Psychotropic Polypharmacy Combinations and Duration of Polypharmacy Among Medicaid-Enrolled Youths.

OBJECTIVE: This study evaluated psychotropic polypharmacy frequency and patterns of use among Medicaid-enrolled youths. METHODS: A cross-sectional study of a state Medicaid claims database (2015-2020) focused on youths (≤17 years old) with at least one psychotropic medication claim and ≥90 continuous days of Medicaid enrollment. Psychotropic polypharmacy (claims for three or more therapeutic classes of psychotropics for ≥90 consecutive days) was analyzed as average annual days and annual prevalence of class combinations. Multivariable negative binomial regression models assessed changes in annual psychotropic polypharmacy days. RESULTS: A total of 126,972 unique youths were identified. Almost all youths with psychotropic polypharmacy had three-class combinations, the most common of which included attention-deficit hyperactivity disorder medications, antipsychotics, and antidepressants. The number of polypharmacy days increased from a mean±SD of 227.8±90.3 in 2015 to 235.7±97.5 in 2020. Polypharmacy days significantly increased year over year (rate ratio=1.01, 95% CI=1.00-1.01). CONCLUSIONS: Psychotropic polypharmacy regimens reflect chronic use that is increasing over time.

Antidepressant treatment initiation among children and adolescents with acute versus long COVID: a large retrospective cohort study.

BACKGROUND: Child and adolescent antidepressant use increased post-pandemic, but it is unknown if this disproportionally affected those who develop post-acute sequelae of coronavirus disease 2019 (COVID) or long COVID. This study compared the risk of antidepressant initiation among children and adolescents with long COVID with those who had COVID but did not have evidence of long COVID. METHODS: Our retrospective cohort study of children and adolescents aged 3-17 years at the first evidence of COVID or long COVID from October 1, 2021 through April 4, 2022 was conducted within Komodo's Healthcare Map™ database. The index date was the earliest date of a medical claim associated with a COVID (COVID comparators) or long COVID diagnosis (long COVID cases). The baseline period was six months before the index date. The outcome was antidepressant initiation within twelve months after the index date. Due to the large number of COVID relative to long COVID cases, COVID comparators were randomly selected with a ratio of 2 COVID to 1 long COVID. We used propensity score matching to control for confounding due to imbalances in the baseline covariates. Log-binomial models estimated the relative risk (RR) of antidepressant initiation in the propensity score matched sample. We conducted several sensitivity analyses to test the robustness of our findings to several assumptions. RESULTS: Our child and adolescent sample included 18 274 with COVID and 9137 with long COVID. Compared with those with COVID, a larger proportion of long COVID children and adolescents had psychiatric disorders, psychotropic use, medical comorbidities, were previously hospitalized, or visited the emergency department. In the propensity score-adjusted analysis, the long COVID group had a statistically significant higher risk of antidepressant initiation relative to the COVID comparator (adjusted-RR: 1.40, 95% CI = 1.20, 1.62). Our findings were robust across sensitivity analyses. CONCLUSIONS: The increased risk of antidepressant initiation following long COVID warrants further study to better understand the underlying reasons for this higher risk. Emerging evidence of long COVID's impact on child mental health has important implications for prevention and early interventions.

Risk of incident gout following exposure to recombinant zoster vaccine in US adults aged ≥65 years.

OBJECTIVE: Assess the risk of incident gout following exposure to recombinant zoster vaccine (RZV). METHODS: This case-only, self-controlled risk interval study included a cohort of US fee-for-service Medicare (Part A, B, and D) beneficiaries aged ≥65 years. The exposure was receipt of at least one dose of the two-dose RZV regimen in 2018 or 2019. The risk and control windows were days 1-30 and days 31-60, respectively, following vaccination. Incident gout was defined as the first episode of gout during the risk or control window, with no evidence of gout in the last 365 days. We estimated the relative risk (RR) and 95 % confidence interval (CI) of incident gout in the risk window relative to the control window, using conditional Poisson regression models. Sensitivity analyses included a dose-compliant subanalysis of individuals who received dose 2 60-183 days after dose 1; dose-specific analysis; seasonality adjustment; and COVID-19 adjustment for potential detection bias due to the pandemic. RESULTS: The 1290 RZV-exposed individuals with incident gout were primarily White (86.98 %), male (61.16 %), and aged 70-79 years (55.82 %). The RR of incident gout was 1.00 (95 % CI 0.90, 1.12). In the dose-compliant sensitivity analysis (n = 959 cases of incident gout), the RR of incident gout was 0.99 (95 % CI 0.87, 1.13). The findings were unchanged in the dose-specific, seasonality, and COVID-19 sensitivity analyses. CONCLUSION: The findings suggest that RZV is not significantly associated with an increased risk of incident gout in the Medicare population aged ≥65 years.

Incident Psychotropic Medication Use Among US Commercially Insured Children and Adolescents from 2019 to 2022.

Objective: To compare the proportion of children and adolescents with incident psychotropic medication use from 2019 through 2022. Methods: This cross-sectional study used the IQVIA PharMetrics® Plus for Academics health plan claims database. Our study sample consisted of children and adolescents ages 6-18 who had at least one psychotropic medication in March 2019-February 2022. We examined psychotropic medication use in three distinct study periods: pre-pandemic (March 2019 to February 2020), pandemic-year-1 (March 2020-February 2021), and pandemic-year-2 (March 2021-February 2022). Incident use was defined as no evidence of psychotropic medication in the 12 months preceding the child and adolescent's first psychotropic dispensing in each study period. We estimated incident psychotropic use in the three study periods. Average marginal effects tested for significant differences in psychotropic initiation, overall and stratified by age and sex. Results: In our sample of 42,346 children and adolescents who were dispensed any psychotropic medication during the study period, incident psychotropic users were 27.8% in pre-pandemic, 26.0% in pandemic-year-1, and 27.8% in pandemic-year-2. Incident use of antidepressants was 51.4% in pandemic-year-1 and 54.6% in pandemic-year-2. The probability of incident psychotropic use was 2.4% lower in pandemic-year-1 than in the pre-pandemic year (p < 0.001). The proportion of 6-11-year-olds and females initiating a psychotropic was higher in pandemic-year-2 than pre-pandemic. Conclusion: Incident psychotropic use was most notable in younger and female children 2 years after the pandemic onset.

Discrete Choice Experiments to Elicit Patient Preferences for the Treatment of Major Depressive Disorder: A Systematic Review.

BACKGROUND: Individual preferences for treatment options for major depressive disorder can impact therapeutic decision making, adherence, and ultimately outcomes. OBJECTIVES: This systematic review of discrete choice experiments (DCEs) on patient preferences for major depressive disorder treatment assessed the range of DCE applications in major depressive disorder to document patient stakeholder involvement in DCE development and to identify the relative importance of treatment attributes. METHODS: We searched MEDLINE via Ovid (1946-present), EMBASE (Elsevier interface), Cochrane Central Register of Controlled Trials (Wiley interface), and PsycINFO (EBSCO interface) databases on 29 May, 2024. Covidence software facilitated the review, which four members completed independently. The review was conducted in two phases: title and abstract and then a full-text review. We used an established quality reporting tool to evaluate selected articles. The Covidence extraction tool was adapted for this study. RESULTS: A total of 19 articles were included in this review. Most studies elicited preferences for depression treatment (63.2%) and care delivery (10.5%). Two assessed willingness to pay. Individuals prefer a combination of medicine and counseling over each treatment alone. Treatment efficacy, relapse prevention, and symptom relief were among the most important attributes. Individuals were willing to accept larger risks to achieve symptom improvement. Few studies examined preference heterogeneity with latent subgroups. CONCLUSIONS: Discrete choice experiments for major depressive disorder treatment preferences enable an assessment of trade-offs for first-line therapeutic options. Patient stakeholders are infrequently involved as collaborators in the DCE development. Few examined preference heterogeneity among subgroups.

Patient-Informed Value Elements in Cost-Effectiveness Analyses of Major Depressive Disorder Treatment: A Literature Review and Synthesis.

OBJECTIVES: Prior work identified 6 key value elements (attributes of treatment and desired outcomes) for individuals living with major depressive disorder (MDD) in managing their condition: mode of treatment, time to treatment helpfulness, MDD relief, quality of work, interaction with others, and affordability. The objective of our study was to identify whether previous cost-effectiveness analyses (CEAs) for MDD treatment addressed any of these value elements. A secondary objective was to identify whether any study engaged patients, family members, and caregivers in the model development process. METHODS: We conducted a systematic literature review to identify published model-based CEAs. We compared the elements of the published studies with the MDD patient value elements elicited in prior work to identify gaps and areas for future research. RESULTS: Of 86 published CEAs, we found that 7 included patient out-of-pocket costs, and 32 included measures of productivity, which were both priorities for individuals with MDD. We found that only 2 studies elicited measures from patients for their model, and 2 studies engaged patients in the modeling process. CONCLUSIONS: Published CEA models for MDD treatment do not regularly include value elements that are a priority for this patient population nor do they include patients in their modeling process. Flexible models that can accommodate elements consistent with patient experience are needed, and a multistakeholder engagement approach would help accomplish this.

Psychotropic Polypharmacy Among Youths Enrolled in Medicaid.

This cross-sectional study aims to identify temporal changes and characteristics associated with psychotropic polypharmacy among youths aged 17 years or younger who were enrolled in Medicaid in Maryland.

Impact of Private Payer Policies on the Transition to Telemental Health Care Among Privately Insured Patients with Mental Health Disorders.

Introduction: Mental health patients in states without private payer telehealth reimbursement policies before the public health emergency (PHE) may have experienced reduced access to telemental health (TMH). We estimate the association between private payer telehealth policy status in 2019 and the transition to TMH in 2020. Methods: Retrospective cohort study of privately insured individuals 2-64 years old with a mental health disorder and without TMH use in 2019. We examined new telemental use in 2020 by three categories of policy reimbursement status in 2019 (partial parity, full parity vs. no policy), overall (any telemental), and by modality (live video, audio-only, and online assessments) using logistic regression models clustered by state. Results: Among the 34,612 enrollees, 54.7% received TMH for the first time. Relative to no policy states, enrollees in partial or full parity states were equally likely to receive TMH in 2020. However, enrollees in states with a private payer telehealth policy were less likely to receive audio-only (partial parity: odds ratio [OR]: 0.59, 95% confidence interval [CI]: 0.39-0.90; full parity: OR: 0.38, 95% CI: 0.26-0.55), but more likely to receive online assessments (full parity: OR: 2.28, 95% CI: 1.4-4.59). Conclusions: Privately insured enrollees similarly transitioned to TMH across states suggesting a broad impact of the PHE policies on access to this care. The differences in audio-only and online assessments suggest that providers were possibly better prepared to implement TMH care via live video or patient portals in states with telehealth policies.

Psychotropic Prescriptions During the COVID-19 Pandemic Among U.S. Children and Adolescents Receiving Mental Health Services.

Objective: Increased mental health problems among children and adolescents during the COVID-19 pandemic may have impacted psychotropic medication use. This study describes trends in monthly psychotropic medications before and early in the COVID-19 pandemic among 2- to 17-year-old children and adolescents with mental health disorders. Methods: A cross-sectional study design using the 2019-2020 IQVIA™ prescription and medical commercial claims data to estimate the proportion of children and adolescents with any psychotropic prescription in the month out of all with any mental health-related medical or prescription services in the month and the year-over-year percent change. We assessed monthly proportions of youth who filled a psychotropic prescription overall and by psychotropic class, stratified by age and gender. Results: Of the 8,896,713 children and adolescents in the sample, 24.7% received psychotropic medication during the study period. The proportion of the cohort prescribed a psychotropic medication in a given month averaged 27%-28% from January 2019 to February 2020, peaked at 36.9% in April 2020, and gradually declined to 28.7% in September 2020. The largest year-over-year percent change was in April for antipsychotic (41.9%) and antidepressant (37.9%) medication, which remained higher in September 2020 compared to September 2019, particularly among ages 6 years or older and females. Conclusion: The proportion of youth with a psychotropic prescription increased at the onset of the COVID-19 pandemic, later returning to prepandemic levels. However, antipsychotics and antidepressants remained higher than prepandemic, highlighting the need to further understand the long-lasting effects of the pandemic on children and adolescents.

Barriers to using clinical decision support in ambulatory care: Do clinics in health systems fare better?

OBJECTIVE: We quantify the use of clinical decision support (CDS) and the specific barriers reported by ambulatory clinics and examine whether CDS utilization and barriers differed based on clinics' affiliation with health systems, providing a benchmark for future empirical research and policies related to this topic. MATERIALS AND METHODS: Despite much discussion at the theoretic level, the existing literature provides little empirical understanding of barriers to using CDS in ambulatory care. We analyze data from 821 clinics in 117 medical groups, based on in Minnesota Community Measurement's annual Health Information Technology Survey (2014-2016). We examine clinics' use of 7 CDS tools, along with 7 barriers in 3 areas (resource, user acceptance, and technology). Employing linear probability models, we examine factors associated with CDS barriers. RESULTS: Clinics in health systems used more CDS tools than did clinics not in systems (24 percentage points higher in automated reminders), but they also reported more barriers related to resources and user acceptance (26 percentage points higher in barriers to implementation and 33 points higher in disruptive alarms). Barriers related to workflow redesign increased in clinics affiliated with health systems (33 points higher). Rural clinics were more likely to report barriers to training. CONCLUSIONS: CDS barriers related to resources and user acceptance remained substantial. Health systems, while being effective in promoting CDS tools, may need to provide further assistance to their affiliated ambulatory clinics to overcome barriers, especially the requirement to redesign workflow. Rural clinics may need more resources for training.

Trends in the use of computerized physician order entry by health-system affiliated ambulatory clinics in the United States, 2014-2016.

BACKGROUND: Computerized provider order entry (CPOE) can help providers deliver better quality care. We aimed to understand recent trends in use of CPOE by health system-affiliated ambulatory clinics. METHODS: We analyzed longitudinal data (2014-2016) for 19,109 ambulatory clinics that participated in all 3 years of the Healthcare Information and Management Systems Society Analytics survey to assess use of CPOE and identify characteristics of clinics associated with CPOE use. We calculated descriptive statistics to examine overall trends in use, location of order entry (bedside vs. clinical station), and system-level use CPOE across all clinics. We used linear probability models to explore the association between clinic characteristics (practice size, practice type, and health system type) and two outcomes of interest: CPOE use at any point between 2014 and 2016, and CPOE use beginning in 2015 or 2016. RESULTS: Between 2014 and 2016, use of CPOE increased more than 9 percentage points from 58 to 67%. Larger clinics and those affiliated with multi-hospital health systems were more likely to have reported use of CPOE. We found no difference in CPOE use by primary care versus specialty care clinics. When used, most clinics reported using CPOE for most or all of their orders. Health systems that used CPOE usually did so for all system-affiliated clinics. CONCLUSIONS: Small practice size or not being part of a multi-hospital system are associated with lower use of CPOE between 2014 and 2016. Less than optimal use in these environments may be harming patient outcomes.

Health information technology for ambulatory care in health systems.

OBJECTIVES: The adoption and use of health information technology (IT) by health systems in ambulatory care can be an important driver of care quality. We examine recent trends in health IT adoption by health system-affiliated ambulatory clinics in the context of the federal government's Meaningful Use and Promoting Interoperability programs. STUDY DESIGN: We analyzed a national sample of 17,861 ambulatory clinics affiliated with 1711 health systems, using longitudinal data (2014-2016) from the HIMSS Analytics annual surveys. METHODS: We used descriptive analyses and linear probability models to examine the adoption of electronic health records (EHRs), as well as 16 specific functionalities, at the clinic level and the system level. We compared the differential trends of adoption by various characteristics of health systems. RESULTS: We find that the adoption of an EHR certified by the Office of the National Coordinator for Health IT (ONC) increased from 73% to 91%. However, in 2016, only 38% of clinics reported having all 16 health IT functionalities included in this study. Small health systems lag behind large systems in ambulatory health IT adoption. Patient-facing functionalities were less likely to be adopted than those oriented toward physicians. Health information exchange capabilities are still low among ambulatory clinics, pointing to the importance of the ONC's recent Promoting Interoperability initiative. CONCLUSIONS: The relatively low uptake of health IT functionalities important to care improvement suggests substantial opportunities for further improving adoption of ambulatory health IT even among the current EHR users.

Level of agreement on health information technology adoption and use in survey data: a mixed-methods analysis of ambulatory clinics in 1 US state.

OBJECTIVE: Adoption of health information technology (HIT) is often assessed in surveys of organizations. The validity of data from such surveys for ambulatory clinics has not been evaluated. We compared level of agreement between 1 ambulatory statewide survey and 2 other data sources: a second survey and interviews with survey respondents. MATERIALS AND METHODS: We used 2016 data from 2 surveys of ambulatory providers in Minnesota-the Healthcare Information and Management Systems Society (HIMSS) survey and the Minnesota HIT Ambulatory Clinic Survey-and primary data collected through qualitative interviews with survey respondents. We conducted a concurrent triangulation mixed-methods assessment of the Minnesota HIT survey by assessing level of agreement between it and HIMSS, and a thematic analysis of interview data to assess the respondent's understanding of what was being asked and their approach to responding. RESULTS: We find high agreement between the 2 surveys on questions related to common HIT functionalities-such as computerized provider order entry, medication-based decision support, and e-prescribing-which were widely adopted by respondents' organizations. Qualitative data suggest respondents found wording of items about these functionalities clear but encountered multiple challenges including interpreting items for less commonly adopted functionalities, estimating degree of HIT usage, and indicating relevant barriers. Respondents identified multiple errors in responses and likely reported greater within-group homogeneity than actually existed. CONCLUSIONS: Survey items related to the presence or absence of widely adopted HIT functionalities may be more valid than items about less common functionalities, degree of usage, and barriers.

Asthma mortality in Puerto Rico: 1980-2007.

BACKGROUND: Asthma is a highly prevalent chronic disease. Prevalence and mortality are particularly high in Puerto Ricans living in the United States as compared with other populations. OBJECTIVE: To determine asthma mortality rates in Puerto Rico (1980-2007) and to assess the sociodemographic variables that may be associated with these rates. METHODS: Data were obtained from the Vital Statistics Office at the Puerto Rico Department of Health. Crude mortality rates (CMRs) and their 95% confidence intervals (95% CIs) were used to evaluate differences between age groups and across years. Mortality risk ratios (RRs) by sociodemographic variables were estimated using generalized lineal models with a Poisson link function to identify at-risk groups. RESULTS: During the study period, there were 4232 deaths recorded with asthma as the cause of death. From 1980 to 1998, annual asthma mortality rates fluctuated between 3.32 and 6.56 deaths per 100,000 (mean 4.77), followed by a decline after implementation of the ICD-10 for reporting cause of death in 1999. Between 1999 and 2007, the mean asthma death rate declined to 3.01 (4.89 in 1999 to 2.02 in 2007). Overall, asthma mortality rates were between 1.77 and 4.0 times higher in Puerto Rico than in the United States. Throughout the whole study period, mortality rates were higher in older age groups. In addition, the adjusted regression model for asthma deaths showed that persons divorced or widowed, and persons with only elementary education had significantly higher risk of asthma mortality than their counterparts. CONCLUSION: Asthma death rates were higher in Puerto Rico than in the United States general population. Although asthma mortality in Puerto Rico declined, rates continued to be significantly higher than those recorded in the United States. There was a progressive decline in asthma mortality rates after 1999 that may be explained by changes in reporting classification, increased use of corticosteroids, and improved asthma awareness. After controlling for possible confounding variables, age and elementary education were found to increase the risk of mortality due to asthma among Puerto Ricans.