and 20.7%, respectively). Of those treated with antipsychotics, only 8.7% received glucose and lipids screening. Most children diagnosed with ADHD are prescribed the recommended first-line stimulants; however, follow-up after initiation of medication is poor. 85% of children diagnosed with ADHD were prescribed an amphetamine or methylphenidate-based stimulant. Only about a third of youth (32.9%) had at least one follow-up visit with a prescribing practitioner within 30 days of initiating the stimulant. Quality of care for Preschoolers Most young children treated with psychotropic medications do not receive psychosocial treatment. The prevalence of antipsychotic use among children aged 2-5 was .78%. Of those young children prescribed antipsychotics, most (70.9%) were diagnosed with behavioral disorders. Of those young children prescribed psychotropic medications, only about one fifth (20.5%) had 6 or more psychosocial visits prior to initiating the medication and 54.6% had 6 or more psychosocial visits after initiating the medication. Continuity of Care Most children with mental health problems admitted to the emergency room and/or hospital do not receive timely outpatient follow-up. Of the children admitted to the emergency room, only 38% (4 out of 10 children) received an outpatient follow-up within 30 days. Less than two-thirds (62.2%) receiving an outpatient visits after hospital discharge Policy Implications The findings provide important guidance for policy and practice to improve the quality of care for children and adolescents. Three main implications emerge from this study: Need for quality improvement efforts focused on inappropriate prescribing The results from the study suggest that questionable psychotropic prescribing is common including the use of concomitant medications, doses that exceed the recommended maximum, and prescribing to children under age six. Such practices not only pose health risks but the effectiveness is virtually unknown. Quality improvement initiatives are needed to improve psychotropic prescribing practices, especially for children in foster care.
Table 2 Quality of Care Process Measures for Medicaid-Enrolled Youth with Mental Health and Substance Abuse Disorders Measure Description Developer Evidence Ratinga Polypharmacy > 4 medications > 2 antipsychotics > 3 mood stabilizers > 2 stimulants % of enrollees 18 years of age or younger on four (4) or more psychotropic medications for ≥ 60 days during the measurement year % of children 18 years of age or younger who are on two (2) or more antipsychotic medications for ≥ 60 days concomitantly during the measurement year % or children 18 years of age or younger who are on three (3) or more concomitant mood stabilizing agents for ≥ 60 days during the measurement year % of enrollees 18 years of age or younger who are on two (2) or more concomitant amphetamine and methylphenidate-based stimulants for ≥ 60 days during the measurement year PSYCKES/TEXAS PSYCKES/TEXAS/ MMDLN/Rutgers CERTS SYKES/TEXAS PSYCKES/TEXAS C B C C Dosing and Duration Chronic use of benzodiazepine Higher than recommended dose of antipsychotic medications Higher than recommended dose of ADHD medications % of enrollees 18 years of age or younger with a mental health diagnosis who used benzodiazepines for ≥ 60 days or more % or enrollees 18 years of age or younger who are prescribed a dose of antipsychotic medication that exceeds the recommended maximum during the measurement period % of enrollees 18 years of age or younger on ADHD medications with evidence of a dose higher than the recommended maximum during the measurement period Research PSYCKES PSYCKES B A B Depressive Disorders Antidepressant medication management, acute phase % of members 18 years of age and younger diagnosed with a new episode of depression and treated with antidepressant medication who remained on an antidepressant drug during the 84-day (12 week) acute treatment phase NCQA/HEDIS/AHRQ A
Antidepressant medication management, continuation phase Optimal medication provider contacts, acute phase Optimal psychotherapy provider contacts, acute phase Adequacy of antidepressant dosage % members 18 years of age or younger diagnosed with a new episode of depression and treated with antidepressant medication, who remained on an antidepressant for at least 180 days % of members 18 years of age or younger with a new episodes of depression with 3 or more medication visits by a prescribing provider (e.g., physician or nurse practitioner) in the 84-day (12 week) acute treatment phase % of members 18 years of age or younger with a new episodes of depression with 6 or more outpatient mental health visits in the 84-day (12 week) acute treatment phase % of members 18 years of age or younger with new episodes of depression and treated with antidepressants, who received an appropriate dose (e.g., within the recommended therapeutic range) NCQA/HEDIS/AHRQ NCQA/HEDIS/AHRQ NCQA/HEDIS/AHRQ APA/AHRQ A C C A Bipolar Disorder Use of appropriate medication Blood levels for mood stabilizers Side effect monitoring of mood stabilizers Metabolic screening when an antipsychotic is prescribed % of enrollees 18 years of age or younger who receive either a mood stabilizer and/or antipsychotic within 84-days (12 weeks) of the initial bipolar diagnosis % of enrollees 18 years of age or younger with ≥ 1 serum medication blood level test within 84-days (12 weeks) of initiation of lithium or mood stabilizer (carbamazepine, divalproex sodium/valproic acid) % of enrollees 18 years of age or younger with ≥ 1 thyroid or renal function test within 84-days (12 weeks) after initiation of lithium or ≥ 1 liver test within 84-days (12 weeks) after initiation of valproic acid or carbamazepine % of enrollees 18 years of age or younger with ≥ 1 plasma glucose test and ≥ 1 lipids test within 112-days (16 weeks) after initiating an atypical antipsychotic CQAIMH/STABLE/ AACAP/APA CQAIMH/STABLE/ Research AACAP CQAIMH/STABLE A B B A
include increased the risk of obesity in children, Type 2 diabetes, cardiovascular conditions, neurologic effects including tardive dyskinesia, and extrapyramidal symptoms, and cognitive impairment. 14. Mood stabilizer polypharmacy (> 3 mood stabilizers) (All diagnoses) % or children 18 years of age or younger who are on three (3) or more concomitant mood stabilizing agents for ≥ 60 days Numerator: Those members in the denominator who were prescribed three (3) or more medications concomitantly for 60 days or more Denominator: The number of children (≤18 years) who were prescribed at least one mood stabilizer for 60 days or longer during the measurement year See Appendix F for listing of psychotropic medications Polypharmacy is common in the treatment of refractory bipolar disorder. There have been few controlled studies of the use of combinations of mood stabilizers. Combination therapy increases the risk for drug interactions and creates more side effect burden.. Common side effects of mood stabilizers in pediatric populations include: weight gain, cognitive blunting, enuresis, GI distress, acne, sedation, and lethargy. The interactions of combinations of mood stabilizers are complex and can be potentially dangerous, particularly because children have higher metabolism. Combination therapy may also decrease compliance. Treatment guidelines recommend caution in administration of multiple classes of anticonvulsants together because of the associated risks. Medicaid Claims & Encounter Data Pharmacy file Eligibility file C 15. Stimulant polypharmacy (> 2 stimulants) (All diagnoses) % of enrollees 18 years of age or younger who are on two (2) or more concomitant amphetamine and methylphenidate-based stimulants for ≥ 60 days during Numerator: Those member in the denominator who were prescribed two (2) or more amphetamine and methylphenidate-based stimulants concurrently for 60 days or more Treatment of behavioral symptoms associated with ADHD, disruptive disorders, and autism is a major driver of polypharmacy in children and adolescents. Research Medicaid Claims & Encounter Data Pharmacy file Eligibility file C
B for diagnosis codes and follow-up codes F for medication list Medication treatments for ADHD have known side effects and need to be closely monitored by a prescribing practitioner. 19. Use of a stimulant medication for ADHD % of enrollees 18 years of age or younger diagnosed with ADHD who receive a stimulant medication during the measurement year Numerator: Those children from the denominator who received a stimulant medication Denominator: The total number of children with continuous enrollment and diagnosed with disorder (ADHD) during the measurement year. See Appendix F for stimulant medication list Attention Deficit/Hyperactivity Disorder (ADHD) is a common psychiatric condition with an estimated prevalence between 3% and 6% among school-aged children in the United States. treatment options for ADHD include medication, environmental and behavioral modification, and interventions addressing skill deficits or psychological issues. Studies have shown that stimulant medication is relatively safe and efficacious for short-term treatment of inattentiveness, impulsivity and hyperactivity. Medicaid Claims & Encounter Data Pharmacy Files Eligibility Files Professional Files Inpatient Files B 20. Higher than recommended dose of ADHD medications % of enrollees 18 years of age or younger on ADHD medications with evidence of a dose higher than the recommended maximum during the measurement period Numerator: Those in the denominator with evidence of a dose higher than the recommended maximum Denominator: The number of children 18 years of age or younger who were prescribed at least one stimulant medication for 30 days or more during the measurement year See Appendix D for ADHD dose guidelines While the most effective and tolerable dose of medication varies from individual to individual, studies suggest that doses higher than recommended are not generally associated with improved clinical response. High dosing also increases the risk for poor adherence and adverse side effects. Research suggests that children and youth are particularly vulnerable to adverse effects of psychotropic medications. In children, high doses of stimulants can cause insomnia and appetite suppression. Medicaid Claims & Encounter Data Pharmacy Files Eligibility Files B
Preschool Measures 21. Psychotropic medication use for preschool-aged children (All diagnoses) % of enrollees ≤ 5 who receive 6 outpatient visits prior to initiating psychotropic (antidepressants, stimulants, antipsychotics) medication treatment Numerator: Those in the denominator who received ≥ 6 outpatient mental health visits prior to initiating psychotropic medication Denominator: Number of children ≤ 5 years with continuous enrollment with a mental health diagnosis who had ≥ 1 psychotropic medication prescription fills during the measurement year See Appendix C for procedure codes The use of psychotropic medication in young children of preschool ages is a practice that is limited by the lack of evidence. Guidelines published by The Preschool Psychopharmacology Working Group (PPWG) recommend treating preschool-aged children with interventions (for up to 12 weeks) before starting psychopharmacological treatment due to the potential impact on their developing brains. Medicaid Claims & Encounter Data Pharmacy Files Professional Files Eligibility Files C 22. Psychosocial visits among preschool-aged children prescribed psychotropic medications (All diagnoses) % of enrollees ≤ 5 who receive ≥ 6 outpatient visits after initiation of psychotropic medications (antidepressants, stimulants, antipsychotics) Numerator: Those in the denominator who received ≥ 6 outpatient mental health visits after initiation of psychotropic medications Denominator: Number of children ≤ 5 years with continuous enrollment who were prescribed a psychotropic medication during the measurement year Rationale from above measure Medicaid Claims & Encounter Data Professional Files Eligibility Files C 23. Use of antipsychotics in preschoolers (All diagnoses) % of enrollees under 6 years of age who are prescribed an antipsychotic medication during the measurement year Numerator: Those members from the denominator aged ≤ 5 who were prescribed an antipsychotic medication Denominator: The number of children (≤ 18 years) who were enrolled in Medicaid during the measurement year During the past decade rates of prescription for psychotropic medications to preschoolers have risen for both Medicaid and privately insured populations, particularly the use of antipsychotics and stimulants. According to a national study, the rate of antipsychotic use in privately insured preschoolers more than doubled from 1999 to Medicaid Claims & Encounter Data Pharmacy file Eligibility file C
2007. The effectiveness and safety, and appropriate dosing of atypical antipsychotics in preschool children remain unknown. Adverse effects have been documented in the literature (even at low doses) including: excessive weight gain and obesity, increases in prolactin, and extrapyramidal side effects. The effect of antipsychotics on the neurodevelopment of young children is also unknown. Anxiety Measures 24. Pharmacotherapy with SSRIs for anxiety disorders % of enrollees 18 years of age or younger with a new episode of anxiety disorder who received at least one prescription for an selective serotonin reuptake inhibitor (SSRI) within the 84 days (12 weeks) of the initial diagnosis Numerator: Those children in the denominator with at least one prescription for an SSRI medication Denominator: The number of children (≤ 18 years of age) with continuous enrollment and a new diagnosis for anxiety disorder who had at least one prescription for a psychotropic medication during the 84 day (12 week) acute treatment phase. See Appendix F for listing of SSRI antidepressants SSRIs are the first-line medication treatment for childhood anxiety disorders. AACAP practice guidelines recommend pharmacological interventions when anxiety symptoms are moderate or severe and/or in instances of partial response to psychotherapy. Multiple RCTs have demonstrated the efficacy of SSRIs for the treatment of childhood anxiety disorders, including: GAD, social phobia, and SAD. SSRIs are also well tolerated in children and adolescents with anxiety disorders. Medicaid Claims & Encounter Data Pharmacy Files Eligibility Files Professional Files A 25. Chronic use of benzodiazepine (All diagnoses) % of enrollees 18 years of age or younger with a mental health diagnosis who used benzodiazepines for ≥ 60 days or more Numerator: Those children in the denominator with continuous benzodiazepine treatment (≥ 60 days of use) Denominator: The number of children (≤ 18 years of age) who were continuously enrolled and had a Reports from the literature suggest a nearly threefold increase in use of anxiolytics for children and adolescents during the past decade. Despite this trend, the literature supporting the therapeutic role of benzodiazepines in children is sparse. The safety and efficacy of Medicaid Claims & Encounter Data Pharmacy Files Eligibility Files Professional Files B
potential. Higher than recommended doses increase the risk of side effects. All Diagnoses 28. Follow-up after emergency room visit (All diagnoses) % of members 18 years of age or younger with an emergency room visit for mental health or substance abuse disorder and/or deliberate self-harm who received a follow-up outpatient mental health within 30 days of discharge from the ED Numerator: Those members in the denominator who received a outpatient mental health visit within 30 days of discharge from the ED Denominator: The number of members 18 years of age or younger who were continuously enrolled during the measurement period and diagnosed with a mental health or substance abuse disorder and discharged from the emergency room See Appendix C for CPT codes A substantial proportion of young Medicaid beneficiaries who present to EDs with deliberate self-harm are discharged to the community and do not receive emergency mental health assessments or follow-up outpatient mental health care. For example, a recent national study found that only 43% of youths received outpatient care following and ED visit for mental health. Medicaid Claims & Encounter Data Eligibility Files Professional File B 29. Follow-up after hospitalization 30 Days (All diagnoses) % of patients hospitalized for treatment of depressive disorder, seen by a mental health provider within 30 days of discharge Numerator: Those members in the denominator who had an ambulatory or other specified type of outpatient follow-up within 30 days after discharge from the hospital Denominator: The number of members < 18 who were continuously enrolled and who received inpatient treatment for a mental health disorder during the measurement period See Appendix C for CPT codes In the United States, inpatient services account for about 33% ($3.9 billion) of the total mental health expenditures for children and adolescents; across age groups adolescents are the highest users of inpatient services. Lack of timely follow-up care is associated with increased risk for suicide/suicidal behavior, readmission, and relapse. Medicaid Claims & Encounter Files Inpatient Files Eligibility Files Professional Files C 30. Treatment engagement % of members of members 18 years of age or younger who Numerator: Those members from the denominator who had a mental health Many patients discontinue treatment prematurely, resulting in failure to Medicaid Claims & Encounter C