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Figure.  Policy-Related Trends in the Mean Quarterly Prevalence of Atypical Antipsychotic Use Across 36 Months Among Medicaid-Insured Youth According to Age Restriction Criteria
Policy-Related Trends in the Mean Quarterly Prevalence of Atypical Antipsychotic Use Across 36 Months Among Medicaid-Insured Youth According to Age Restriction Criteria

Age group was defined according to the age restriction criteria set by the peer review prior authorization policies for atypical antipsychotic prescribing to Medicaid-insured youth in the 4 study states. In state A, the policy applied to children younger than 8 years; in states B and C, children younger than 6 years; and in state D, children younger than 5 years.

Table.  Changes in the Mean Monthly Prevalence of AAP Use Among Medicaid-Insured Youth Following Implementation of Peer Review Prior Authorization Policies According to Age Restriction Criteriaa
Changes in the Mean Monthly Prevalence of AAP Use Among Medicaid-Insured Youth Following Implementation of Peer Review Prior Authorization Policies According to Age Restriction Criteriaa
1.
Egger  H.  A perilous disconnect: antipsychotic drug use in very young children.  J Am Acad Child Adolesc Psychiatry. 2010;49(1):3-6.PubMedGoogle Scholar
2.
Burcu  M, Zito  JM, Safer  DJ,  et al.  Concomitant use of atypical antipsychotics with other psychotropic medication classes and the risk of type 2 diabetes mellitus.  J Am Acad Child Adolesc Psychiatry. 2017;56(8):642-651.PubMedGoogle ScholarCrossref
3.
Schmid  I, Burcu  M, Zito  JM.  Medicaid prior authorization policies for pediatric use of antipsychotic medications.  JAMA. 2015;313(9):966-968.PubMedGoogle ScholarCrossref
4.
Shadish  WR, Cook  TD, Campbell  DT. Quasi-experiments: interrupted time-series designs. In: Shadish  WR, Cook  TD, Campbell  DT, eds.  Experimental and Quasi-Experimental Designs for Generalized Causal Inference. Boston, Massachusetts: Houghton Mifflin Co; 2002:171-206.
5.
Crystal  S, Mackie  T, Fenton  MC,  et al.  Rapid growth of antipsychotic prescriptions for children who are publicly insured has ceased, but concerns remain.  Health Aff (Millwood). 2016;35(6):974-982.PubMedGoogle ScholarCrossref
6.
Zito  JM.  Advancing the quality of pediatric antipsychotic use: maybe it takes a PAL.  Health Serv Res. 2017;52(2):555-560.PubMedGoogle ScholarCrossref
Research Letter
January 2018

Pediatric Use of Antipsychotic Medications Before and After Medicaid Peer Review Implementation

Author Affiliations
  • 1Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore
  • 2Department of Psychiatry, University of Maryland, Baltimore
  • 3Now with Merck & Co Inc
  • 4Acumen, LLC, Burlingame, California
  • 5Centers for Medicare & Medicaid Services, Washington, DC
JAMA Psychiatry. 2018;75(1):100-103. doi:10.1001/jamapsychiatry.2017.3493

In response to the growing cardiometabolic safety concerns about the use of atypical antipsychotic (AAP) medications in children,1,2 several state Medicaid agencies have adopted a novel, more clinically nuanced and individualized approach to reviewing the appropriateness of AAP use, namely, peer review prior authorization (PA) policies.3 Physicians must receive preapproval through contracted clinicians (peer reviewers) to prescribe AAPs to certain-aged children. We assessed the effect of peer review PA policies on AAP use among Medicaid-insured youth according to age restriction criteria.

Methods

We used Medicaid administrative claims data from 4 geographically diverse states wherein AAP-related peer review PA policies were implemented between April 2008 and August 2009. Data analysis was conducted from November 4, 2014, to June 12, 2017. Peer review policies were implemented for children younger than 8 years in state A, younger than 6 years in states B and C, and younger than 5 years in state D. We used an interrupted time-series design to assess monthly and quarterly use of AAPs across 36 months, including 12-month prepolicy, 12-month transition, and 12-month postpolicy analysis.4 The unit of analysis was child with any AAP dispensing. The 12-month transition period represented 6 months before and after the policy implementation date in each state. The study was an extension of an interagency agreement between the Centers for Medicare & Medicaid and the US Food and Drug Administration’s Safe Use Initiative. The US Food and Drug Administration Research in Human Subjects Committee determined that the study does not qualify as human research (records review with no identifiers). In multivariable logistic regression models with generalized estimating equations, we added interaction terms for time period and age group to assess whether changes in AAP use differed by age group in the postpolicy vs prepolicy periods.

Results

Compared with the prepolicy period, AAP prevalence after policy implementation decreased significantly from 0.25% to 0.17% (odds ratio [OR], 0.68; 95% CI, 0.64-0.72) for children younger than 8 years in state A, from 0.09% to 0.05% (OR, 0.57; 95% CI, 0.50-0.66) for children younger than 6 years in state B, from 0.09% to 0.07% (OR, 0.76; 95% CI, 0.69-0.84) for children younger than 6 years in state C, and from 0.03% to 0.02% (OR, 0.64; 95% CI, 0.46-0.88) for children younger than 5 years in state D (Table and Figure).

Among older youth (lacking peer review), AAP use increased significantly in states A, B, and C. Although there was a decrease in AAP use in both older (5-17 years) and younger (<5 years) groups in state D, the decrease was significantly greater only in children younger than 5 years (interaction P = .03).

Discussion

With the implementation of the peer review PA policies instituted in 4 geographically diverse state Medicaid programs, AAP use declined substantially in children younger than 5 to 8 years. The policy generally had little or no discernible effect on AAP use in older youth, possibly reflecting evidence-based practice.

These findings are consistent with recent national estimates suggesting that the rapid increase in AAP use among publicly insured young children had stabilized since 2008.5 However, challenges exist, such as growing use of complex AAP regimens and low uptake of recommended cardiometabolic monitoring.5 Educationally oriented peer review, as demonstrated in state D, may account for spillover effects among older youth who were not similarly monitored.6

The study is limited by the inability to control for all the external factors that may affect prescribing patterns. Moreover, the findings may not be nationally representative and do not imply clinical appropriateness. Nonetheless, our study reports significant decreases in AAP use among Medicaid-insured young children following the implementation of these peer review PA policies and motivates research on the long-term consequences of these policies on clinical outcomes.

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Article Information

Accepted for Publication: September 20, 2017.

Corresponding Author: Julie M. Zito, PhD, Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore, 220 Arch St, 12th Floor, Baltimore, MD 21201 (jzito@rx.umaryland.edu).

Published Online: November 15, 2017. doi:10.1001/jamapsychiatry.2017.3493

Author Contributions: Drs Zito and Burcu had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Burcu, McKean, Kelman.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Zito, Burcu.

Critical revision of the manuscript for important intellectual content: Burcu, McKean, Warnock, Kelman.

Statistical analysis: Burcu, McKean, Warnock.

Obtained funding: Kelman.

Administrative, technical, or material support: Burcu, Kelman.

Study supervision: Zito, Burcu, McKean, Kelman.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was funded by the US Food and Drug Administration (FDA).

Role of the Funder/Sponsor: The FDA had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The opinions expressed in this report do not necessarily represent the opinions of the US government, FDA, or the Centers for Medicare & Medicaid Services. The study was initiated and conducted during Dr Burcu's employment at the University of Maryland, Baltimore. The views and opinions expressed in this report do not also represent the views and opinions of any public or private entity, eg, agency, organization, institution, government, or company. The authors do not have any conflict of interest to disclose regarding the content of the study.

References
1.
Egger  H.  A perilous disconnect: antipsychotic drug use in very young children.  J Am Acad Child Adolesc Psychiatry. 2010;49(1):3-6.PubMedGoogle Scholar
2.
Burcu  M, Zito  JM, Safer  DJ,  et al.  Concomitant use of atypical antipsychotics with other psychotropic medication classes and the risk of type 2 diabetes mellitus.  J Am Acad Child Adolesc Psychiatry. 2017;56(8):642-651.PubMedGoogle ScholarCrossref
3.
Schmid  I, Burcu  M, Zito  JM.  Medicaid prior authorization policies for pediatric use of antipsychotic medications.  JAMA. 2015;313(9):966-968.PubMedGoogle ScholarCrossref
4.
Shadish  WR, Cook  TD, Campbell  DT. Quasi-experiments: interrupted time-series designs. In: Shadish  WR, Cook  TD, Campbell  DT, eds.  Experimental and Quasi-Experimental Designs for Generalized Causal Inference. Boston, Massachusetts: Houghton Mifflin Co; 2002:171-206.
5.
Crystal  S, Mackie  T, Fenton  MC,  et al.  Rapid growth of antipsychotic prescriptions for children who are publicly insured has ceased, but concerns remain.  Health Aff (Millwood). 2016;35(6):974-982.PubMedGoogle ScholarCrossref
6.
Zito  JM.  Advancing the quality of pediatric antipsychotic use: maybe it takes a PAL.  Health Serv Res. 2017;52(2):555-560.PubMedGoogle ScholarCrossref
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