Cardiovascular Events Following Treatment Initiation with Atypical Antipsychotic Medications in Publicly Insured U.S. Youth.

OBJECTIVE: To assess the risk of incident cardiovascular events that led to hospitalizations or emergency department visits following atypical antipsychotic (AAP) treatment initiation in youth according to dose, duration of use, and concomitant use of leading psychotropic medication classes. METHODS: We used computerized Medicaid claims to conduct a retrospective cohort study of youth (5-20 years) who initiated AAP treatment. AAP use was operationalized in a time-dependent manner according to current vs. former use, average daily dose (in risperidone dose equivalents), and duration of use. In a secondary analysis, concomitant use of (1) stimulants and (2) serotonin-reuptake inhibitors (SSRI/SNRIs) with AAPs was also assessed. To account for confounding, disease risk score methodology was used in discrete time failure models. RESULTS: There were 74,700 youth who initiated AAP treatment (average follow-up = 24.8 months). During follow-up, the risk of cardiovascular events was significantly greater during current than former AAP use (RR = 1.55, 95% CI = 1.09-2.21). Furthermore, for current users of AAPs, the risk of cardiovascular events intensified with average daily dose (RR = 2.04, 95% CI = 1.11-3.77 for >3.75 mg/day vs. ≤1.25 mg/day). The risk of cardiovascular events did not significantly differ according to duration of AAP use. In AAP-treated youth, concomitant SSRI/SNRI use was associated with an increased risk of cardiovascular events (RR = 1.61, 95% CI = 1.01-2.57). By contrast, stimulant use concomitant with AAPs was not significantly associated with an increased risk of cardiovascular events. CONCLUSIONS: In publicly insured U.S. youth, current AAP use was associated with an increased risk of incident cardiovascular events, which intensified with increasing dose and with concomitant SSRI/SNRI use. Prudent interpretation of these findings suggests that further research is needed to identify youth subpopulations with the greatest risk of developing AAP treatment-emergent cardiovascular events.

The Impact of a State Medicaid Peer-Review Authorization Program on Pediatric Use of Antipsychotic Medications.

OBJECTIVE: This cross-sectional study assessed the impact of a peer-review program on the prevalence of pediatric antipsychotic use among Medicaid-insured youths in a Mid-Atlantic state. METHODS: Medicaid claims (2010-2014) were assessed among continuously enrolled youths in the 12 months before and after implementation of peer review. The study identified children ages zero to four preimplementation (N=118,815) and postimplementation (N=121,431), ages five to nine preimplementation (N=98,681) and postimplementation (N=107,872), and ages 10 to 17 preimplementation (N=154,696) and postimplementation (N=161,370). (Age ranges are inclusive of the final number). In each age group, multivariable logistic regression models with generalized estimating equations assessed the change in annual prevalence of antipsychotic use pre- to postimplementation. Use of other leading psychotropic classes and antipsychotic prescribing by medical specialty were also examined. RESULTS: The annual pre- to postimplementation prevalence of antipsychotic use decreased significantly, from .07% to .03% (adjusted odds ratio [AOR]=.41) among children ages zero to four, from 1.57% to .86% (AOR=.54) among those ages five to nine, and from 3.28% to 2.40% (AOR=.72) among those ages 10 to 17. With the exception of alpha-agonist use, which increased postimplementation (AOR=1.30) among those ages zero to four, no clinically significant pre-post change was noted in other leading psychotropic classes among children ages zero to four and 10 to 17. By contrast, postimplementation use of other psychotropic medications decreased among those ages five to nine (AOR=.73). CONCLUSIONS: A state Medicaid peer-review program resulted in decreased antipsychotic use across all age groups, particularly among children younger than ten. No notable substitution of other psychotropic classes for antipsychotics was observed.

Association of Antidepressant Medications With Incident Type 2 Diabetes Among Medicaid-Insured Youths.

Importance: Antidepressants are one of the most commonly prescribed classes of psychotropic medications among US youths. For adults, there is emerging evidence on the increased risk of type 2 diabetes in association with antidepressant use. However, little is known about the antidepressant treatment-emergent risk of type 2 diabetes among youths. Objective: To assess the association between antidepressant use and the risk of incident type 2 diabetes in youths by antidepressant subclass and according to duration of use, cumulative dose, and average daily dose. Design, Setting, and Participants: A retrospective cohort study was conducted using Medicaid claims data from 4 geographically diverse, large states of youths 5 to 20 years of age who initiated antidepressant treatment from January 1, 2005, to December 31, 2009. Exposures: Antidepressant use (selective serotonin reuptake inhibitors [SSRIs] or serotonin-norepinephrine reuptake inhibitors [SNRIs], tricyclic or other cyclic antidepressants, and other antidepressants) was assessed using the following 4 time-varying measures: current or former use, duration of use, cumulative dose, and average daily dose. Main Outcomes and Measures: Incident type 2 diabetes was assessed using discrete-time failure models, adjusting for disease risk score estimated using more than 125 baseline and time-dependent covariates. Results: In this cohort of 119 608 youths aged 5 to 20 years who initiated antidepressant treatment (59 087 female youths and 60 521 male youths; 54.7% between 5 and 14 years of age) with a mean follow-up of 22.8 months, 79 285 [66.3%] had SSRI or SNRI exposure. The risk of type 2 diabetes was significantly greater during current use than former use of SSRIs or SNRIs (absolute risk, 1.29 per 10 000 person-months vs 0.64 per 10 000 person-months; adjusted relative risk [RR], 1.88; 95% CI, 1.34-2.64) and tricyclic or other cyclic antidepressants (absolute risk, 0.89 per 10 000 person-months vs 0.48 per 10 000 person-months; RR, 2.15; 95% CI, 1.06-4.36), but not of other antidepressants (absolute risk, 1.15 per 10 000 person-months vs 1.12 per 10 000 person-months; RR, 0.99; 95% CI, 0.66-1.50). Furthermore, for youths currently using SSRIs or SNRIs, the risk of type 2 diabetes increased with the duration of use (RR, 2.66; 95% CI, 1.45-4.88 for >210 days and RR, 2.56; 95% CI, 1.29-5.08 for 151-210 days compared with 1-90 days) and with the cumulative dose (RR, 2.44; 95% CI, 1.35-4.43 for >4500 mg and RR, 2.17; 95% CI, 1.07-4.40 for 3001-4500 mg compared with 1-1500 mg in fluoxetine hydrochloride dose equivalents). By contrast, neither the duration nor the cumulative dose of other antidepressants was associated with an increased risk of type 2 diabetes. The risk of type 2 diabetes increased significantly with the average daily dose among youths with more than 150 days of SSRI or SNRI use (RR, 2.39; 95% CI, 1.04-5.52 for >15.0 vs ≤15.0 mg/d) but not among youths with 1 to 150 days of SSRI or SNRI use. Conclusions and Relevance: In a large cohort of youths insured by Medicaid, the use of SSRIs or SNRIs-the most commonly used antidepressant subclass-was associated with an increased risk of type 2 diabetes that intensified with increasing duration of use, cumulative dose, and average daily dose.

Concomitant Use of Atypical Antipsychotics With Other Psychotropic Medication Classes and the Risk of Type 2 Diabetes Mellitus.

OBJECTIVE: More than half of youth treated with atypical antipsychotic (AAP) medications are also treated with concomitant antidepressants or stimulants. This study assessed the association between antidepressant or stimulant use concomitant with AAPs and the risk of incident type 2 diabetes mellitus (T2DM). METHOD: Medicaid Analytic eXtract data were used to conduct a retrospective cohort study of youth (aged 5-20 years) who initiated AAP treatment. In AAP-treated youth, concomitant antidepressant (selective serotonin reuptake inhibitors [SSRI]/serotonin-norepinephrine reuptake inhibitors [SNRIs], tricyclic/other cyclic antidepressants [TCAs], and other antidepressants) or stimulant use was assessed. The risk of incident T2DM was estimated using discrete time failure models, adjusting for disease risk score estimated using >125 baseline and time-dependent covariates. RESULTS: Among 73,224 AAP initiators, 43.0% had concomitant antidepressant use (76.4% were SSRI/SNRIs) and 43.8% had concomitant stimulant use. The study cohort had an average follow-up of 24.8 months (median = 22.0 months, interquartile range [IQR] = 10.0-38.0 months). In current AAP-treated youth, concomitant SSRI/SNRI (relative risk [RR] = 1.84, 95% CI = 1.30-2.59) or TCA use (RR = 2.75, 95% CI = 1.28-5.87) was associated with an increased risk of T2DM. By contrast, concomitant use of other antidepressants or stimulants with AAPs was not associated with an increased risk of T2DM. In concomitant users of AAPs and SSRI/SNRIs, the risk of T2DM increased with the duration of SSRI/SNRI use (RR = 2.35, 95% CI = 1.15-4.83 for ≥180 days vs. 1-180 days) as well as with the cumulative SSRI/SNRI dose (RR = 1.99, 95% CI = 1.08-3.67 for >2,700 mg vs. 1-2,700 mg fluoxetine dose equivalents), after adjusting for the duration and cumulative dose of AAP use. By contrast, in concomitant users of AAPs and stimulants, neither duration nor cumulative dose of stimulants was associated with an increased risk of T2DM. CONCLUSION: In AAP-treated Medicaid-insured youth, concomitant SSRI/SNRI use was associated with a heightened risk of T2DM, which intensified with increasing duration and dose.

Hispanic Residential Isolation, ADHD Diagnosis and Stimulant Treatment among Medicaid-Insured Youth.

OBJECTIVE: This study aimed to evaluate a conceptual framework that assessed the effect of Hispanic residential isolation on Attention Deficit Hyperactivity Disorder (ADHD) health service utilization among 2.2 million publicly insured youth. DESIGN: Cross-sectional. SETTING: Medicaid administrative claims data for ambulatory care services from a US Pacific state linked with US census data. PARTICIPANTS: Youth, aged 2-17 years, continuously enrolled in 2009. MAIN OUTCOME MEASURES: The percent annual prevalence and odds of ADHD diagnosis and stimulant use according to two measures of racial/ethnic residential isolation: 1) the county-level Hispanic isolation index (HI) defined as the population density of Hispanic residents in relation to other racial/ethnic groups in a county (<.5; .5-.64; ≥.65); and 2) the proportion of Hispanic residents in a ZIP code tabulation area (<25%; 25%-50%; >50%). RESULTS: Among the 47,364 youth with a clinician-reported ADHD diagnosis, 60% received a stimulant treatment (N = 28,334). As the county level HI increased, Hispanic residents of ethnically isolated locales were significantly less likely to receive an ADHD diagnosis (adjusted odds ratio [AOR]=.92 [95% CI=.88-.96]) and stimulant use (AOR=.61 [95% CI=.59-.64]) compared with Hispanic youth in less isolated areas. At the ZIP code level, a similar pattern of reduced ADHD diagnosis (AOR=.81 [95% CI=.77-.86]) and reduced stimulant use (AOR=.65 [95% CI=.61-.69]) was observed as Hispanic residential isolation increased from the least isolated to the most isolated ZIP code areas. CONCLUSIONS: These findings highlight the opportunity for Big Data to advance mental health research on strategies to reduce racial/ethnic health disparities, particularly for poor and vulnerable youth. Further exploration of racial/ethnic residential isolation in other large data sources is needed to guide future policy development and to target culturally sensitive interventions.

Antipsychotic prescribing for behavioral disorders in US youth: physician specialty, insurance coverage, and complex regimens.

PURPOSE: To assess antipsychotic prescribing patterns according to insurance coverage type and physician specialty in the outpatient treatment of behavioral disorders (BD) in US youth. METHODS: We used 2003-2010 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data to compare antipsychotic prescribing in the outpatient treatment of BD in youth (6-19 years) according to insurance coverage (public vs. private) and physician specialty (psychiatrist vs. non-psychiatrist) using population-weighted Chi-square and multivariable analyses. Also, we examined co-prescribing of antipsychotics with other psychotropic medication classes. Subgroup analyses were conducted in BD visits with no other clinician-reported psychiatric diagnosis (non-comorbid BD visits). RESULTS: A large majority (71.0%) of BD visits were provided by non-psychiatrists. However, psychiatrists prescribed antipsychotics far more frequently than non-psychiatrists (24.2% vs. 4.6%; adjusted odds ratio (AOR) = 5.1 [95% confidence interval (CI), 2.8-9.2]) in total BD visits as well as in non-comorbid BD visits (18.6% vs. 3.6%; AOR = 5.8 [95% CI, 3.2-10.5]). Antipsychotic prescribing was nearly two-fold greater in visits by publicly insured 6-12 year olds (11.3% vs. 5.8%; AOR = 1.9 [95% CI, 1.1-3.5]) and 13-19 year olds (16.2% vs. 8.9%; AOR = 2.0 [95% CI, 1.1-3.6]) compared with their privately insured counterparts. In more than one-third of antipsychotic-prescribed BD visits, antipsychotics were prescribed concomitantly with ≥2 psychotropic medication classes regardless of age group, insurance coverage, or even in the absence of psychiatric comorbidities. CONCLUSION: In outpatient visits by youth for BD, antipsychotics were primarily prescribed by psychiatrists, concomitantly, and for the publicly insured. These treatment patterns merit further investigation.

Assessment of an Expanded Functional Disability Scale for Older Adults With Diabetes.

Although prior literature has shown the plausibility of combining the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) items to form an expanded scale for measuring the degree of functional decline, this has not been shown in older adults with diabetes who are disproportionately affected by functional disability. Using the 2009 Medicare Current Beneficiary Survey data, we evaluated the factor structure of the pooled ADL and IADL items. Based on our study comprising 2,158 community-dwelling older adults (≥65 years) with diabetes, the unidimensional model exhibited good fit. Despite well-fitting indices, high correlations were observed between the latent constructs (>.70) of the multi-factor models, suggesting a lack of discriminant validity. These findings provide empirical support for a combined scale that can comprehensively and efficiently characterize the extent of functional disability in older adults with diabetes for research, risk adjustment, and evaluation in patient-centered medical homes.

Health care access and smoking cessation among cancer survivors: implications for the Affordable Care Act and survivorship care.

PURPOSE: The study objectives are to examine prevalence of current smoking, and to assess the association of both health insurance (HI) and access to care with smoking cessation among cancer survivors. METHODS: We performed an analysis from a cross-sectional study of cancer survivors aged 18-64 years using nationally representative data from the 2009 Behavioral Risk Factor Surveillance System survey. We assessed the prevalence of current smoking among cancer survivors. Also, in a subset excluding never smokers, we assessed cessation status of cancer survivors operationalized as comparing current to former smokers. RESULTS: The study population (N = 18,896) was predominantly 45-64 years of age, female, and white. The prevalence of current smoking was substantially greater among cancer survivors without HI (40.9 %) than for those with HI (19.5 %). Cancer survivors with no HI had 2-fold greater adjusted odds of not quitting cigarette smoking compared to those with HI. Among those with insurance, cancer survivors who did not have regular health care provider or could not see doctor due to cost or had their last routine checkup ≥1 year ago had 60-80 % fold greater adjusted odds of not quitting cigarette smoking compared to cancer survivors who had better access to health care. CONCLUSIONS: Cancer survivors without HI have substantially greater current smoking rates compared with those with HI. Among cancer survivors with HI, those who experienced health care access-related problems had lower cessation rates than their counterparts. IMPLICATIONS FOR CANCER SURVIVORS: Smoking cessation needs to be recognized as a crucial component of preventive care for cancer survivors. Continuous patient engagement and cancer-patient-centered strategies are urgently needed to achieve optimal results for quit rates particularly for young cancer survivors who are most susceptible to current smoking.

Construct validity and factor structure of survey-based assessment of cost-related medication burden.

BACKGROUND: Millions of Americans are burdened by out-of-pocket prescription costs. Although many survey measures have been developed to assess this burden, the construct validity and the factor structure of these instruments have not been rigorously assessed. OBJECTIVES: To characterize the factor structure and the construct validity of items assessing cost-related medication burden. METHODS: We applied exploratory factor and confirmatory factor analyses to the 2009 Medicare Current Beneficiary Survey, focusing on 10 items assessing cost-related mediation burden among a nationally representative sample of community-dwelling Medicare beneficiaries. The fit of competing models was compared using several indices. RESULTS: The study population (N=8777) was predominantly aged over 65 years (83.3%), female (54.4%), and white (84.3%). Two distinct factors were present for the medication cost-reduction strategies: (1) cost-related medication nonadherence and (2) drug-shopping behaviors, not directly impacting medication compliance. The two factors were moderately correlated (r=0.55), highlighting the presence of a 2 distinct but related constructs for cost-related medication burden. An item assessing the use of mail or internet pharmacies did not load well on either factor and may not necessarily measure medication-related cost burden. An item assessing reduced spending on basic needs loaded strongly on the same factor with the cost-related medication nonadherence items, suggesting they together may represent extreme compensatory behaviors that may adversely affect health outcomes. CONCLUSIONS: Two distinct constructs were derived from these items examining cost-related medication burden. Although cost-related medication burden is often associated with nonadherence, drug-shopping behaviors that do not directly impact adherence are also important measure of this burden.

Atypical antipsychotic use among Medicaid-insured children and adolescents: duration, safety, and monitoring implications.

OBJECTIVE: Over the last two decades, the increased use of atypical antipsychotic medications, often for unlabeled indications including attention-deficit/hyperactivity disorder (ADHD), has been profound. This study aims to characterize duration of atypical antipsychotic use by age group and Medicaid eligibility category, and among youth with noncomorbid ADHD. METHODS: Administrative data on 266,590 youth 2-17 years of age, and continuously enrolled in a mid-Atlantic state Medicaid program in 2006, were assessed in terms of median days of atypical antipsychotic use using bivariate analyses and multivariable quantile regression. Also, in a subanalysis of youth diagnosed with ADHD without any reported psychiatric comorbidities (i.e., noncomorbid ADHD), age-specific adjusted odds and adjusted median days of atypical antipsychotic use by Medicaid eligibility category were assessed. Additionally, patterns of use of single atypical antipsychotic regimens and two concomitant atypical antipsychotic regimens were described. RESULTS: Overall, the median annual duration of atypical antipsychotic use was 180 days (interquartile range: 69-298 days). Children (2-12-year-olds) had longer durations of use than did adolescents (13-17-year-olds) (median 192 vs. 179 days), respectively. In the absence of any comorbid psychiatric diagnosis, ADHD-diagnosed foster care youth had more than threefold greater adjusted odds of atypical antipsychotic use than did youth enrolled in income-eligible Medicaid categories. Nearly one third of such ADHD-diagnosed foster care youth received atypical antipsychotics regardless of age group, with annual duration of use >250 median days in 2-12-year-olds. In concomitant atypical antipsychotic regimens, risperidone, aripiprazole, and quetiapine were the most common. CONCLUSIONS: Exposure to atypical antipsychotics in Medicaid-insured youth, in particular for children in foster care and those diagnosed with ADHD, was substantial, warranting outcomes research for long-term effectiveness, safety, and oversight for appropriate cardiometabolic monitoring.

Pharmacotherapeutic management of dementia across settings of care.

OBJECTIVES: To describe population-based use of cognitive-enhancing and psychopharmacological medications across care settings in Medicare beneficiaries with dementia. DESIGN: One-year (2008) cross-sectional study. SETTING: Medicare administrative claims from a 5% random sample. PARTICIPANTS: Medicare beneficiaries with dementia aged 65 and older with continuous Medicare Parts A, B, and D coverage and alive throughout 2008. To ascertain dementia, one or more medical claims with a dementia International Classification of Diseases, Ninth Revision, Clinical Modification code was required before 2008, and an additional claim was required in 2008 to confirm active disease. MEASUREMENTS: Use of medications commonly prescribed in managing dementia (cognitive enhancers, antidepressants, antipsychotics, and mood stabilizers) was assessed using three measures: annual prevalence of use, consistency of use, and count of psychopharmacological medication classes. Care setting was determined using the number of months of nursing home (NH) residency: no NH (0 months), partial NH (1-11 months), and full NH (12 months). RESULTS: Community-dwellers represented 41.3% of the cohort, whereas 42.4% and 16.3% resided partially and fully in a NH, respectively. Annual prevalence of use was 57.1% for cognitive enhancers, 56.4% for antidepressants, 34.0% for antipsychotics, and 8.8% for mood stabilizers. Cognitive enhancer use was significantly lower in those with any NH stay (partial NH vs no NH, adjusted prevalence ratio (APR) = 0.84, 99% confidence interval (CI) = 0.83-0.86; full NH vs no NH, APR = 0.83, 99% CI = 0.81-0.85). In contrast, those with any NH residence had significantly higher use of all psychopharmacological medication classes than community-dwellers. More than half the cohort had consistent medication regimens during 2008 (64.8%). The number of psychopharmacological medication classes used increased with increasing NH stay duration. CONCLUSION: This population-based study documents significant differences in medication use for managing dementia between care settings and substantial use of psychopharmacological medications in older adults with dementia.

Antipsychotic use by medicaid-insured youths: impact of eligibility and psychiatric diagnosis across a decade.

OBJECTIVE: This cross-sectional study evaluated the impact of Medicaid-eligibility category on the increased use of antipsychotic medication by Medicaid-insured youths across a decade. METHODS: The authors analyzed computerized administrative claims data for 456,315 youths aged two to 17 years who were continuously enrolled in Medicaid in a mid-Atlantic state in 1997 (N=159,171) and 2006 (N=297,144). Bivariate and multivariable analyses quantified changes in antipsychotic use in relation to the youths' psychiatric diagnosis and eligibility category (Temporary Assistance for Needy Families [TANF], state Children's Health Insurance Program [SCHIP], Supplemental Security Income [SSI], and foster care). A second multivariable regression model examined changes in demographic and clinical characteristics of antipsychotic users with a psychiatric diagnosis. RESULTS: The prevalence of antipsychotic use increased from 1.2% in 1997 to 3.2% in 2006. The increase in odds of antipsychotic use in 2006 was greatest among youths enrolled in SCHIP (adjusted odds ratio [AOR]=5.9), followed by youths enrolled in foster care (AOR=4.1), TANF (AOR=3.6), and SSI (AOR=2.8). Among users of antipsychotics who had a psychiatric diagnosis, youths with externalizing behavior disorders and bipolar disorder had 2.4- to 3.8-fold greater odds of using antipsychotics in 2006 versus 1997 compared with youths with schizophrenia or other psychoses and pervasive developmental disorders. The proportion of youths using antipsychotics between 1997 and 2006 increased significantly more among African Americans and Hispanics than among whites. CONCLUSIONS: The expansion of antipsychotic use was most prominent among youths who were Medicaid eligible because of low family income (SCHIP) and reflects increased medication use for behavioral problems.