Physician Care Coordination and the Use of Psychotropic Polypharmacy in the Management of Pediatric Mental Disorders

Abstract

BACKGROUND: Psychotropic polypharmacy is a concern in the management of pediatric mental disorders due to the lack of pediatric data to support the practice. Although seeing multiple providers has been identified as an important predictor of polypharmacy, no study has yet assessed the effect of care coordination between providers on receipt of psychotropic polypharmacy. OBJECTIVE: To examine the association between the intensity of care coordination within a patient's care team and the likelihood of the patient receiving multiclass psychotropic polypharmacy.METHODS: A retrospective study was conducted using the 2013-2015 administrative claims data from a Medicaid managed care organization (Texas Children's Health Plan). Children and adolescents aged 18 years or younger with a diagnosis of a mental/behavioral disorder and receipt of psychotropic prescriptions from multiple prescribers were included in the study. Psychotropic polypharmacy was defined as the receipt of 2 or more psychotropic medications from different drug classes concurrently for 60 days or more. Care coordination was measured using social network analysis (SNA), a new technique included in the Agency for Healthcare Research and Quality Care Coordination Measures Atlas. Care density, an SNA surrogate for care coordination, was calculated as the ratio of the sum of patients shared by physician pairs within a patient's care team to the total number of physician pairs. The Andersen behavioral model was used to guide multivariate logistic regression analyses conducted to assess the association between care density and the likelihood of patients receiving psychotropic polypharmacy after controlling for predisposing and need factors. RESULTS: A total of 24,147 children and adolescents diagnosed with a mental/ behavioral disorder were identified. About 34.0% (n = 8,092) of these individuals received psychotropic medications from multiple prescribers who were either primary care physicians (PCPs) or specialists. Logistic regression analysis showed a significant association between care density and the use of psychotropic polypharmacy. However, the direction of this relationship varied depending on the composition of the patient's care team. Among patients with only PCPs involved in their care team, patients in the higher care-density group were 28% less likely to receive psychotropic polypharmacy (OR = 0.72; 95% CI = 0.62-0.96) than those in the lower care-density group. In contrast, among patients who had both PCPs and specialists involved in their care team, those in the higher care-density group were 2 times more likely to experience psychotropic polypharmacy (OR = 2.01; 95% CI = 1.68-2.40). Care density was not significantly associated with the receipt of psychotropic polypharmacy in the specialist-only group.CONCLUSIONS: This study found significant associations between care density and prescription of psychotropic polypharmacy. This relationship varied depending on the patient's diagnosis, disease complexity, and composition of the patient's care team.

The Relationship of Continuity of Care, Polypharmacy and Medication Appropriateness: A Systematic Review of Observational Studies

“…The majority of studies ( n = 16) investigated the relationship between COC and MARO [ 43 – 47 , 51 , 56 – 58 , 60 , 61 , 63 , 64 , 66 , 68 , 69 ]. Seven studies focused on the relationship between COC and polypharmacy [ 48 , 53 , 54 , 62 , 65 , 67 ], and four studies investigated both the relationship between COC and MARO and between COC and polypharmacy [ 49 , 50 , 52 , 59 ].…”

“…The included studies were from North America ( n = 12), Europe ( n = 6), and Asia ( n = 9). Most of the studies ( n = 9) were from the US [ 46 , 48 , 51 , 57 , 60 , 63 , 66 , 67 , 69 ] and Taiwan ( n = 6) [ 43 – 45 , 47 , 50 , 62 ]. The population of interest was mostly at least 60 years old.…”

“…The population of interest was mostly at least 60 years old. Only five studies included younger patients [ 45 , 48 , 51 , 57 , 58 ]. Nine studies focused on patients with specific diseases or risks, such as patients with a mental and/or behavioral disorder or dementia [ 47 , 48 , 51 – 54 , 62 , 67 , 68 ].…”

“… RR 0.58 (95% CI 0.39–0.85) (high COC vs low COC) Guilcher et al 2020 [ 54 ] Cross-sectional Register/claims data Canada Primary care/outpatient n = 2309 Age ≥ 66 years Patients with nontraumatic spinal cord dysfunction following inpatient rehabilitation COC Dimension 1 Objective standard measure UPC index at physician level Low COC (< 50%) compared with higher COC (> 75%) (ref.) is significantly associated with polypharmacy RR 1.07 (95% CI 1.02–1.12) Medhekar et al 2019 [ 48 ] Cross-sectional Register/claims data USA Primary care / outpatient n = 8092 Age ≤ 18 years Patients with a mental/behavioral disorder COC Dimension 1 Objective non-standard measure Number of prescribers COC Dimension 2 and 3 Objective standard measure Care density Increase in the number of prescribers involved in treatment was associated with a higher likelihood of receiving psychotropic polypharmacy among all groups Care density was strongly associated with the likelihood of receiving psychotropic polypharmacy However, relationship between care density and polypharmacy varied depending on the type of physicians involved in the care team Number of prescribers PCPs only: OR 1.12 (95% CI 1.02–1.23) Specialists only: OR 1.68 (95% CI 1.46–1.92) PCPs + specialists: OR 1.40 (95% CI 1.29–1.51) Care density PCPs only: OR 0.72 (95% CI 0.62–0.96) Specialists only: OR 0.93 (95% CI 0.75–1.15) PCPs + specialists: OR 2.01 (95% CI 1.68–2.40) Kann et al 2015 [ 55 ] Longitudinal Register/claims data Norway Primary care/outpatient n = 624,308 Age ≥ 70 years COC Dimension 1 Objective non-standard measure Number of prescribers The number of prescribing physicians per patient increased the patients’ risk of polypharmacy; increasing the number of prescribers by one more than doubled the risk of polypharmacy Polypharmacy: OR 2.323 (95% CI 2.316–2.331) Excessive polypharmacy: OR 1.987 (95% CI 1.978–1.997) ...…”

Análise das vivências dissociativas e das modalidades de tratamentos prestados a adolescentes portadores de transtorno de personalidade Borderline

“…Até o momento, não há qualquer evidência sólida que dê suporte ao uso de medicamentos psicotrópicos como tratamento de primeira linha em adolescentes com TPB (136) . Adicionalmente, o uso de polifarmácia, tanto em adolescentes quanto em adultos, está associado a diversos riscos tais como interações adversas, interações medicamentosas, altos custos financeiros e maior morbidade (137)(138)(139)(140) . Também, deve-se levar conta que adolescentes podem ser mais propensos a apresentar efeitos adversos decorrentes do uso de psicotrópicos (141) .…”