Abstract
Antipsychotic polypharmacy (APP) lacks evidence of effectiveness in the care of schizophrenia or other disorders for which antipsychotic drugs are indicated, also exposing patients to more risks. Authors assessed APP prevalence and APP association with beneficiary race/ethnicity and payer among publicly-insured adults regardless of diagnosis. Retrospective repeated panel study of fee-for-service (FFS) Medicare, Medicaid, and dually-eligible white, black, and Latino adults residing in California, Georgia, Iowa, Mississippi, Oklahoma, South Dakota, or West Virginia, filling antipsychotic prescriptions between July 2008 and June 2013. Primary outcome was any monthly APP utilization. Across states and payers, 11% to 21% of 397,533 antipsychotic users and 12% to 19% of 9,396,741 person-months had some APP utilization. Less than 50% of person-months had a schizophrenia diagnosis and up to 19% had no diagnosed mental illness. Payer modified race/ethnicity effects on APP utilization only in CA; however, the odds of APP utilization remained lower for minorities than for whites. Elsewhere, the odds varied by race/ethnicity only in OK, with Latinos having lower odds than whites (odds ratio 0.76; 95% confidence interval 0.60–0.96). The odds of APP utilization varied by payer in several study states, with odds generally higher for Dual eligibles, although the differences were generally small; the odds also varied by year (lower at study end). APP was frequently utilized but mostly declined over time. APP utilization patterns varied across states, with no consistent association with race/ethnicity and small payer effects. Greater use of APP-reducing strategies are needed, particularly among non-schizophrenia populations.
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References
Association, A. P. (2020). The American Psychiatric Association Practice Guideline for the Treatment of Patients with Schizophrenia (0890424691). Retrieved from https://doi.org/10.1176/appi.books.9780890424841
Baker, D. W., Qaseem, A., Reynolds, P. P., Gardner, L. A., & Schneider, E. C. (2013). Design and use of performance measures to decrease low-value services and achieve cost-conscious care. Annals of Internal Medicine, 158(1), 55–59. https://doi.org/10.7326/0003-4819-158-1-201301010-00560
Barnes, T. R., Drake, R., Paton, C., Cooper, S. J., Deakin, B., Ferrier, I. N., Gregory, C. J., Haddad, P. M., Howes, O. D., Jones, I., & Joyce, E. M. (2020). Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 34(1), 3–78
Brunette, M. F., de Nesnera, A., Swain, K., Riera, E. G., Lotz, D., & Bartels, S. J. (2011). Public-academic partnerships: A program to improve the quality of antipsychotic prescribing in a community mental health system. Psychiatric Services, 62(9), 1004–1006. https://doi.org/10.1176/appi.ps.62.9.1004
Bureau of Labor Statistics. (2019, December 2). Databases, Tables & Calculators by Subject. PPI industry data for Pharmaceutical preparation manufacturing, not seasonally adjusted. Retrieved from https://data.bls.gov/pdq/SurveyOutputServlet
Busch, A. B., Frank, R. G., Sachs, G., & Normand, S. L. (2009). Bipolar-I patient characteristics associated with differences in antimanic medication prescribing. Psychopharmacology Bulletin, 42(1), 35–49
Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58–66. https://doi.org/10.1056/NEJMra1906193
Centers for Medicare & Medicaid Services. (2008). Medicare Prescription Drug Benefit Manual, Chapter 6. Baltimore, MD.
Centers for Medicare & Medicaid Services. (2020). Adult Core Set Reporting Resources. Baltimore, MD: Medicaid.gov. Retrieved from https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/adult-and-child-health-care-quality-measures/adult-core-set-reporting-resources/index.html
Chan, L. F., Zai, C., Monda, M., Potkin, S., Kennedy, J. L., Remington, G., Lieberman, J., Meltzer, H. Y., & De Luca, V. (2013). Role of ethnicity in antipsychotic-induced weight gain and tardive dyskinesia: Genes or environment? Pharmacogenomics, 14(11), 1273–1281
Constantine, R., Andel, R., & Tandon, R. (2010). Trends in adult antipsychotic polypharmacy: Progress and challenges in florida’s medicaid program. Community Mental Health Journal, 46(6), 523–530. https://doi.org/10.1007/s10597-009-9288-2
Correll, C. U., Joffe, B. I., Rosen, L. M., Sullivan, T. B., & Joffe, R. T. (2015). Cardiovascular and cerebrovascular risk factors and events associated with second-generation antipsychotic compared to antidepressant use in a non-elderly adult sample: results from a claims-based inception cohort study. World Psychiatry, 14(1), 56–63. https://doi.org/10.1002/wps.20187
Cubanski, J., Rae, M., Young, K., & Damico, A. (2019). How does prescription drug spending and use compare across large employer plans, medicare part D, and medicaid? Retrieved from https://www.kff.org/medicare/issue-brief/how-does-prescription-drug-spending-and-use-compare-across-large-employer-plans-medicare-part-d-and-medicaid/
Daumit, G. L., Goff, D. C., Meyer, J. M., Davis, V. G., Nasrallah, H. A., McEvoy, J. P., Rosenheck, R., Davis, S. M., Hsiao, J. K., Stroup, T. S., & Lieberman, J. A. (2008). Antipsychotic effects on estimated 10-year coronary heart disease risk in the CATIE schizophrenia study. Schizophrenia Research, 105(1–3), 175–187
Daviglus, M. L., Pirzada, A., & Talavera, G. A. (2014). Cardiovascular disease risk factors in the Hispanic/Latino population: lessons from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). Progress in Cardiovascular Diseases, 57(3), 230–236. https://doi.org/10.1016/j.pcad.2014.07.006
Daviglus, M. L., Talavera, G. A., Avilés-Santa, M. L., Allison, M., Cai, J., Criqui, M. H., Gellman, M., Giachello, A. L., Gouskova, N., Kaplan, R. C., & LaVange, L. (2012). Prevalence of major cardiovascular risk factors and cardiovascular diseases among Hispanic/Latino individuals of diverse backgrounds in the United States. JAMA, 308(17), 1775–1784
Eicheldinger, C., & Bonito, A. (2008). More accurate racial and ethnic codes for Medicare administrative data. Health Care Financing Review, 29(3), 27–42
Fontanella, C. A., Hiance-Steelesmith, D. L., Guirgis, H., & Campo, J. V. (2018). Trends in and predictors of long-term antipsychotic polypharmacy use among Ohio medicaid patients with schizophrenia, 2008–2014. Psychiatric Services (washington, d. c.), 69(9), 1015–1020. https://doi.org/10.1176/appi.ps.201800052
Ganguly, R., Kotzan, J. A., Miller, L. S., Kennedy, K., & Martin, B. C. (2004). Prevalence, trends, and factors associated with antipsychotic polypharmacy among Medicaid-eligible schizophrenia patients, 1998–2000. Journal of Clinical Psychiatry, 65(10), 1377–1388
Garfield, R., Hinton, E., Cornachione, E., & Hall, C. (2018). Medicaid Managed Care Plans and Access to Care: Results from the Kaiser Family Foundation 2017 Survey of Medicaid Managed Care Plans. Retrieved from https://www.kff.org/medicaid/report/medicaid-managed-care-plans-and-access-to-care-results-from-the-kaiser-family-foundation-2017-survey-of-medicaid-managed-care-plans/
Gilmer, T. P., Dolder, C. R., Folsom, D. P., Mastin, W., & Jeste, D. V. (2007). Antipsychotic polypharmacy trends among Medicaid beneficiaries with schizophrenia in San Diego County, 1999–2004. Psychiatric Services (washington, d. c.), 58(7), 1007–1010. https://doi.org/10.1176/ps.2007.58.7.1007
Horvitz-Lennon, M., Donohue, J. M., Domino, M. E., & Normand, S. L. T. (2009). Improving quality and diffusing best practices: The case of schizophrenia. Health Affairs (millwood), 28(3), 701–712. https://doi.org/10.1377/hlthaff.28.3.701
Horvitz-Lennon, M., Volya, R., Donohue, J. M., Lave, J. R., Stein, B. D., & Normand, S.-L.T. (2014). Disparities in quality of care among publicly insured adults with schizophrenia in four large US States, 2002–2008. Health Services Research, 49(4), 1121–1144. https://doi.org/10.1111/1475-6773.12162
Jacobson, G., Damico, A., Neuman, T., & Gold, M. (2017). Medicare Advantage 2017 Spotlight: Enrollment Market Update. Retrieved from Menlo Park: https://www.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment-market-update/
Jaffe, A. B., & Levine, J. (2003). Antipsychotic medication coprescribing in a large state hospital system. Pharmacoepidemiology and Drug Safety, 12(1), 41–48
Kreyenbuhl, J., Marcus, S. C., West, J. C., Wilk, J., & Olfson, M. (2007). Adding or switching antipsychotic medications in treatment-refractory schizophrenia. Psychiatric Services, 58(7), 983–990
Kuramoto-Crawford, J., & Zodet, M. (2014). Behavioral health conditions and health care expenditures of adults aged 18 to 64 dually eligible for medicaid and medicare. Retrieved from Rockville, MD: https://www.ncbi.nlm.nih.gov/books/NBK384683/pdf/Bookshelf_NBK384683.pdf
Lambert, B. L., Chou, C. H., Chang, K. Y., Tafesse, E., & Carson, W. (2005). Antipsychotic exposure and type 2 diabetes among patients with schizophrenia: A matched case-control study of California Medicaid claims. Pharmacoepidemiology and Drug Safety, 14(6), 417–425. https://doi.org/10.1002/pds.1092
Leckman-Westin, E., Kealey, E., Gupta, N., Chen, Q., Gerhard, T., Crystal, S., Olfson, M., & Finnerty, M. (2014). Validation of a claims-based antipsychotic polypharmacy measure. Pharmacoepidemiology and Drug Safety, 23(6), 628–635
Leucht, S., Samara, M., Heres, S., & Davis, J. M. (2016). Dose equivalents for antipsychotic drugs: The DDD method. Schizophrenia Bulletin, 42(Suppl 1), S90-94. https://doi.org/10.1093/schbul/sbv167
Medicare Payment Advisory Commission. (2018). Chapter 9: Managed care plans for dual-eligible beneficiaries. In Report to the congress: Medicare and the health care delivery system (pp. 243–283). Washington, DC.
Mojtabai, R., & Olfson, M. (2010). National trends in psychotropic medication polypharmacy in office-based psychiatry. Archives of General Psychiatry, 67(1), 26–36. https://doi.org/10.1001/archgenpsychiatry.2009.175
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, 29(1), 183–195
National Association of State Mental Health Program Directors Research Institute, Inc. (2012). History of HBIPS Core Measure Set. Retrieved from Falls Church, VA. http://www.nri-inc.org/media/1100/2012-history-of-hbips-bhpms.pdf
National Priorities Partnership. (2008). National priorities and goals: Aligning our efforts to transform America's Healthcare.
Nielsen, J., Skadhede, S., & Correll, C. U. (2010). Antipsychotics associated with the development of type 2 diabetes in antipsychotic-naive schizophrenia patients. Neuropsychopharmacology, 35(9), 1997–2004. https://doi.org/10.1038/npp.2010.78
Ortiz-Orendain, J., Castiello-de Obeso, S., Colunga-Lozano, L. E., Hu, Y., Maayan, N., & Adams, C. E. (2017). Antipsychotic combinations for schizophrenia. Cochrane Database Systematic Review, 6(6), Cd009005. https://doi.org/10.1002/14651858.CD009005.pub2
Patrick, V., Schleifer, S. J., Nurenberg, J. R., & Gill, K. J. (2006). Best practices: An initiative to curtail the use of antipsychotic polypharmacy in a state psychiatric hospital. Psychiatric Services (washington, d. c.), 57(1), 21–23. https://doi.org/10.1176/appi.ps.57.1.21
Stowell, K. R., Ghinassi, F. A., Fabian, T. J., Nash, K. C., & Haskett, R. F. (2009). Best practices: An intervention to promote evidence-based prescribing at a large psychiatric hospital. Psychiatric Services (washington, d. c.), 60(3), 294–296. https://doi.org/10.1176/appi.ps.60.3.294
The Joint Commission. (2019). Measure Information Form. Specifications manual for joint commission national quality measures (v2019A). Retrieved from https://manual.jointcommission.org/releases/TJC2019A/MIF0120.html
Tiihonen, J., Taipale, H., Mehtälä, J., Vattulainen, P., Correll, C. U., & Tanskanen, A. (2019). Association of antipsychotic polypharmacy vs monotherapy with psychiatric rehospitalization among adults with schizophrenia. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2018.4320
U.S. Department of Health & Human Services Office of Minority Health. (2019, December 19). Diabetes and African Americans. Retrieved from https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=18
U.S. Department of Health & Human Services Office of Minority Health. (2020, February 14). Heart Disease and African Americans. Retrieved from https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=19
United States Government Accountability Office. (2014). Prescription Drugs: Comparison of DoD, Medicaid, and Medicare Part D Retail Reimbursemnet Prices. Retrieved from Washington, DC. https://www.gao.gov/assets/670/664521.pdf
Valuck, R. J., Morrato, E. H., Dodd, S., Oderda, G., Haxby, D. G., Allen, R., & Medicaid Pharmacotherapy Research, C. (2007). How expensive is antipsychotic polypharmacy? Experience from five US state Medicaid Programs. Current Medical Research and Opinion 23(10), 2567–2576 https://doi.org/10.1185/030079907X233214
Ward, A., Quon, P., Abouzaid, S., Haber, N., Ahmed, S., & Kim, E. (2013). Cardiometabolic consequences of therapy for chronic schizophrenia using second-generation antipsychotic agents in a medicaid population: clinical and economic evaluation. Pharmacy and Therapeutics, 38(2), 109–115
Young, K. (2019). Utilization and spending trends in medicaid outpatient prescription drugs. Retrieved from http://files.kff.org/attachment/Issue-Brief-Utilization-and-Spending-Trends-in-Medicaid-Outpatient-Prescription-Drugs
Zhou, X., Keitner, G. I., Qin, B., Ravindran, A. V., Bauer, M., Del Giovane, C., & Zhang, Y. (2015). Atypical antipsychotic augmentation for treatment-resistant depression: A systematic review and network meta-analysis. International Journal of Neuropsychopharmacology, 18(11), p060
Zhu, B., Ascher-Svanum, H., Faries, D., Correll, C., & Kane, J. (2008). Cost of antipsychotic polypharmacy in the treatment of schizophrenia. BMC Psychiatry, 8(1), 19. https://doi.org/10.1186/1471-244X-8-19
Zur, J., Musumeci, M., & Garfield, R. (2017). Medicaid's role in financing behavioral health services for low-income individuals. Retrieved from http://files.kff.org/attachment/Issue-Brief-Medicaids-Role-in-Financing-Behavioral-Health-Services-for-Low-Income-Individuals
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Authors report no financial relationships with commercial interests. This research was supported by R01 MH106682 from the National Institute of Mental Health and R01 MDO12428 from the National Institute of Minority Health and Health Disparities.
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Horvitz-Lennon, M., Volya, R., Zelevinsky, K. et al. Significance and Factors Associated with Antipsychotic Polypharmacy Utilization Among Publicly Insured US Adults. Adm Policy Ment Health 49, 59–70 (2022). https://doi.org/10.1007/s10488-021-01141-7
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DOI: https://doi.org/10.1007/s10488-021-01141-7