Identifying Clinically Questionable Psychotropic Prescribing Practices for Medicaid Recipients in New York State

Essock, Susan M.; Covell, Nancy H.; Leckman‐Westin, Emily; Lieberman, Jeffrey A.; Sederer, Lloyd I.; Kealey, M.S.W. Edith; Finnerty, Molly

doi:10.1176/ps.2009.60.12.1595

Cited by 47 publications

(38 citation statements)

References 16 publications

(11 reference statements)

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“…Audits and surveys consistently reveal relatively high levels of prescription of combined antipsychotics internationally, in Australia, [7] Belgium, [109] Canada, [110] Finland, [111] France, [112,113] Germany, [114] Israel, [115] Italy, [116] Japan, [8,83,117] China and East Asia, [118][119][120] the Netherlands, [121] the US [10,109,[122][123][124][125] and the UK. [17,25,126] Data from the US suggest that an apparent increase in the prescription of antipsychotics since the introduction of second-generation antipsychotics [127] has been accompanied by a significant increase in the prevalence of second-generation antipsychotic polypharmacy.…”

Section: Antipsychotic Polypharmacy In Clinical Practicementioning

confidence: 99%

Antipsychotic Polypharmacy in Schizophrenia

2011

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Antipsychotic polypharmacy refers to the co-prescription of more than one antipsychotic drug for an individual patient. Surveys of prescribing in psychiatric services internationally have identified the relatively frequent and consistent use of combined antipsychotics, usually for people with established schizophrenia, with a prevalence of up to 50% in some clinical settings. A common reason for prescribing more than one antipsychotic is to gain a greater or more rapid therapeutic response than has been achieved with antipsychotic monotherapy. However, the evidence on the risks and benefits for such a strategy is equivocal, and not generally considered adequate to warrant a recommendation for its use in routine clinical practice in psychiatry. Combined antipsychotics are a major contributor to high-dose prescribing, associated with an increased adverse effect burden, and of limited value in helping to establish the optimum maintenance regimen for a patient. The relatively widespread use of antipsychotic polypharmacy identified in cross-sectional surveys reflects not only the addition of a second antipsychotic to boost therapeutic response, but also the use of as-required antipsychotic medication (mainly to treat disturbed behaviour), gradual cross-titration while switching from one antipsychotic to another, and augmentation of clozapine with a second antipsychotic where the illness has failed to respond adequately to an optimized trial of clozapine. This review addresses the clinical trial data and other evidence for each of these pharmacological approaches. Also reviewed are examples of systematic, practice-based interventions designed to reduce the prevalence of antipsychotic polypharmacy, most of which have met with only modest success. Guidelines generally agree that if combined antipsychotics are prescribed to treat refractory psychotic illness, this should be after other, evidence-based, pharmacological treatments such as clozapine have been exhausted. Further, their prescription for each patient should be in the context of an individual trial, with monitoring of the clinical response and adverse effects, and appropriate physical health monitoring.

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Section: Antipsychotic Polypharmacy In Clinical Practicementioning

confidence: 99%

Antipsychotic Polypharmacy in Schizophrenia

2011

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“…First, because of concerns over high rates of polypharmacy and off-label use of psychotropic medications across clinical and residential treatment settings, researchers and policymakers are working to establish indicators of questionable psychotropic polypharmacy (e.g., Essock, et al, 2009). Second, although adherence to best practice for many child and adolescent mental disorders suggests the potential benefits of combining medication with other psychosocial/behavior interventions, (Burns, Hoagwood, & Mrazek, 1999; Walkup, et al, 2008; TADS Team, 2007; Swanson, et al, 2008), there has been concern that some data may suggest increasing numbers of patients are receiving medications without concurrent mental health services (Olfson & Marcus, 2010).…”

Section: Introductionmentioning

confidence: 99%

Use of Psychotropic Medications Among Youth in Treatment Foster Care

et al. 2013

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We describe the use of psychotropic medications among youth in treatment foster care (TFC). Data from 240 youth were coded to examine rates of medication use, including polypharmacy and an indicator of “questionable polypharmacy.” Fifty-nine percent of youth in TFC had taken a psychotropic medication within the past two months. Of the youth taking psychotropics, 61% took two or more and 22% met criteria for questionable polypharmacy. The majority of youth taking psychotropics also received psychosocial mental health services and were more likely to receive such services than youth not taking medication. Use of psychotropic medication use was not significantly related to demographic factors, maltreatment history, or custody. However, youth with more severe symptoms were more likely to be on medications and to be on multiple medications. Youth with “questionable polypharmacy” were less likely than other youth on multiple medications to have a recent visit to a psychiatrist.

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“…We used this definition because of the lack of empirical evidence for the effectiveness of three or more medications. Moreover, this definition also has been adopted by several state Medicaid programs as an indicator of quality of care (22,23). Third, what are the most common medication combinations for each eligibility group, and have they changed over time?…”

mentioning

confidence: 99%

Trends in Psychotropic Polypharmacy Among Youths Enrolled in Ohio Medicaid, 2002–2008

Fontanella¹,

Warner²,

Phillips³

et al. 2014

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Objective This study examined polypharmacy patterns and rates over time among Medicaid-enrolled youths by comparing three enrollment groups (youths in foster care, with a disability, or from a family with low income). Methods Serial cross-sectional trend analyses of Medicaid claims data were conducted for youths age 17 and younger who were continuously enrolled in Ohio Medicaid for a one-year period and prescribed one or more psychotropic medications during fiscal years 2002 (N=26,252) through 2008 (N=50,311). Outcome measures were any polypharmacy (three or more psychotropic medications from any drug class) and multiclass polypharmacy (three or more psychotropic medications from different drug classes). Results Both types of polypharmacy increased across all three eligibility groups. Any polypharmacy increased from 8.8% to 11.5% for low-income youths (adjusted odds ratio [AOR]=1.12, 99% confidence interval [CI]=1.10–1.13), from 18.0% to 24.9% for youths with a disability (AOR=1.11, CI=1.09–1.13), and from 19.8% to 27.3% for youths in foster care (AOR=1.09, CI=1.07–1.11). Combinations associated with positive increases were two or more antipsychotics, two or more stimulants, and antipsychotics with stimulants. Conclusions Polypharmacy increased across all enrollment groups, with the highest absolute rates for youths in foster care. Both the overall prevalence and increases in prescriptions for drug combinations with limited evidence of safety and efficacy, such as the prescription of two or more antipsychotics, underscore the need for targeted quality improvement efforts. System oversight and monitoring of psychotropic medication use appears to be warranted, especially for higher-risk groups, such as youths in foster care and those from low-income households who were prescribed multiple antipsychotics.

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Identifying Clinically Questionable Psychotropic Prescribing Practices for Medicaid Recipients in New York State

Cited by 47 publications

References 16 publications

Antipsychotic Polypharmacy in Schizophrenia

Antipsychotic Polypharmacy in Schizophrenia

Use of Psychotropic Medications Among Youth in Treatment Foster Care

Trends in Psychotropic Polypharmacy Among Youths Enrolled in Ohio Medicaid, 2002–2008

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