussions and surveys are used to ensure
  validity
• Data is aggregated
• The beginning

• Centralized Model
• Research idea responding to an RFP
• Null hypothesis and project plan in an RO1
• Data is centralized and analyzed (typically line
  level)
• Some mechanism is used to validate data
• Report or publication comes out
• The end

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What were project challenges? The search for
truth or something close.

• Centralized Model
• Pros
• The project has a narrow focus
• Definitions setting is not egalitarian
• Line level data allows for validity checks
• Cons
• Data and trends may be confounded scalar changes
  and unknowns
• The research question may not address the
  community need

• Distributed Model
• Cons
• The project can morph
• Definitions is set by committee
• Aggregate data relies on state analyst
  understanding
• Pros
• Each state knows their community and structures
  to address trend issues
• States gain a unique understanding through the
  process

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What were project challenges? Both models are
needed and need coordination!

• Centralized Model
• Can define the confounders and influencing issues
• Can test the intended and unintended consequences
• Can assist in merging costs and outcomes

• Distributed Model
• Defines the problem(s)
• Each state may have differing issues
• Integrates research into business/program model
• Sets the next step agenda for research

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What were the key findings in 16 States CY
2004-2007 Data?

• Growth trends in Antipsychotic (AP) medication
  varied widely (48 percent decrease to a 39
  percent increase) among the 16 States
• More children in foster care (12.4 percent) were
  prescribed AP medications than non-foster care
  children (1.7 percent)
• Just over 11 percent of children using AP
  medications were prescribed four or more during a
  calendar year (non-concurrent)
• Over one-third of children (36 percent) had a
  greater than 20-day gap in AP medication
• 16 States, generated 26 best, promising and
  emerging quality practices to assist states in
  improving quality and reducing variation

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How can we measure issues? Red flags can assist
in Measures of Program Performance

• The project identified a common set of quality
  concerns (red flags) to raise safety concerns
• Children less than 5 years of age receiving AP
  medications
• Children and adolescents being prescribed three
  or more mental health medications in a calendar
  year
• Children and adolescents being prescribed two or
  more AP medications in a calendar year
• Doses of antipsychotic medications exceeding
  recommended range
• Gaps in therapy that exceed 20 days
• States can use these red flags to highlight
  variation in performance and trends as well as
  review the best, promising, and emerging
  practices to work with the prescribing community
  to improve quality.

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How is Washington State using project data?
Executive Summary CY 2007

• Total users 4,978 (1.4) of enrolled kids used
  an AAP
• Growth trends AAP users grew 25 and unit costs
  grew 38 comparing 2004 to 2007
• AAP use in the very young 187 AAPs users are
  less than 5 years old
• High dose 499 (10) of users are prescribed
  high doses of AAPs
• Multiple AAP use 896 (19) of users had two or
  more AAP prescriptions
• Multiple Mental Health Drug use 621 (2.3) of
  kids are prescribed 5 or more mental health drugs
• Adherence 1588 (39) had a gap in AAP use of
  greater than 20 days.
• Provider types AAP were prescribed by
  Psychiatrists (45), PCP (34) and ARNP (21)

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How is Washington State using project data? CY
2004 2007 Trends

•  
• A look at the trend data WA State found
•  
• Next Steps Provider groups are reviewing chart
  data and reasons for trends

PCP ARNP PSYCHIATRIST
gt 2 AAPs 13 24 63
gt 5 MHD 19 31 50
gt 20 day Gap 34 21 46
gt 2 MHD Prescribers 53 20 27
 Comparing 2004-2007, these quality indicators appear to be improving for PCP and Psychiatrists and decreasing in ARNPs  Comparing 2004-2007, these quality indicators appear to be improving for PCP and Psychiatrists and decreasing in ARNPs  Comparing 2004-2007, these quality indicators appear to be improving for PCP and Psychiatrists and decreasing in ARNPs  Comparing 2004-2007, these quality indicators appear to be improving for PCP and Psychiatrists and decreasing in ARNPs
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How is Washington State using project data? CY
2004 Regional Variation in Clients using 4 or
More Mental Health Drugs by County
Showing the regional variations engaged the
provider community in solutions and that quality
issues are present.
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How is Washington State using project data?
Because of variation a statewide call line was
setup.

• PAL is a Call in Line for mental health
  questions by a Ped Psychiatrist
• The UW will be doing a program review

Data Drives Programs, Statutes, Funding and
Quality
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Summary This Project will Assist States in
Ensuring Mental Health Drugs are Given the right
care at the right time for the right reason
Questions?