Impact of Demographics and Insurance Coverage on Schizophrenia Treatment and Healthcare Resource Utilization Within an Integrated Healthcare System.

Purpose: Little is known about the impact of health disparities on antipsychotic treatment and healthcare resource utilization (HRU) among patients with schizophrenia. The objective of this analysis is to examine treatment patterns and HRU by age, race/ethnicity, and insurance coverage among patients with schizophrenia in an integrated delivery network (IDN). Patients and Methods: This cross-sectional study used electronic health record data from MedStar Health, an IDN in the Baltimore-Washington, DC, area. Patients were aged ≥18 years and had ≥2 outpatient encounters or ≥1 hospitalization with a diagnosis of schizophrenia between January 1, 2017 and March 31, 2021. Outcomes assessed included oral antipsychotic prescriptions, long-acting injectable antipsychotic (LAI) utilization, hospitalizations, emergency department (ED) visits, and outpatient visits. Analyses compared subgroups based on age, race/ethnicity (non-Hispanic Black, non-Hispanic White, and other), and type of insurance coverage at index (Medicare, Medicaid, and other) during 12 months of follow-up. Results: A total of 78.1% of patients had ≥1 prescription for an antipsychotic and 69.1% received ≥1 second-generation antipsychotic. Second-generation long-acting injectables (SGA LAI) were utilized by 9.0% of patients, with the elderly and Medicaid beneficiaries having the lowest SGA LAI utilization. Overall, 61.7% of patients had ≥1 hospitalization, 56.4% had ≥1 outpatient visit, and 50.5% had ≥1 ED visit. Hospitalizations and ED visits were most common in those 18 to 24 years of age and in Medicaid beneficiaries, whereas outpatient visits were more common for the elderly and Medicare beneficiaries. Conclusion: At the population level, the results indicate widespread underprescription/underutilization of antipsychotics that have been shown to improve clinical and economic outcomes in patients with schizophrenia, particularly SGA LAI. Within specific subpopulations, disparities in treatment selection and HRU were observed, suggesting the need for increased attention to at-risk groups to ensure consistent quality of care regardless of age, race/ethnicity, or insurance coverage.

Unraveling ethnic disparities in antipsychotic prescribing among patients with psychosis: A retrospective cohort study based on electronic clinical records.

BACKGROUND: Previous studies have shown mixed evidence on ethnic disparities in antipsychotic prescribing among patients with psychosis in the UK, partly due to small sample sizes. This study aimed to examine the current state of antipsychotic prescription with respect to patient ethnicity among the entire population known to a large UK mental health trust with non-affective psychosis, adjusting for multiple potential risk factors. METHODS: This retrospective cohort study included all patients (N = 19,291) who were aged 18 years or over at their first diagnoses of non-affective psychosis (identified with the ICD-10 codes of F20-F29) recorded in electronic health records (EHRs) at the South London and Maudsley NHS Trust until March 2021. The most recently recorded antipsychotic treatments and patient attributes were extracted from EHRs, including both structured fields and free-text fields processed using natural language processing applications. Multivariable logistic regression models were used to calculate the odds ratios (OR) for antipsychotic prescription according to patient ethnicity, adjusted for multiple potential contributing factors, including demographic (age and gender), clinical (diagnoses, duration of illness, service use and history of cannabis use), socioeconomic factors (level of deprivation and own-group ethnic density in the area of residence) and temporal changes in clinical guidelines (date of prescription). RESULTS: The cohort consisted of 43.10 % White, 8.31 % Asian, 40.80 % Black, 2.64 % Mixed, and 5.14 % of patients from Other ethnicity. Among them, 92.62 % had recorded antipsychotic receipt, where 24.05 % for depot antipsychotics and 81.72 % for second-generation antipsychotic (SGA) medications. Most ethnic minority groups were not significantly different from White patients in receiving any antipsychotic. Among those receiving antipsychotic prescribing, Black patients were more likely to be prescribed depot (adjusted OR 1.29, 95 % confidence interval (CI) 1.14-1.47), but less likely to receive SGA (adjusted OR 0.85, 95 % CI 0.74-0.97), olanzapine (OR 0.82, 95 % CI 0.73-0.92) and clozapine (adjusted OR 0.71, 95 % CI 0.6-0.85) than White patients. All the ethnic minority groups were less likely to be prescribed olanzapine than the White group. CONCLUSIONS: Black patients with psychosis had a distinct pattern in antipsychotic prescription, with less use of SGA, including olanzapine and clozapine, but more use of depot antipsychotics, even when adjusting for the effects of multiple demographic, clinical and socioeconomic factors. Further research is required to understand the sources of these ethnic disparities and eliminate care inequalities.

Antipsychotic utilisation and persistence in Australia: A nationwide 5-year study.

OBJECTIVES: To evaluate the utilisation and persistence of antipsychotics for the treatment of schizophrenia in Australia. METHODS: A retrospective study using the Australian Pharmaceutical Benefits Scheme database of a representative 10% sample. All adults with schizophrenia who were dispensed three or more supplies of oral (including clozapine) or long-acting injectable antipsychotics between 1 June 2015 and 31 May 2020 were included. Persistence time in treatment was evaluated using survival analysis and Cox hazard ratios. RESULTS: In all, 26,847 adults with schizophrenia were studied. Oral second-generation antipsychotics were more frequently dispensed than the other antipsychotic groups studied. Median treatment persistence times were 18.3 months for second-generation antipsychotic long-acting injectables, 10.7 months for oral second-generation antipsychotics and were significantly lower for both formulations of first-generation antipsychotics at 5.2 months (long-acting injectables) and 3.7 months (oral). The median persistence time for clozapine was significantly longer than all other antipsychotics groups. CONCLUSIONS: Oral second-generation antipsychotics and second-generation antipsychotic long-acting injectables accounted for over 75% and 13% of all antipsychotics in Australia, respectively. Concerns over medication adherence and subsequent relapse have not translated into increased long-acting injectable usage despite their significantly longer persistence. Clozapine, the single most 'persistent' antipsychotic, was only used in 9% of people, although up to a third of all cases are likely to be treatment-resistant. Our data suggest clinicians should give consideration to the earlier use of second-generation antipsychotic long-acting injectables and clozapine, to ameliorate prognosis in schizophrenia.

The impact of COVID-19 on antipsychotic prescriptions for patients with schizophrenia in Australia.

OBJECTIVE: To assess the impact, in the Australian setting, of the COVID-19 lockdown on antipsychotic supplies for patients with schizophrenia following a prescription from a new medical consultation when compared to the same periods in the previous 4 years. A secondary objective was to assess the volume of all antipsychotic supplies, from new and repeat prescriptions, over these same periods. METHODS: A retrospective pharmaceutical claims database study was undertaken, using the Department of Human Services Pharmaceutical Benefits Scheme 10% sample. The study population included all adult patients with three or more supplies of oral or long-acting injectable antipsychotics for the treatment of schizophrenia at any time between 1 June 2015 and 31 May 2020. The primary outcome compared volumes of dispensed antipsychotics from new prescriptions (which require a medical consultation) between 1 April and 31 May each year from 2016 to 2020. This was to analyse the period during which the Australian Government imposed a lockdown due to COVID-19 (April to May 2020) when compared the same periods in previous years. RESULTS: There was a small (5.7%) reduction in the number of antipsychotics dispensed from new prescriptions requiring a consultation, from 15,244 to 14,372, between April and May 2019 and the same period in 2020, respectively. However, this reduction was not statistically significant (p = 0.75) after adjusting for treatment class, age, gender, location and provider type. CONCLUSION: The COVID-19 restrictions during April and May 2020 had no significant impact on the volume of antipsychotics dispensed from new prescriptions for patients with schizophrenia when compared to the volume of antipsychotics dispensed from new prescriptions during the same period in previous years.

Polypharmacy in a hospitalized psychiatric population: risk estimation and damage quantification.

BACKGROUND: Polypharmacy increases the risk of pharmacological interactions, prevalence of secondary effects and with this the lack of adherence to treatment. It is estimated that between 10 and 40% of patients hospitalized in psychiatric institutions are prescribed more than one antipsychotic. The objective of the present study was to identify the prevalence of polypharmacy, evaluate adverse effects associated to the use of psych drugs and to estimate the risk in specific groups. METHODS: We carried out a longitudinal, retrospective study that included the analysis of all discharged patients (n = 140) in the first trimester of the year in a psychiatric hospital in Mexico. The information was classified into 7 sections: sociodemographic, diagnosis, clinical follow-up information, prescribed drugs, adverse reactions, substance abuse, laboratory and complementary results. Risk estimation was obtained with Odds Ratios, to correlate continuous variables Pearson's correlation was used. Student's T and Mann Whitney's U were used to compare 2 independent samples; multiple and linear regressions were carried out. RESULTS: The mean number of drugs used during hospitalization was 7.8 drugs per patient. The mean prescribed psych drugs was 4.07. The mean antipsychotic dose was the risperidone equivalent of 5.08 mg. 29.2% of patients had at least one secondary effect associated to the use of drugs, 17.8% presented extrapyramidal symptoms. 81.4% of patients were prescribed 6 or more drugs (polypharmacy) and were 5 times more likely to suffer a secondary effects (OR 6.24). 14.2% had polypharmacy while receiving antipsychotics and had more than twice the risk of presenting extrapyramidal symptoms (OR 3.05). For each added psych drug, hospital stay increased by 6.56 days. CONCLUSIONS: Despite international guideline recommendations where reasoned and conciliatory prescription of psych drugs is advised, there is still a high prevalence of polypharmacy in patients hospitalized in psychiatric institutions. In the present study 4 out of 5 patients received polypharmacy decreasing tolerability, treatment adherence and increasing the risk and costs secondary to an increased hospital stay.

Age-dependent determinants of antipsychotic use among newly admitted residents of skilled nursing facilities: A population-based study.

OBJECTIVES: To assess factors related to antipsychotic (AP) use in skilled nursing facilities for newly admitted residents aged 18 to 49, 50 to 64, 65 to 84, and 85 years or older. METHODS: Retrospective, population-level, Minimum Data Set (MDS) 2.0 data from the United States during the year of 2009 were used. Over 1 million residents were included. Fourteen clinically relevant variables were identified through a literature search. Antipsychotic use was defined as APs dispensed daily for the prior 7 days. Logistic regression was used to identify clinically relevant variables, which were then ranked based on magnitude of their association with APs. RESULTS: Bipolar disorder and schizophrenia were consistently related to AP use across age groups. For older age groups, off-label indications such as cognitive impairment, dementia, behavioral symptoms, and physical restraint use were more closely related to AP use, while delusions and hallucinations decreased in strength. Higher proportions of APs were found in all diseases and symptoms in nonelderly adults, with the exception of physical restraint use. Concurrent physical restraint and AP use was highest for older adults aged 65 to 84 at 36%. CONCLUSIONS: Correlates of AP use varied by age, with stronger associations between on-label conditions and AP use among younger adults and off-label conditions among older adults. Several less conventional determinants, namely, Parkinson disease, traumatic brain injury, and the use of physical restraints were identified to increase the likelihood of AP use. This study highlights the importance of monitoring for adverse effects for residents of all ages.