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PROFILING CHILDREN AND ADOLESCENTS WITH SERIOUS

EMOTIONAL DISTURBANCES

PART II: QUALITY ASSESSMENT

FINAL REPORT

Cynthia A. Fontanella, Ph.D.

Danielle L. Hiance, MSW

Jeffrey Bridge, Ph.D.

John V. Campo, M.D.

Eric Seiber, Ph.D.

Jeff J. Guo, B. Pharm., Ph.D.

The Ohio State University

College of Social Work &

Department of Psychiatry, College of Medicine

TABLE OF CONTENTS

EXECUTIVE SUMMARY............................................................................................................

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INTRODUCTION ......................................................................................................................... 6

STUDY AIMS AND OBJECTIVES …………………………………………................ 6 BACKGROUND ……………………………………………………...……….…............ 7 SIGNIFICANCE ...…………………………………………………………..….

………. 8

METHODS …..…………………………………………………………………………………...8

DEVELOPMENT OF QUALITY INDICATORS…………………………………….. 8DATA FOR ESTIMATED CONFORMANCE RATES……………………..………... 12QUALITY MEASURES………………………………………………………………… 12DATA ANALYSIS……………………………………………………………..………… 21

RESULTS …………………………………………………………………………...…............... 22

POPULATION CHARACTERISTICS……………………………………………….. 22CONFORMANCE RATES…………………………………………………......……… 22

CONCLUSION …….………………………………………………………………….………… 27

ACKNOWLEDGEMENTS …..………………………………………………………………… 31

REFERENCES …..……………………………………………………………………………… 32

APPENDICES …...……………………………………………………………………………... 38

APPENDIX A: EXPERT PANEL…………………………….……………………….. 38APPENDIX B: SAMPLE RATING SHEET…………………………………..……… 41APPENDIX C: SUMMARY OF RATING SCORES…………………………............ 44APPENDIX D: QUALITY OF CARE MEASURE PACKET………………………. 47

MEDTAPP Research Project Clinical Profile of Children and Adolescents with SED

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EXECUTIVE SUMMARY

Background

An estimated 20% of youth (15 million) between the ages of 9 and 17 are diagnosed with a mental disorder, 9 to 13% (approximately 6 to 9 million) have significant functional impairments, and 5 to 9% have serious emotional disturbances. Despite the high prevalence of childhood mental disorders, costs, and availability of effective interventions, many youths receive inadequate treatment or no treatment at all. Epidemiological studies indicate that 75 to 80% of children between the ages of 6 to 17 with mental health disorders do not receive any mental health care, and rates of unmet need vary significantly by geographic region, ethnic group, and service sector.

Even when youths are able to access mental health services, quality of care is often poor. Empirically validated treatment exists for a number of major childhood conditions including: 1) ADHD; 2) depression; 3) anxiety disorders; and 4) conduct disorders. Over the past decade, there has also been a proliferation of clinical practice guidelines, quality indicators, and medication algorithms, all intended to improve quality of care by articulating evidence-based practices and by identifying the steps needed to implement optimal treatment. However, research has documented wide variations in quality of care including; a) failures to conform to evidence-based practice guidelines; b) underuse, overuse, and misuse of certain treatments; and c) racial and ethnic disparities in access and quality of care.

Study Objectives

The primary aim of this project was to assess patterns and quality of care received by children in Ohio’s public mental health system. Specific objectives included:

(1) To develop quality of care measures for common childhood diagnoses(2) To describe the quality of care for specific diagnostic groups

Data and Methods

The development of the quality of care measures involved two phases. In the first phase, we conducted a systematic review of the scientific and clinical literature to identify quality indicators on treatment of the common childhood disorders: depression, bipolar disorder, attention deficit hyperactivity disorder, and anxiety. In addition, we also reviewed the literature on other relevant topics including questionable psychotropic prescribing practices, evidence-based treatment for preschoolers, and continuity of care. In the second phase, we convened an expert panel which was assigned to rate the quality indicators using the RAND Appropriateness Method.

To examine conformance rates for identified quality indicators, we used Ohio Medicaid claims data. The target population included all children and youth (aged 0-18) enrolled in Medicaid for at least one month between January 1, 2006 and December 31, 2010 who had a primary and/or


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secondary mental health diagnosis (ICD-9 CM 290-319) or one or more mental health claims or at least one psychotropic medication during the study period. Excluded were youth with a diagnosis of substance abuse (ICD _9_CM codes: 291, 292, 303, 304, 305) or mental retardation (ICD-9-CM codes: 315, 317-319) and no other mental health diagnosis.

Key Findings

Psychotropic Prescribing Practices

Evidence of inappropriate psychotropic prescribing A total of 250,149 (29.3%) children and youth who were mental health users

had one or more prescriptions for a psychotropic medication. Of this group, 5.4% were prescribed four or more psychotropic medications concurrently for 60 days or longer. Rates of polypharmacy were highest for the use of two or more antipsychotics (4.5%) and lowest for the use of two or more stimulants (0.39%).

Most prescriptions for antipsychotic medications are for off-label use. Of those youth in Medicaid prescribed two or more antipsychotic medications

concomitantly, 70.1% were for off-label use. Children in foster care are more vulnerable to poor quality of care than other aid

groups. A greater proportion of children in foster care compared to nonfoster care

children were prescribed: 1) four or more psychotropic medications concurrently; 2) two or more antipsychotic medications; and 3) dosages of medications higher than the recommended maximum. Rates of four or more medications concomitantly were 15.3% for children in foster care compared to 8.5% of youths in the ABD and adoptive care group, and 4.0% for youth in the CFC group.

Quality of care for Common Childhood Disorders

Nonadherence with antidepressant medications is common among Medicaid-covered youth with depression. Research suggests that follow-up care is critical to ensure successful outcomes; however, many children do not receive adequate follow-up.

Among youth newly diagnosed with depressive disorder, about half (47%) were adherent with their antidepressant treatment during the acute phase and about a quarter (24.3%) were adherent during the continuation phase. Only 27.6 % received at least 3 visits by their prescribing providers, and 43.1% had at least 6 outpatient psychotherapy visits. The overwhelming majority (85%) received an appropriate dose of antidepressant medication.


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Most children diagnosed with bipolar disorder do not receive medical monitoring. Among youth newly diagnosed with bipolar disorder and prescribed mood

stabilizers during the acute phase of treatment, only about one-fifth received appropriate laboratory tests for blood levels or side effect monitoring (18.8% 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 prescribingThe results from the study suggest that questionable psychotropic prescribing is common including the use of concomitant medications, doses that exceed the


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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.

Ensure that preschoolers have access to evidence-based psychosocial services.Despite the availability of effective psychosocial treatments for young children such as parent management, problem solving, and multisystemic therapy for aggression, our data suggests that nonpharmacological services are being underutilized, contrary to existing guidelines. Ensuring access to psychosocial interventions is critical for successful outcomes for young children.

Promote continuity of care during high-risk periods, including following an emergency room or hospital admission and the initial period of treatment. Failure to receive timely outpatient follow-up or discontinuities of care after an emergency room and/or hospital discharge can have tragic consequences; the elevated risk for death by suicide, suicide reattempts, and readmission during the post-discharge time period are well-documented as are the high rates of treatment non-adherence. The low level of follow-up care after discharge from the emergency room and hospital and during the initial phases of treatment underscores the need to improve care continuity of care during these critical high-risk time periods.


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INTRODUCTION

Study Aims and Objectives

Childhood mental disorders are prevalent, disabling, and costly. An estimated 20% of youth

(15 million) between the ages of 9 and 17 are diagnosed with a mental disorder, 9 to 13%

(approximately 6 to 9 million) have significant functional impairments, and 5 to 9% have serious

emotional disturbances--most commonly anxiety, mood, or disruptive behavior disorders.1-3 These

conditions are often chronic, associated with significant functional impairments; family burden; poor

health outcomes; co-morbidities, and serious mental illness in adulthood. 4-6 The risk of suicide is

especially high for youths with depression:7 studies have shown that 60% of adolescent suicide

victims had a depressive disorder at the time of death.8-10 The economic costs are also substantial:

the U.S. spent nearly $12 billion on children's mental health services in 1998, according to the most

recent national survey,11 and children with serious emotional disturbances constitute one-third of all

high-cost users.12

Despite the high prevalence of childhood mental disorders, costs and availability of effective

interventions, many youths receive inadequate treatment or no treatment at all.13, 14 The primary aim

of this project was to assess patterns and quality of care received by children in Ohio’s public mental

health system. Using existing statewide administrative Medicaid data, this project focused on two

dimensions of quality: 1) effectiveness of care, the use of appropriate treatments that are consistent

with evidence-based practice guidelines; and 2) accessibility, the ability to receive needed services.

Project goals and objectives are consistent with national health priorities and broad aims as set forth

by the Department of Health and Human Services to better care by making health care more

accessible and to promote the use of best practices to enable healthy living. Specific objectives

included:

(1) Develop quality measures for common childhood disorders

(2) Describe the quality of care for specific diagnostic groups

Background

Characteristics of Children with Serious Emotional Disturbances. Children and youth

with serious emotional disturbances have complex needs often requiring comprehensive services of


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varying levels of intensity over extended periods of time and involvement with multiple providers

and service systems.15 Many have multiple psychiatric disorders—disruptive behavioral disorders

and mood disorders are the most highly prevalent--and experience significant functional

impairments that interfere with their functioning at home, school, and with community activities; left

untreated these youths are at risk for a number of adverse outcomes including substance abuse,

suicide, school dropout, teen pregnancy, and incarceration.16,17 The burden of illness is also high,

particularly for families 5 Because children with serious emotional disturbances use more services,

they generate health care costs well beyond the majority of other mental health users; many of these

youths are involved with the child welfare and juvenile justice system.18-21 Adolescents, males, and

minority youths are overrepresented, as are youth from lower SES. 21

Barriers to Effective Care. Most youths with mental disorders do not receive any treatment,

and the demand for children’s mental health services is expected to double by 2020.

Epidemiological studies indicate that 75 to 80% of children between the ages of 6 to 17 with mental

health disorders do not receive any mental health care, and rates of unmet need vary significantly by

geographic region, ethnic group, and service sector.13,22 Across states, rates of unmet need range from

as low as 51% to as high as 81%; these variations are likely related to differences in state policies

and health care market characteristics.23 Across ethnic groups, minorities have the highest rates of

unmet needs, with Latino children less likely to receive services for their mental health problems

than any other ethnic group, despite higher rates of suicide.13, 24,25 Across systems of care, children

and youths in the child welfare and juvenile justice system have the highest rates of unmet need--

85% of these children do not receive services.19 Taken together, these findings underscore the need

to improve access to care, particularly for low-income, minority, and rural populations.

Even when youths are able to access mental health services, quality of care is often poor.

Empirically validated treatment exists for a number of major childhood conditions including: 1)

ADHD;26 2) depression;27 3) anxiety disorders;28 and 4) conduct disorders.29 Over the past decade,

there has also been a proliferation of clinical practice guidelines,30-32 quality indicators,33 and

medication algorithms,34 all intended to improve quality of care by articulating evidence-based

practices and by identifying the steps needed to implement optimal treatment. However, research has

documented wide variations in quality of care including; a) failures to conform to evidence-based

practice guidelines; b) underuse, overuse, and misuse of certain treatments; and c) racial and ethnic

disparities in access and quality of care.14, 35


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Why Focus on Quality of Care for Children in Medicaid? First, Medicaid is the largest

financing program supporting children’s mental health services in the United States, contributing

more than any other private or public source of funding.36 Second, children covered by Medicaid

use more mental health services—outpatient, inpatient, and pharmacy-- than privately insured and

uninsured children.37-39 Because they live in poverty and are exposed to multiple psychosocial

stressors, they have more severe psychiatric illnesses that frequently require more intensive services.

Third, children covered by Medicaid are more likely to receive poorer quality care and have worse

health outcomes.40 For example, in a seven-state study, it was found that Medicaid covered youths

are 4 times as likely as privately insured youth to receive antipsychotic medications.41

Significance

Childhood mental illness is a major public health issue, not only because of its high

prevalence, but because of the potential adverse outcomes resulting from ineffective or

undertreatment. Without early identification and effective treatments, children and youths are at

increased risks for school failure, poor employment opportunities, and poverty in adulthood.42

Quality assessment can potentially improve delivery of care by identifying variations in practice

patterns, at-risk populations, and structural factors that promote or impede quality.

METHODS

Development of Quality Indicators

In this section, we describe the process by which quality indicators were selected. The

process involved two phases. In the first phase, we conducted a systematic review of the scientific

and clinical literature to identify quality indicators on treatment of the common childhood disorders:

depression, bipolar disorder, attention deficit hyperactivity disorder, and anxiety. In addition, we

also reviewed the literature on other relevant topics including questionable psychotropic prescribing

practices, evidence-based treatment for preschoolers, and continuity of care. In the second phase, we

convened an expert panel which was assigned to rate the quality indicators using the RAND

Appropriateness Method.


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Phase 1: Systematic Literature Review

Fundamental to any study on quality of care is a critical review of the literature and

evaluation of the available scientific evidence. Towards this end, we briefly outline the steps taken to

review the literature. We first conducted a search of the published articles from 1990-2011 using the

following research databases: Medline/PubMed, Psychology and Behavioral Health, Academic

Search Complete, and Cochrane Database of Systematic Reviews. For example, key word search

terms for depression included: major depression, antidepressants, psychotherapy, quality of care,

depression treatment, evidence-based treatment, practice guidelines, practice parameters, quality

indicators, and medication algorithms. Next, we manually reviewed the following selected journals:

American Journal of Child & Adolescent Psychiatry

American Journal of Psychiatry

Archives of General Psychiatry

Pediatrics

Archives of Pediatric & Adolescent Medicine

Psychiatric Services

We then conducted a search of key stakeholder groups that have developed quality measures.

These groups included clinical groups, government agencies, managed care

organizations/accreditors, health resource centers, and research organizations. Table 1 provides a

complete listing of the stakeholder groups contacted.

Based on the review of the literature, the project staff drafted quality indicators for each of

the 7 topic areas listed above. Criteria used in drafting quality indicators included: 1) the indicators

measured an intervention or treatment with potential benefits for the patient; 2) the indicator was

supported by scientific evidence or professional consensus (e.g., practice guidelines); 3) the care was

under the control or influence of the health care provider; and 4) the indicator could be assessed

from available administrative data.43 Once the information was synthesized and the quality indicators

were developed, we then rated the strength of the supporting evidence using the Agency for

Healthcare Research & Quality (AHRQ) three-level rating system: (1) Level A: strong research

evidence based on randomized controlled trials (RCT); 2) Level B: fair research evidence based on

observational cohort, case control or multiple time series; and; 3) Level C: descriptive study or


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expert opinion. For each proposed indicator, project staff wrote a summary of the measure,

including description and technical specifications, clinical rationale, and the assigned evidence

rating. It should be noted that nearly all of the indicators included in this report are process

indicators. We specifically chose process measures because we were interested in assessing the

appropriateness of treatment (e.g., the extent to which care conforms to practice guidelines and can

be modified by providers).

Table 1. Developers of Quality Measures for Mental Health and Substance Abuse Disorders

Category Organization

Accreditor National Committee for Quality Assurance (NCQA)

Health Resource Center

National Quality Forum (NQF)

Clinical Organizations

APA Committee on Quality IndicatorsAmerican Psychiatric Association (APA)American Academy of Pediatrics (AAP)American Academy of Child & Adolescent Psych (AACAP)

Government Agency

Agency for Healthcare Research & Quality (AHRQ)Center for Medicare & Medicaid Services (CMS)National Institute for Clinical Excellence (NICE)Medicaid Medical Directors Learning Network/Rutgers Center for Education & Research on Therapeutics (CERTs)Texas Department of Family and Protective Services and The University of Texas at Austin College of PharmacyGovernment Accountability Office (GAO): HHS Report on Psychotropic Prescription OversightPsychiatric Services and Clinical Knowledge Enhancement System (PSYCKES): New York Office of Mental Health

Research Center for Quality Assessment and Improvement in Mental Health (CQAIMH)Standards for Bipolar Excellence Performance Measures (STABLE)Comprehensive Neuroscience, Inc. (CNS)

Phase 2: Expert Panel


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A local consensus panel was recruited and consisted of 29 mental health experts from

multiple disciplines including: physicians (child psychiatrists, pediatricians, developmental

specialists), nurses, psychologists, social workers/case managers, pharmacists, researchers, health

administrators, and other key mental health stakeholders (See Appendix A for a listing of expert

panel members). The panel was a convenience sample of professionals from Columbus and

Cincinnati who were interested in improving the quality of care for children in the state of Ohio.

The RAND Appropriateness method was used to rate the indicators. In general, the method

quantitatively assesses the expert judgment of a group of experts regarding the indicators by using a

scale with values ranging from 1 to 9.44 The method is iterative with two rounds of anonymous

ratings of the indicator and a face-to-face group discussion between rounds. In the first round,

panelists were sent the packets with the literature reviews, indicators and rating sheets and were

asked to rate each indicator for meaningfulness and feasibility on a 9 point likert scale, where “1”

indicates strongest agreement and “9” indicates strongest disagreement (See Appendix B for sample

rating sheet). A quality indicator is defined as meaningful if: 1) the measure addresses a clinically

important topic; 2) the measure addresses a topic with a gap in quality of care; and 3) providers can

influence their performance on the measure. A quality indicator is defined as feasible if: 1) the

measure components are clearly specified and can be abstracted from administrative data and; 2) the

measure has the capacity to provide fair comparisons across providers.44

To facilitate the rating process, the rating sheet was posted online using Survey Monkey

software. We encouraged panelists to comment on the literature reviews, the definitions of key

terms, and the indicators. We also encouraged them to suggest additions or deletions to the

indicators.

Five expert panel meetings were convened from February to April 2012. Before each

meeting, the panelists were given a summary sheet of the results of the first round of ratings. The

summary sheet provided both the individual confidential ratings as well as the overall panelist

ratings. Specifically, the results showed the distribution of ratings for each indicator, the median

rating, and measure of dispersion (mean absolute deviation from the median, indicating degree of

agreement). At the meeting, panelists discussed the indicators and initial ratings, explored reasons

for disagreements, and made additional suggestions for modifying or adding indicators. After


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discussion, panelist confidentially rerated all indicators (See Appendix C for summary of ratings by

panelists). Of the 46 measures that were reviewed, 18 were eliminated, resulting in a final core set

of 28 measures.

Data for Estimated Conformance Rates

The data for this study were drawn from Ohio Medicaid claims for the years 2006 to 2010.

The source data included all eligibility and enrollment files, pharmacy, professional, and institutional

claims files for children enrolled in the Ohio Medicaid program. The target population, herein

referred to as “mental health users” included all children and youth (aged 0-18), enrolled in

Medicaid for at least one month between January 1, 2006 and December 31, 2010, who had a

primary and/or secondary mental health diagnosis or one or more mental health claims, or at least

one psychotropic medication during the study period. The diagnosis codes used to identify mental

health problems were the first three digits of the ICD-9-CM codes 290-319. Mental health service

claims included those for inpatient, outpatient, or emergency room use that was associated with a

mental health disorder (primary or secondary) or current psychiatric procedure codes. Psychotropic

medications were identified from the NDC codes for 9 different drug classes: antidepressants,

antipsychotics, anticonvulsants, lithium, stimulants, other ADHD drugs, anxiolytics, alpha-agonists,

and hypnotics/sedatives. Excluded were youth with a diagnosis of substance abuse (ICD-9-CM

codes: 291, 292, 303, 304, 305) or mental retardation (ICD-9-CM codes: 315, 317-319) and no other

mental health diagnosis.

Quality Measures

Twenty-seven measures assessing clinical processes of care were selected based on the

systematic review of the literature and a multidisciplinary panel of experts. The clinical rationale and

evidence base are described below and in Table 2.

Polypharmacy. Polypharmacy was defined as the use of two or more overlapping drug

prescriptions for 60 days or more. We used a 60 day window rather than a 30 day window to

exclude concomitant use due to cross-tapering. Within the 60 day period, we also allowed for a 15

day gap between prescription fills to account for imperfect adherence or short inpatient hospital

stays. Four measures were used to capture clinically questionable polypharmacy practices. These


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measures do not necessarily indicate inappropriate practice, but warrant further clinical review. The

first assesses the proportion of children who were prescribed 4 or more psychotropic medications

concomitantly from the same or different drug classes. The use of multiple medications increases

the risk for medication-related adverse effects and drug-drug interactions, complicates the drug

regimen making compliance more difficult, and potentially creates the need for more medication.45,46

The second measure assesses the proportion of children prescribed 2 or more antipsychotic

medications (typical and atypical) concomitantly. Currently there is little evidence of the safety and

efficacy of antipsychotic polypharmacy.47 A growing body of research has also documented adverse

events associated with antipsychotic medications including increased the risk of obesity in children,

Type 2 diabetes, cardiovascular conditions, neurologic effects including tardive dyskinesia and

extrapyramidal symptoms, and cognitive impairment.48,49 The third measure assesses the proportion

of children prescribed 3 or more mood stabilizers (includes both lithium and anticonvulsants) and the

fourth assesses the proportion of children prescribed 2 or more stimulants concomitantly (excluding

prescriptions from long-acting stimulants and an immediate release stimulant from the same

chemical entity).

Dosing and Duration. Three measures, developed by the New York State Office of Mental Health,

were used to assess medication dosages that were higher than the recommended range. The first two

measures assess the proportion of children prescribed antipsychotic and/or ADHD medications who

received a dose higher than the recommended maximum (See Appendix for dose guidelines). While

the most effective and tolerable dose of medication varies from individual to individual, studies

suggest that dosages higher than recommended are generally not associated with clinical

improvement.50,51 Higher doses of psychotropic medications also increase the risk for serious side

effects and problems with adherence.51 The third measure assesses the proportion of children with a

mental health diagnosis who used benzodiazepines for ≥ 60 days or more. Reports from the literature

suggest a nearly threefold increase in use of anxiolytics for children and adolescents during the past

decade.52 Yet the safety and efficacy of these medications have not been established, and adverse

effects are well documented including central nervous system depression, impaired psychomotor

performance, amnesia, respiratory depression, and dependence and abuse potential.53

Depressive Disorder. Five measures were used to assess the quality of antidepressant medication

management. Four of the five measures are taken from or are a modified version of the Health Plan


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Employer Data and Information Set (HEDIS) and one was developed by the American Psychiatric

Association. The first measure assesses the proportion of children with a new episode of depression

and treated with antidepressant medication that remained on an antidepressant drug during the 12

week acute treatment phase, and the second examines the proportion of those who completed a six-

month continuation phase. A new episode of depression is defined as no prior prescriptions for

antidepressants or claims for depression diagnosis within 6 months prior to the index prescription

(date of the first prescription for an antidepressant). The third and fourth measures are adapted from

the HEDIS measure on optimal practitioner contacts. The third measure assesses the proportion of

children who received at least three medication management visits with the prescribing provider

(e.g., physician or nurse practitioner) during the acute phase. The fourth measure assesses the

proportion of children who had at least six psychotherapy visits with a mental health provider during

the acute phase. The last measure examines adequacy of antidepressant dose, specifically the

proportion of children with a new diagnosis of depression who received an appropriate dose for at

least 4 consecutive weeks after initiation of medication.


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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


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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


17


Individual and group psychotherapy

% of enrollees 18 years of age or younger with ≥ 6 claims for any outpatient visits by a mental health practitioner within 84-days (12 weeks) of initial diagnosis

Research/STABLE C

Attention-Deficit Hyperactivity Disorder

Follow-up care during initiation phase

Follow-up during continuation phase

Use of stimulant medication for ADHD

% of members age 6 to 18 with a new prescription for an ADHD medication who had ≥ 1 follow-up visit with a prescribing practitioner within 30 days of the index prescription date

% of members 6 to 18 years of age with a new prescription for ADHD medication who remained on the medication for at least 210 days and had at least two follow-up visits with a prescribing practitioner within 270 days (9 months) after the initiation phase ended.

% of enrollees 18 years of age or younger diagnosed with ADHD who receive a stimulant medication during the measurement year

NCQA

NCQA

APA/CQAIMH

B

B

B

Preschoolers

Use of antipsychotics in preschoolers

Psychosocial visits prior to initiation of medication

Psychosocial visits after initiation of medication

% of enrollees under 2 to 5 years of age who are prescribed an antipsychotic medication during the measurement year

% of enrollees 2 to 5 years of age who receive 6 outpatient visits prior to initiating psychotropic (antidepressants, stimulants, antipsychotics) medication treatment

% of enrollees 2-5 years of age who receive ≥ 6 outpatient visits after initiation of psychotropic medications (antidepressants, stimulants, antipsychotics)

PSYCKES/TEXAS/MMDLN/Rutgers CERTS

PSYCKES/TEXAS

PSYCKES/TEXAS

C

C

C


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Continuity of care

Medical checkup

Follow-up after emergency room visit, 30 days

Follow-up after hospitalization, 30 days

Provider continuity

% of enrollees 18 years of age or younger with ≥ 1 medical visit by a primary care practitioner within 1 year of starting any mental health treatment

% 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

% of patients hospitalized for treatment of depressive disorder, seen by a mental health provider within 30 days of discharge

% of members 18 years of age or younger with a mental health diagnosis who had at least 4 outpatient visits and who received outpatient mental health visits through the same provider or facility during the measurement year

PSYCKES

Research

HEDIS/NCQA

CQAIMH/ValueOptions

C

B

C

C

Acute Care Utilization

High utilization of ED/inpatient Services

% of enrollees 18 years of age or younger with ≥ 4 ED visits or ≥ 2 inpatient psychiatric hospitalizations among those who are currently receiving mental health services

Research B

Abbreviations: PSYKES= Psychiatric Services and Clinical Knowledge Enhancement System; GAO = Government Accountability Office; MMDLN = Medicaid Medical Directors Learning Network; NCQA=National Committee for Quality Assurance; HEDIS = Healthcare Effectiveness Data Information Set; AHRQ = Agency for Healthcare Research and Quality; CQAIMH = Center for Quality Assessment and Improvement in Mental Health; STABLE = Standards for Bipolar Excellence; AACAP = American Academy of Child and Adolescent Psychiatry; APA=American Psychological Association.

aAHRQ rating categories were used to assess the research evidence supporting the association between the clinical processes and patient outcomes: A = good research evidence; B = fair research evidence; C = based on clinical consensus or opinion


19

Bipolar Disorder. Five measures were used to assess the quality of treatment for children and

youth diagnosed with bipolar disorders. Three of the five measures examine medical monitoring

of laboratory results, one examines the appropriateness of psychotropic medications, and one

examines optimal follow-up visits. The first measure, originally developed for Pennsylvania

Medicaid beneficiaries, assesses the proportion of children diagnosed with a new episode of

bipolar disorder and treated with a mood stabilizer (e.g., lithium, carbamazepine, and valproic

acid) whose blood levels are monitored in accordance with clinical practice guidelines. Lithium,

valproate, and carbamazepine are most effective when blood levels fall within the specified

ranges.54,55 Lower levels are associated with increased risk of relapse; higher levels typically

cause increased side effects without therapeutic benefit.54,55 The second measure assessed the

proportion of children prescribed mood stabilizers who received blood level tests for monitoring

side effects (e.g., thyroid function for lithium). The third measure, one with the highest level of

evidence, assesses the proportion of children who were prescribed atypical antipsychotic

medications who received metabolic screening. Based on reviews of RCTs, treatment with

antipsychotic medications has been associated with weight gain and impaired glucose

metabolism, exacerbation of existing Type 1 and Type 2 diabetes, new onset of Type 3 diabetes

and diabetic ketoacidosis. Monitoring of weight and plasma glucose levels can help indicate

which patients are at early risk for diabetes related diseases.56 The fourth measure assesses the

proportion of children who received an antipsychotic or mood stabilizer, as recommended by the

practice guidelines. The fifth measure assesses the proportion of children who received at least 6

outpatient visits with a mental health practitioner during the acute treatment phase.

Attention-Deficit Hyperactivity Disorder. Three measures were used to assess the quality of

treatment for children and youth diagnosed with attention deficit hyperactivity disorder. Two of

the three measures were developed by HEDIS and used by the National Committee for Quality

Assurance (NCQA) for accreditation and one was based on treatment guidelines. The first

measure assesses the proportion of children with a new prescription for an ADHD medication

who had at least 1 follow-up visit with a prescribing practitioner within 30 days after initiating

the medication. The second measure assesses the proportion of children with new prescription

for ADHD who remained on the medication for at least 210 days and had at least two follow-up


20

visits with a prescribing provider within 9 months of after the initiation phase ended. Research

studies suggest that follow-up in primary care is substantially below recommended national

guidelines.57 Medications used to treat ADHD have known side effects and need to be closely

monitored by a practitioner with prescribing authority. The third measure assesses the proportion

of children diagnosed with ADHD who received either methamphetamine-based or

amphetamine-based stimulants during the measurement.

Preschoolers. Three measures were used to assess the quality of psychotropic prescribing to

preschool children. The first measure, developed by the Medicaid Medical Directors Learning

Collaborative (MMDLN) and Rutgers Center for Education and Research on Clinical

Therapeutics (CERTS), assesses the proportion of young children aged 2 to 5 years of age who

were prescribed an antipsychotic medication 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.58 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.58 The second measure assess assesses the proportion of young

children who had at least 6 psychosocial visits prior to initiating psychotropic medications,

whereas the third measures examines the proportion who had at least 6 visits after initiating the

medications. The use of psychotropic medication in young children of preschool ages is a

practice that is limited by the lack of evidence. Practice guidelines recommend treating

preschool-aged children with non-psychopharmacological interventions (for up to 12 weeks)

before starting psychopharmacological treatment due to the potential impact on their developing

brains.

Continuity of Care. Four measures were used to assess continuity of care for children with

mental health disorders. The first two measures assess the proportion of children who received

an outpatient visit with 30 days of discharge from the emergency room and/or psychiatric

hospital. Research suggests that 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 after


21

hospitalizations.59 Lack of timely follow-up care is associated with increased risk for

suicide/suicidal behavior, readmission, and relapse.60 The third measure assesses the proportion

of children with a mental health diagnosis who had at least one visit with their primary care

physician during the measurement year. Psychotropic medications including antidepressants,

stimulants, mood stabilizers and antipsychotics, prescribed alone or in combination, all have the

potential for adverse side effects. Medical follow-up is needed to monitor potential adverse side

effects (e.g. weight gain, metabolic changes, cardiovascular effects) to maintain good health. The

fourth measure, a modified version of the Continuity of Care Index,61 assesses the proportion of

children with a mental health diagnosis within 4 or more visits who saw the same provider

during the year. This Continuity of Care index takes on values between 0 and 1. A value of “0”

signifies maximum dispersion, which occurs when a different provider is seen, whereas a value

of “1” signifies minimal dispersion, which occurs when the same provider is seen at every visit.

High Utilization of Emergency Room and Inpatient Services. Derived from the New York State

Office of Mental Health Psychiatric Clinical Knowledge Enhancement System (PSYKES), this

measure examines the proportion of children who were mental health users who had 2 or more

hospitalizations and/or 4 or more emergency room visits during the year. Hospitalizations are

costly, accounting for approximately 31% of the total health care expenditures. High utilization

of emergency room (ER) and/or inpatient hospital services is generally considered an indicator

of poor quality of care or poor transitions between different providers and settings or systemic

failures (e.g., poor coordination, lack of services).62-64 Identifying high-risk groups with frequent

readmissions can provide opportunities for targeted quality improvement efforts.

Data Analysis

Conformance rates were calculated for each measure for all eligible individuals in the

sample by using detailed technical specifications (see Appendix D). Each measure was

constructed as a proportion or rate, with the denominator specification describing the eligible

sample and the numerator describing the desired characteristic of care. Measure specifications

used ICD-9-CM codes for diagnoses and generic drug names to identify medications. Healthcare

Common Procedure Coding (HCPCS) codes were used for procedures and services.


22

RESULTS

Population Characteristics

Of the 853,057 children, 58% were male (N= 493,544) and the mean age was 9.17 (SD

5.3) years. Seventy-one percent (N= 608,389) of the children were identified as white, 27.2%

(N= 231,813) were identified as black, and the remaining 1.5% (N= 12,855) were from other

racial and ethnic groups. The majority of youth (85%, N= 724,108) in the sample were eligible

for Medicaid through the covered families and children program, 9.8% (N= 83,144) were

disabled, and 5.4% (N= 45,805) were in foster care/adoptive program. Approximately two-thirds

(67%, N= 569,909) had a mental health diagnosis, most commonly disruptive behavior, mood,

and adjustment disorders. Approximately one-fifth (21.9%) of the sample had two or more

psychiatric diagnoses.

Conformance Rates

Polypharmacy. Of the 853,057 Medicaid beneficiaries (under age 18) who were mental health

users, 29.3% (N= 250,149) had one or more prescriptions for a psychotropic medication. Of this

group, 5.4% (N = 13,468) were prescribed four or more psychotropic medications concurrently

for 60 days or longer. Across the different categories of polypharmacy regimens, conformance

rates were highest for the use of two or more antipsychotics (4.5%) and lowest for the use of two

or more stimulants (0.39%) (Table 3). Of the 3,810 children prescribed two or more

antipsychotics concurrently, 70% of youth received the medications for off-label use.

Table 3. Rates of Polypharmacy Among Medicaid-Enrolled Youth (0-18 years) who are

Mental Health Users

N Prescribedthe class of medication

Conformance Rate

Quality Indicator N %≥ 4 psychotropic medications 250,149 13,468 5.38

≥ 2 antipsychotics 84,039 3,810 4.53

≥ 2 stimulants 182,852 705 0.39

≥ 3 mood stabilizers 39,355 490 1.25

Source: Ohio Medicaid data, 2006-2010


23

Rates of polypharmacy were notably higher for youth in foster care compared to other

Medicaid eligibility groups. For example, of the 8,255 children in foster care prescribed at least

one psychotropic medication, 15.3% received four or more psychotropic medications for 60 days

or more compared to 8.5% of youths in the ABD and adoptive care group, and 4.0% for youth in

the CFC group. Rates were for antipsychotic polypharmacy were also higher for youth in foster

care compared to other aid groups (Table 4)

Table 4. Rates of Polypharmacy by Medicaid Eligibility Groups

Foster care Adoptive ABD CFC

NRate

NRate

NRate

NRate

n % n % n % n %

≥ 4 psychotropics 8,255 1,262 15.29 15,922 1,345 8.45 40,510 3,425 8.45 185,462 7,436 4.00

≥ 2 antipsychotics 5,422 492 9.07 6,695 356 5.32 19,999 1,124 5.62 50,085 1,838 3.67

≥ 2 stimulants 5,322 27 .51 12,390 55 .44 26,394 102 .39 138,746 521 .38

≥ 3 mood stabilizers 2,632 62 2.36 2,920 40 1.37 10,632 172 1.62 23,171 216 .93


Dosing and Duration. Prescriptions of benzodiazepines for youth in this sample were rare. Only

8,574 (1%) of children under 18 who were mental health users were prescribed a

benzodiazepine; however, almost half of these youth (44%) were using benzodiazepines on a

chronic basis. Table 5 provides the conformance rates for the indicators of dosages higher than

the recommended range for antipsychotic and stimulant medications. Here again, it is notable

that when the data is stratified by Medicaid eligibility categories, a higher proportion of children

in foster care compared to other aid groups, even disabled youth, are prescribed medications at

dosages above the recommended maximum. For example, of the 5,422 children in foster care

that are prescribed antipsychotic medications, 573 (10.8%) received a dose of antipsychotic

medications that exceeded the recommended maximum compared to 7.9% for youths in the ABD

(Table 6).


24

Table 5. Rates for Quality Indicators of Psychotropic Prescribing Practices

N of Eligible

Cases

Conformance Rate

Quality Indicator N %

Dosages higher than recommended for antipsychotic 84,039 6,025 7.2

Dosage higher than recommended for stimulant 182,852 20,553 11.2

Chronic use of benzodiazepine (≥ 60 days) 8,574 3,774 44.0


Table 6. Rates of Psychotropic Prescribing Practices by Medicaid Eligibility Group

Foster care Adoptive ABD CFC

NRate

NRate

NRate

NRate

n % n % n % n %

Higher than recommended dose of antipsychotics

5,422 573 10.57 6,695 473 7.06 19,999 1,574 7.87 51,923 3,405 6.56

Higher than recommended dose of ADHD medications

5,322 802 15.0712,39

01405

11.3

426,394 3,500 13.26 138,746 14,846 10.70

Chronic benzodiazepines 271 122 45.02 375 174

46.4

03,159 1,586 50.21 4,769 1,892 39.67


Depression. During the study period, 24,965 (aged 5 to 18) had a new diagnosis for depressive

disorder and 1,155 (4.6%) were prescribed an antidepressant medication within 30 days of their

initial diagnosis. Of this group, 543 (47%) were adherent with their antidepressant treatment

during the acute phase (12 weeks) and 281 (24.3%) were adherent during the continuation phase

(6 months). Of those prescribed antidepressants, 27.6 % received at least 3 visits by their

prescribing providers, and 43.1% had at least 6 outpatient psychotherapy visits with a mental

health practitioner. The overwhelming majority (85%) of newly diagnosed youth received an

appropriate dose (e.g., within therapeutic range) of antidepressant medication (Table 7).


25

Table 7. Conformance Rates for Quality of Care Indicators for Medicaid Enrolled Youth

with Depression

N of eligible

cases

Conformance Rate


Antidepressant medication management acute phase 1,155 543 47.0

Antidepressant medication management continuation phase 1,155 281 24.3

Optimal medication provider contact acute phase 1,155 319 27.6

Optimal psychotherapy provider contact acute phase 1,155 498 43.1

Adequacy of antidepressant dosage 1,155 971 85.1


Bipolar Disorder. During the study period, 4,279 youth (aged 5 to 18) had a new diagnosis for

bipolar disorder. Of this group, over two-thirds (68.1%) were prescribed either a mood stabilizer

and/or an antipsychotic medication within 84 days (12 weeks) of their initial diagnosis, in

accordance with the practice guidelines (Table 8). The proportion of youth who received medical

monitoring was much lower, however. Among youths prescribed either lithium or

anticonvulsants (valproic acid, carbamazepine) during the acute phase of treatment, only about

one-fifth received appropriate laboratory tests for blood levels or side effect monitoring (18.8%

and 20.7% respectively). Of the 1,942 youth prescribed antipsychotic medications, only 169

(8.7%) received metabolic screening (e.g., glucose and lipids testing) within 16 weeks of

initiating an atypical antipsychotic.


26

Table 8. Conformance Rates for Quality of Care Indicators for Medicaid Enrolled Youth

with Bipolar Disorder

N of eligible

cases

Conformance Rate


Use of appropriate medication 4,279 2,913 68.1

Blood levels for mood stabilizers 836 157 18.8

Side monitoring for mood stabilizers 836 173 20.7

Metabolic screening with an atypical antipsychotic 1,942 169 8.7

Individual and group psychotherapy 4,279 2,509 58.6


Attention Deficit Hyperactivity. Of the 73,055 children aged 5-18 diagnosed with attention deficit

hyperactivity disorder, 85.1% were prescribed an amphetamine or methylphenidate-based

stimulant, which is in accordance with the recommended treatment guidelines. Of this group,

about one third (32.9%) had at least one follow-up visit with a prescribing practitioner within 30

days of initiating the stimulant. Of those children who remained on the medication for 210 out of

the 300 day period, 71% had at least two follow-up visits in the nine months subsequent to the

initiation phase.

Table 9. Conformance Rates for Quality Indicators for Medicaid Enrolled Youth

Diagnosed with Attention Deficit Hyperactivity Disorder

N of eligible

cases

Conformance Rate


Use of a stimulant medication for ADHD 73,055 62,174 85.1

Follow-up care- initiation phase 73,055 24,026 32.9

Follow-up care- continuation care 8,535 6,057 71.0


Preschoolers. Of the 1,018,597 children aged 2-5 years 15,715 (1.5%) who were mental health

users were prescribed at least one psychotropic medication. The most commonly prescribed

classes of medications were stimulants, alpha-agonists and antipsychotics. Less than one percent


27

of children (0.78%: 7,961 out of 1,018,597) were prescribed antipsychotics across all study

years. Of those prescribed antipsychotics, most (70.9%) were diagnosed with disruptive

behavioral disorders. Of the 15,715 young children prescribed medications, about one-fifth

(20.5%: N= 3,221) had at least six outpatient visits prior to initiating psychotropic medications

and a little over half (54.6%; N = 8,577) received at least 6 visits after initiating medications.

Continuity of Care. Table 10 provides conformance rates for the four continuity of care

measures. The overwhelming majority (82.4%) of youth less than 18 years of age who were

diagnosed with a mental health disorder received at least one medical check-up visit with their

primary care physician per year. Of the 26,693 youths admitted from the emergency room with a

mental health disorder, only about a third (38.4%) received at least one follow-up visit with 30

days of discharge. Rates of follow-up after psychiatric hospitalization are considerably higher,

however, with nearly two-thirds (62.2%) receiving an outpatient visits after discharge.

Table 10. Conformance Rates for Continuity of Care Quality Indicators for Medicaid-

Enrolled Youth

N of eligible

cases

Conformance Rate


Medical Check-up 631,213 519,993 82.4

Follow-up within 30 days after emergency room visit 26,693 10,258 38.4

Follow-up within 30 days after hospitalization 21,680 13,478 62.2

Provider continuity


High Utilization of Inpatient and Emergency Room Services. Of the 631,213 eligible mental

health users who were less than 18 years of age during the study period, 36,259 (5.7%) had two

or more psychiatric hospitalizations or four or more emergency room visits per year.

CONCLUSION

The purpose of this study was to assess the quality of mental health care for children and

youth enrolled in Ohio’s Medicaid program. To achieve study objectives, we first conducted a

systematic review of the literature and convened an expert panel to identify quality of care


28

measures. A total of 28 measures were developed that can be used to identify progress and

benchmark successes. These measures examined: 1) diverse processes of care across several

common childhood disorders; 2) questionable psychotropic prescribing practices; 3) evidence-

based prescribing to preschoolers; and 4) continuity of care across all diagnoses. We then used

Medicaid data to examine conformance rates for identified quality indicators.

Collectively, the results provide a snapshot of the quality of mental health care provided

to children and youth in Ohio and demonstrate that aggregate claims data can be used for quality

assessment. Overall, the results suggest that treatment practices often depart from evidence-

based recommendations indicating the need for quality improvement initiatives. These findings

are consistent with other reports of quality of care received by Medicaid recipients.41,65,66 These

results are not surprising, given that Medicaid beneficiaries have disproportionately low incomes

with a large proportion from racial or ethnic minority groups—all characteristics associated with

receiving lower quality of care.67

Policy Implications

These findings have important implications for policy and practice aimed at improving

the delivery care services to children in Ohio. Three main implications emerge from this study,

described below:

Need for quality improvement efforts focused on inappropriate prescribing

Findings from this study suggest inappropriate prescribing practices are common, and children in foster care may be particularly vulnerable to poor quality of care. The Medical Directors Council of the National Association of State Mental Health Program Directors recently published a policy statement to assist policy makers in responding to the evidence regarding psychotropic prescribing practices. They outline several strategies for promoting best practices in prescribing. These and other recommendations are outlined below.

Develop and disseminate best practice guidelines including recommendations about when medications should be used, dosing, trial duration, necessity of medical monitoring of side effects, and strategies for switching or discontinuing medications.


29

Make standardized toolkits for screening, assessment, and monitoring of side effects available to clinicians to inform best practices.

Monitor performance (at the patient, provider, and agency level) and intervene to identify and reduce questionable prescribing practices. Such interventions may include providing “real time” feedback to providers and administrators and identifying where the outliers are concentrated.

Develop a data tracking system using the best available data to monitor rates and types of psychotropic medication use, adverse events, and to identify and flag questionable prescribing practices. Ideally, such a data tracking system would integrate data from multiple state agencies (e.g., SACWIS, Medicaid, mental health)

Provide education and training to practitioners, stakeholders, child-welfare, court personnel and parents/foster parents around evidence-based prescribing.

Share information to ensure that clinicians, parents, and other interested parties have access to comprehensive information about the use and management of psychotropic medications. AACAP best practice guidelines recommend that states create websites to provide ready access to policies and procedures regarding psychotropic medications as well as psycho-educational materials.

Design a consultation program with child psychiatrists to review cases of questionable prescribing and provide support to practitioners.

Ensure that preschoolers have access to evidence-based psychosocial services

Currently there is little evidence on the safety and efficacy of psychotropic medications in preschoolers. The short and long-term effects of the exposure of psychotropic medications on the developing brains of preschoolers are largely unknown, as are the distribution and clearance of medications which normally guide dosing decisions. As a result, the American Academy of Child and Adolescent Psychiatry workgroup recommends a trial of non-pharmacological intervention (at least 12 visits) prior to initiating medications.58 Despite the availability of effective psychosocial treatments for young children such as parent management, problem solving, and multisystemic therapy for aggression, our data suggests that nonpharmacological services are being underutilized, contrary to existing guidelines. Ensuring access to psychosocial interventions is critical for successful outcomes for young children.


30

Promote timely transitions and continuity of care during high-risk periods, including following an emergency room or hospital admission and the initial period of treatment

Continuity of care is considered to be the cornerstone of effective management and successful outcomes for persons with serious mental illness. Nowhere is continuity of care more important than during the transition period from psychiatric hospitalization to outpatient care, especially since hospital stays are often very short with the major focus on safety, stabilization, and quick transfer to less restrictive settings. Failure to receive timely outpatient follow-up or discontinuities of care after and emergency room and/or hospital discharge can have tragic consequences; the elevated risk for death by suicide, suicide reattempts, and readmission during the post-discharge time period are well-documented as are the high rates of treatment non-adherence. The low level of follow-up care after discharge from the emergency room and hospital and during the initial phases of treatment, underscores the need to improve care continuity of care during these critical high-risk time periods.


31

ACKNOWLEDGEMENTS

The authors would like to thank our funding sponsors, the Ohio Office of Medical Assistance (OMA) and the Ohio Department of Mental Health (ODMH), for their support of this research. We would also like to gratefully acknowledge the support and data programming assistance we received from the Government Resource Center, without whom we could not have completed this project, specifically Daniel Weston, Lorin Ranbom and Dushka Crane. Finally, we would also like to thank the members of our expert panel for volunteering their time and for their invaluable feedback.


32

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35. Zima B.T, Hurlbert M.S, Knapp P, Ladd H, Tang L, Duan N, Wallace P, Rosenblatt A, Landsverk J, Wells K.B. Quality of publicly-funded outpatient specialty mental health care for common childhood psychiatric disorders in California. J Am Acad Child Adolesc Psychiatry 2005; 44:130-144.


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36. Buck, J.A. Medicaid, health care financing trends, and the future of state-base public mental

health services. Psychiatric Serv. 2003; 54 (7): 969-975.

37. Olfson, M., Marcus, S.C., Weissman, M. M., & Jensen, P.S. National trends in the use of psychotropic medications by children. J Am Acad Child Adolesc Psychiatry.2002; 41(5): 514-521.

38. Olfson, M., Gameroff, M.J., Marcus, S.C., Jensen, P.S. National Trends in the Treatment of Attention Deficit Hyperactivity Disorder. Am J Psychiatry. 2003;160:1071-1077.

39. Zito, J.M., Safer, D.J., dosReis, S., et al. Psychotropic practice patterns for youth: A tenyear perspective. Arch Pediatr Adolesc Med. 2003; 157:17-25

40. Garland, A. A., Hough, R. L., McCabe, K. M., Yeh, M.,Wood, P. A.,& Aarons, G. A. Prevalence of Psychiatric Disorders in Youths Across Five Sectors of Care. J Am Acad Child Adolesc Psychiatry.2001; 40(4):409-418.

41 Crystal, S., Olfson, M., Huang, C., Harold, P., & Tobias, G. Broadened use of atypical antipsychotics: Safety, effectiveness, and policy challenges. Health Affairs. 2009; 28(5):W770-W781.

42. The President’s new freedom commission on mental health: Transforming the vision. The Carter Center. 2003: 1-66.

43 Schuster, M.A., Asch, S.M., McGlynn, E.A., Kerr, E.A., Hardy, A.M., & Gifford, D.S. Development of a quality of care measurement system for children and adolescents: Methodological considerations and comparisons with a system for adult women. Arch Pediatr Adolesc Med. 1997; 151(11):1085-92.

44 Fitch, K., Bernstein, S.J., Aguilar, M.S., Burnand, B., LaCalle, J.R., Lazaro, P., Loo, M. McDonnell, J., Vader, J., & Kahan, J. P. The RAND/UCLA appropriateness method user manual. Santa Monica, CA: RAND Corporation, 2001

45 Technical report on psychiatric polypharmacy. National Association of State Mental Health Program Directors. September 2001, 1-20.

46 Safer, D.J., Zito, J.M., and DosReis, S. Concomitant psychotropic medication for youths. Am J Psychiatry, 2003. 160(3): 438-49.

47. Constantine, R. J. Boaz, T. & Tandon, R. Antipsychotic polypharmacy in the treatment ofchildren and adolescents in the fee for service component of a large state Medicaid program. Clinical Therapeutics, 2010;32 (5): 949-59.


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48. Correll C.U., Manu, P., Olshanskiy, V., Napolitano, B., Kane, J.M., & Malhotra, A.K. Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents. JAMA, 2009;302:1765-1773.

49. McIntyre, R.S. & J.M. Jerrell, Metabolic and cardiovascular adverse events associated with antipsychotic treatment in children and adolescents. Arch Pediatr Adolesc Med, 2008. 162(10): 929-35.

50. Haas, M., Unis, A.S., Armenteros, J., Copenhaver, M.D., Quiroz, J.A. & Kushner, S.F. A 6 –week randomized, double blind, placebo-controlled study of the efficacy and safety of risperidone in adolescents with schizophrenia. J Child Adolesc Psychopharm. 2009. 19(6): 611-621.

51. Schooler, N., Rabinowitz, J., & Davidson, M., Risperidone and Haloperidol in first-episode psychosis: A long-term randomized trial. Am J Psychiatry, 2005. 162(5): 947-959.

52. RetroDUR Criteria: Chronic benzodiazepine use in children and adolescents. Drug Use Research & Management Program. Portland, OR; Oregon State University.

53. Witek, M.W., Rojas, V., Alonso, C., Minami, H., & Silva, P.R. Review of benzodiazepine use in children and adolescents. Psychiatric Quarterly, 2005; 76(3):283-296. doi: 10.1007/s11126-005-2982-5

54. McClellan, J., Kowatch, R., & Findling, R.L. Work Group on Quality Issues. Practice parameters for the assessment and treatment of children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry, 2007; 46 (1): 107-25.

55. Suppes T, Dennehy E, Hirschfeld R, Altshuler L, Dowden D, Calabrese J, Ketter T, Sahs G, Swann A. The Texas implementation of medication algorithms: Update to the algorithms for treatment of bipolar I disorder. J Clin Psychiatry. 2005; 66:870-886.

56. Ng, F., Mammen, O.K., Wilting, I., Sachs, G.S., Ferrier, I.N., Cassidy, F., Bealieu, S.,

Yatham, L.N., & Berk, M. The international society for bipolar disorders (ISBD) consensus guidelines for the safety monitoring of bipolar disorder treatments. Bipolar Disord, 2009;11(6):559-95.

57. Zima, B.T., Bussing, R., Tang, L., Zhang, L., Ettner, S., Belin, T.R., & Wells, K.B. Quality of care for childhood attention deficit/hyperactivity disorder in a managed care Medicaid program. J Am Acad Child Adolesc Psychiatry, 2010; 49(12): 1225–1238. doi:10.1016/j.jaac.2010.08.012.

58. Gleason, M.M., Egger, H.L., Emslie, G.J., Greenhill, L.L., Kowatch, R.A., Lieberman, A.F., Luby, J.L., Owens, J., Schahill, L.D., Scheeringa, M.S., Stafford, B., Wise, B., & Zeanah, C.H. Psychopharmacological treatment for very young children: contexts and guidelines. J Am Acad Child Adolesc Psychiatry, 2007; 46(12): 1532-1572.


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59. Bridge, J.A., Marcus, S.C., & Olfson, M. Outpatient care of young people after emergency treatment of deliberate self-harm. J Am Acad Child Adolesc Psychiatry, 2012; 51(2):213-222.

60. Fontanella, C.A. The influence of clinical, treatment, and healthcare system characteristics on psychiatric readmission of adolescents. American Journal of Orthopsychiatry, 2008;78(2):187-198.

61. Bice, T.W., & Boxerman, S.B. A quantitative measure of continuity of care. Med Care, 1977; 15:347-349

62. Kripalani, S., Jackson, A.T., Schnipper, J.L., & Coleman, E.A. Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. Journal of Hospital Medicine. 2007; 2(5):314-323.

63. Naylor, M.D. & McCauley, K.M. Comprehensive discharge planning and home follow-up of hospitalized elders. JAMA, 1999; 281(7):613-620.

64. Coleman, E.A., Parry, C., Chalmers, S., & Min, S. The care transitions intervention. Archives of Internal Medicine, 2006; 166:1822-1828.

65. Morrato, E.H., Druss, B., Hartung, D.M., Valuck, R.J., Allen, R., Campagna, E., & Newcomer, J.W. Metabolic testing rates in 3 state Medicaid programs after FDA warnings and ADA/APA recommendations for second-generation antipsychotic drugs. Arch Gen Psychiatry, 2010; 67(1):17-24

66. Richardson, L.P., DiGiuseppe, D., Christakis, D.A., McCauley, E., & Katon, W. Quality of care for Medicaid-covered youth treated with antidepressant therapy. Arch Gen Psychiatry, 2004; 61:475-480. doi: 10.1001/archpsyc.61.5.475

67. Mental health: A report of the surgeon general. Department of Health and Human Services. US Public Health Service. National Institute of Mental Health, Washington, DC, 1999


38

Appendices

Appendix A

Expert Panel Members

Name PositionJohn Ackerman, Ph.D. Psychologist

TEAMSNationwide Children’s Hospital495 East Main StreetColumbus OH 43215

Mary Applegate, MD, FAAP, FACP Mary S. Applegate MD, FAAP, FACPMedicaid Medical DirectorOHP/ODJFS50 W Town Street, 4th FloorColumbus, OH 43215

Jeff Bridge, Ph.D. Associate Professor of PediatricsOhio State University andThe Research Institute at Nationwide Children’s Hospital Center for Innovation in Pediatric Practice700 Children’s DriveColumbus, OH 43205

John V. Campo, M.D. Professor and Interim Chair, Department of PsychiatryChief, Child and Adolescent PsychiatryThe Ohio State University1670 Upham Drive - Suite 130Columbus, OH 43210

Elizabeth Costea, Pharm.D. Cincinnati VA Medical Center3200 Vine StreetCincinnati, OH 45220

Dushka Crane-Ross, Ph.D. Program Director of College and University RelationsOhio Colleges of Medicine Government Resource Center1033 N. High StreetColumbus, OH 43201

Shivani G. Edwards, MSW, LISW-S, LICDC

Director of Clinical DevelopmentThe Buckeye Ranch2865 W. Broad St.Columbus, Ohio 43204

Cynthia Fontanella, Ph.D. Assistant ProfessorOSU College of Social Work1947 College RdColumbus OH 43210

Mary Fristad, Ph.D., ABPP President, Society of Clinical Child and Adolescent PsychologyPresident, American Board of Clinical Child and Adolescent PsychologyProfessor, Psychiatry, Psychology & NutritionVice Chair for Academic Affairs, Dept of PsychiatryDirector, Research & Psychological Services,Division of Child & Adolescent PsychiatryThe Ohio State University1670 Upham Drive Suite 460GColumbus, OH 43210-1250

Barbara Gracious, M.D. Principal Investigator, Center for Innovation in Pediatric Practice, The


39

Research Institute at Nationwide Children's Hospital; Medical Director, TEAMS Program,700 Children's Drive, JWest 4923Columbus, Ohio 43205

Jianfei (Jeff) J. Guo, B.Pharm., Ph.D. ProfessorHealth Professions Bldg - 133C3225 Eden AveCincinnati, OH 45267

Kraig Knudsen, PhD, MHP Chief, Office of Research & EvaluationOhio Department of Mental Health30 E Broad StColumbus, OH 43215-3414

Robert Kowatch, MD, PhD Nationwide Children's Hospital700 Children's DriveCenter for Innovation in Pediatric PracticeJ West 4th FloorRoom G4-4921Columbus, OH 43023

Cheryl A. Laubacher, Pharm.D. Ambulatory Clinical PharmacistPrimary Care NetworkNationwide Children's HospitalDepartment of Pharmacy700 Children's Dr.Columbus, OH 43205

Bernadette Mazurek Melnyk, Ph.D., R.N., CPNP/PMHNP, FNAP, FAAN

Associate Vice President for Health PromotionUniversity Chief Wellness OfficerDean, College of Nursing120 Newton Hall1585 Neil AvenueColumbus, OH 43210

Mary Ann Murphy, M.D., Ph.D. Child/Adolescent Psychiatrist Residency Training Program Director Nationwide Children's Hospital & The Ohio State University Medical Center700 Children's Dr.Columbus, OH 43205

C. Bayard Paschall, III, Ph.D. Senior Clinical Quality Data AnalystUnited Healthcare Quality Management & Performance9200 Worthington Road, 3rd FloorWesterville, OH 43082

Lorin Ranbom DirectorOhio Colleges of Medicine Government Resource Center1033 N. High StreetColumbus, OH 43201

Kevin M. Smith, M.D., MBA, FAAP Chief Medical OfficerMolina Healthcare of Ohio8101 N High StreetColumbus, OH 43235

Kitty Soldano, Ph.D. Clinical Assistant Professor, Psychiatry, OSU1670 Upham Drive, Suite 560Columbus, Ohio 43210OR 2245 Bryden RoadColumbus, OH 43209


40

Michael T Sorter, M.D. Director, Division of Child and Adolescent PsychiatryAssociate ProfessorCincinnati Children's Hospital Medical CenterUniversity of Cincinnati3333 Burnet Avenue, M.L. 3014Cincinnati, OH 45229

Helen Anne Sweeney, M.S. Manager, Research UnitOhio Department of Mental Health30 E Broad StColumbus, OH 43215-3414

Glenn Thomas, Ph.D. Clinical Director of Community-Based ProgramsNationwide Children's Hospital Behavioral HealthClinical Assistant Professor, Department of PsychiatryThe Ohio State University399 East Main StreetColumbus OH 43215

Sue Timan, APRN, MS Nurse Practitioner700 Children’s DriveTimken Hall 2nd floorColumbus, OH 43023

Shari Uncapher, MSW, LISW Nationwide Children’s Hospital700 Children’s DriveTimken Hall 2nd floorColumbus, OH 43023

Kris West, Ph.D. PsychologistCommunity-Based IntakeNationwide Children's Hospital399 East Main StreetColumbus OH 43215

Michael Wiggins Health Services ResearcherOHP/ODJFS50 W Town Street, 4th FloorColumbus, OH 43215


41

Appendix B

Sample Rating Sheet

Please circle your response rating each statement on the following scale:

1 2 3 4 5 6 7 8 9 10 Strongly Uncertain Strongly Agree Disagree

Meaningfulness Feasibility Overall

Important Gap Actionable

This measure addresses a clinically important topic.

This measure addresses a topic with a gap in quality of care

Clinicians (of the type specified) can influence their performance on this measure.

The measure's components (numerator, denominator, data source) can be clearly specified.

Performance on this measure is not significantly influenced by the characteristics of a clinician's patients.

Overall, this measure should be included as part of a set that assesses the quality of a clinician's care.

01 -- Prescribing method to reduce medical errors

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

02 -- Administration of wellness assessment

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

03 -- Assessment of clinical outcomes

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

04 -- Assessment for substance abuse

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

05 -- Symptoms/functioning constituting primary diagnosis

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

06 -- Assessment for suicidality 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

07 -- Screening for bipolar disorder 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

08 -- Treatment: Understandable 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

09 -- Treatment: Listening 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9


42











10 -- Change in primary mental health provider

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

11 --Therapeutic Alliance 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

12 -- Antidepressant medication management: Effective acute phase treatment

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

13 -- Antidepressant medication management: Effective continuation phase treatment

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

14 -- Initiation of depression treatment

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

15 -- Family visits in child mental health care

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

16 -- Change in treatment if not improved

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

17-- Communication among mental health co-treaters

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

18 -- Communication between mental health clinician and PCP

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9


43











19 -- Annual physical exam 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

20 -- Initiation of substance use disorder (SUD) treatment

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

21-- Engagement in SUD treatment 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

22 -- Timely care after hospitalization

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

23 -- Screening for hyperglycemia and hyperlipidemia with atypical antipsychotic agents

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

24 - Side effect monitoring with mood stabilizers

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

25 -- Change in health/wellness with treatment

1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

26 -- Absenteeism/presenteeism 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

27 -- Efficiency of care 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9

Appendix C

Overall Ratings for All Measures


44

First Round Second RoundMeasure N Mode Median Dispersion N Mode Median DispersionOriginal Depression MeasuresAntidepressant medication management (acute phase)

21 2 2 .71 20 2 2 .50

Antidepressant medication management (continuation phase)

21 2 2 .81 19 2 2 .79

Optimal provider contacts (acute phase) 21 1, 2 2 1.24 20 1, 2 2 .80Optimal provider contacts (continuation phase)

21 2 2 1.48 20 3 3 .95

Adequacy of antidepressant dosage 21 1 1 1.19 20 3 1 .45Recommended antidepressant medication

21 2 2 1.57 20 1, 3 2 .70

Adequate antidepressant monotherapy trial before polypharmacy

21 2 2 1.38 20 2 2 1.10

Antidepressant polypharmacy 21 5 3 1.86 20 4 4 1.40Original Bipolar MeasuresUse of appropriate medication 19 1 1 .95 14 1 1 .07Avoidance of antidepressant or stimulant monotherapy

19 1 3 1.47 14 3 3 1.00

Blood levels for mood stabilizers 19 1 2 1.26 14 1 1 .64Side effect monitoring of mood stabilizers 18 2 2 1.39 14 1 1 .77Screening for hyperglycemia with an atypical antipsychotic

18 2 2 1.61 14 1 1.5 .79

Individual and group psychotherapy 18 1 2 1.11 14 1 2 1.00Original Psychotropic Prescribing MeasuresPsychotropic polypharmacy (>3 medications)

18 1 2.5 2.00 14 1, 3 2.5 1.00

Antipsychotic polypharmacy (>2 antipsychotics)

18 1 2 1.28 14 1 1.5 .86

Mood stabilizer polypharmacy (>3 mood stabilizers)

18 2 2 1.28 14 2 2 .50

Stimulant polypharmacy (>2 stimulants) 18 1, 2 2 1.67 14 2 2 .64Use of antipsychotics in preschoolers 18 1 3 1.72 14 1 1 .50Higher than recommended dose of antipsychotic medications

18 1 1.5 1.78 13 3 3 1.31

Original ADHD MeasuresMEDTAPP Research Project Clinical Profile of Children and Adolescents with SED

45

Follow-up care for children prescribed ADHD medication-initiation phase

13 2 2 .92 12 1 1 .08

Follow-up during continuation phase 13 2 2 1.15 13 1 2 .92Use of a stimulant medication for ADHD 13 1 2 1.23 13 1 1 .69Higher than recommended dose of ADHD medications

13 1 2 1.25 13 1 2 .69

Duration of ADHD medication treatment 13 3 3 1.54 13 3 3 1.62Preschool MeasuresPsychotropic medication use for preschool-aged children

13 1 2 1.69 13 1 1 .69

Adequate trial of psychotherapy for preschoolers

21 1 2 1.43 20 1 3 2.20

Stimulant medication for preschool-aged children

13 2 2 .85 13 7 5 2.00

Antidepressant medication for preschool-aged children

13 1 3 1.31 12 8 5.5 2.33

Anxiety MeasuresPharmacotherapy with SSRIs for anxiety disorders

13 1 2 1.31 13 2 2 .54

Chronic use of benzodiazepine 13 2 2 .85 13 1 1 .15Follow-up care for children with anxiety disorders

13 2 2 1.23 13 1 2 1.00

Higher than recommended dose of anxiolytic medication

13 2 2 .85 13 1 1 .62

All Diagnosis MeasuresFamily visits 21 1 2 1.05 20 3, 5 3.5 1.95Dual Diagnosis 21 1, 5 3 1.48 20 3 4 1.70Case management 21 1, 2 2 1.62 20 3 4 1.80Follow-up after emergency room visit 21 1 2 1.00 20 1 1.5 .70Follow-up after hospitalization 7 days 21 1 2 1.48 20 2,3 2 1.10Follow-up after hospitalization 30 days 21 1 2 1.19 20 1 2 .80Treatment engagement 21 1 3 1.38 20 3 3 1.10Provider continuity 21 1 3 1.81 20 3 3 1.05Specialty Care 21 1, 2 2 1.52 20 1 2 1.25Medical checkup 18 2 2 1.17 14 1 1.5 1.14Higher than recommended dose of antipsychotic medications

13 1 2 1.15 13 1, 2 2 .69


46

Appendix D

Measures Packet

Quality of Care Measures

For Childhood Mental Disorders


47

Table of Contents

Measures at a Glance …………………………………………………………….. 3

Depression Measures …………………………………………………………….. 4-6

Bipolar Measures …………………………………………………………….. 6-9

Psychotropic Measures …………………………………………………………….. 9-12

ADHD Measures …………………………………………………………….. 12-13

Preschooler Measures …………………………………………………………….. 14-15

Anxiety Measures …………………………………………………………….. 15-17

All Diagnosis Measures …………………………………………………………….. 17-19

Acute Care Measures …………………………………………………………….. 19

Deleted Measures …………………………………………………………….. 20-21

Appendices …………………………………………………………….. 22

Appendix A Definition of Terms………………………………………. 23-24

Appendix B Diagnostic Categories…………………………………… 25-26

Appendix C Procedure Codes………………………………………… 27

Appendix D Dose Guidelines…………………………………………. 28-31

Appendix E Recommended Mood Stabilizers and Antipsychotics.. 32

Appendix F List of Psychotropic Medications……………………….. 33-35

Appendix G Amphetamine and Methylphenidate Based Stimulants 36

Appendix H Measure Developers ……………………………………… 37

Measures at a GlanceMEDTAPP Research Project Clinical Profile of Children and Adolescents with SED

48

MeasureNumber

Measure Name ClinicalCondition

Evidence Rating a

Measure 1 Antidepressant medication management - acute phase Depression AMeasure 2 Antidepressant medication management - continuation phase Depression AMeasure 3 Optimal medication provider contacts - acute phase Depression CMeasure 4 Optimal psychotherapy provider contacts - acute phase Depression CMeasure 5 Adequacy of antidepressant dosage Depression AMeasure 6 Recommended antidepressant medication Depression AMeasure 7 Use of appropriate medication Bipolar AMeasure 8 Blood levels for mood stabilizers Bipolar BMeasure 9 Side effect monitoring of mood stabilizers Bipolar BMeasure 10 Screening for hyperglycemia and hyperlipidemia when an atypical

antipsychotic is prescribedBipolar A

Measure 11 Individual and group psychotherapy Bipolar CMeasure 12 Psychotropic polypharmacy

(> 4 medications)Psychotropic Prescribing

C

Measure 13 Antipsychotic polypharmacy(> 2 antipsychotics)

Psychotropic Prescribing

B

Measure 14 Mood stabilizer polypharmacy(> 3 mood stabilizers)


C

Measure 15 Stimulant polypharmacy(> 2 stimulants)


C

Measure 16 Higher than recommended dose of antipsychotic medications Psychotropic Prescribing

A

Measure 17 Follow-up care for children prescribed ADHD medication-initiation phase ADHD BMeasure 18 Follow-up during continuation phase ADHD BMeasure 19 Use of a stimulant medication for ADHD ADHD BMeasure 20 Higher than recommended dose of ADHD medications ADHD BMeasure 21 Psychotropic medication use for preschool-aged children Preschool CMeasure 22 Psychosocial visits among preschool-aged children prescribed

psychotropic medicationsPreschool C

Measure 23 Use of antipsychotics in preschoolers Preschool CMeasure 24 Pharmacotherapy with SSRIs for anxiety disorders Anxiety AMeasure 25 Chronic use of benzodiazepine Anxiety BMeasure 26 Follow-up care for children with anxiety disorders Anxiety CMeasure 27 Higher than recommended dose of anxiolytic medication Anxiety BMeasure 28 Follow-up after emergency room visit All Diagnoses BMeasure 29 Follow-up after hospitalization 30 Days All Diagnoses CMeasure 30 Treatment engagement All Diagnoses CMeasure 31 Provider continuity All Diagnoses BMeasure 32 Medical Checkup All Diagnoses CMeasure 33 High Utilization of ED/Inpatient Services All Diagnoses B


49

Table 1. Quality of Care Measures

Measure Name Description Technical Specifications Guideline-Based Rationale Data Source Evidence Rating a

Depression Measures

1. 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

Numerator: Those youth from the denominator who remain on antidepressant treatment for at least 67 day supply (MPR = 80%) of the 84 days following the index prescription.

Denominator: The number of children (<18 years) with continuous enrollment who were diagnosed with a new episode of depression and treated with antidepressant medication during the 84 day (12 week) acute treatment phase.

Randomized controlled trials show antidepressants to be efficacious for the treatment of pediatric depression but remission requires continuous treatment throughout a 12-week acute treatment phase. Studies on Medicaid populations indicate that less than 50% of children and adolescents receive adequate duration of antidepressant therapy. Lack of adherence to medication is associated with worse outcomes (e.g., recurrence of depression, hospitalizations etc.).

Medicaid Claims & Encounter Data

Eligibility Files Pharmacy Files

A

2. Antidepressant medication management continuation phase

% 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

Numerator: Those youths from the denominator with a 144 day supply(MPR = 80%) of treatment during the 180 days following the index prescription.

Denominator: The number of children(< 18years) with continuous enrollment, who were diagnosed with a new episode of depression and as of the 84 day of the measurement period treated with antidepressant medication.

Depressive disorders are highly prevalent and recurrent in pediatric populations, afflicting as many as 20% of youths by age 18, and are associated with a heightened risk of school failure, early pregnancy, increased physical illness, substance abuse, and suicide. Randomized clinical trials show antidepressants to be efficacious for treating depression and preventing relapse. However, antidepressants must be continued for 6 to 12 months after initiation to minimize the likelihood of relapse.


Eligibility Files Pharmacy Files

A

3. Optimal medication provider contacts acute phase

% 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.,

Numerator: Those members from the denominator with > 3 medication visits with a physician (at least 1 visit with the prescribing provider) within 84 days after the index prescription.

Given the high risk of suicide associated with clinical depression, AACAP treatment guidelines recommend frequent follow-up visits during the acute phase of treatment.


Eligibility Files Professional Files

C


50


physician or nurse practitioner) in the 84-day (12 week) acute treatment phase

Denominator: The number of children (<18 years) with continuous enrollment and who were diagnosed with new episode of depression and treated with an antidepressant medication during the 84 day (12 week) acute treatment phase.

See Appendix C for CPT codes

Follow-up visits are also necessary to monitor treatment response, make medication adjustments, and monitor adherence, as well as educate the child and parent about the benefits of antidepressants, side effects, and potential time lag in treatment response while building a therapeutic alliance. Studies of psychotherapy have found remission to occur after an average of 8 to 12 visits.

4. Optimal psychotherapy provider contacts acute 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

Numerator: Those members from the denominator with > 6 follow-up outpatient mental health visits with a primary care or mental health practitioner within 84 days after the index prescription.

Denominator: The number of children (<18 years) with continuous enrollment and who were diagnosed with new episode of depression and treated with an antidepressant medication during the 84 day (12 week) acute treatment phase.

See Appendix C for CPT codes.

Rationale from 3 above Medicaid Claims & Encounter Data


C

5. Adequacy of antidepressant dosage

% 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)

Numerator: Those children included in the denominator who received an adequate antidepressant dosage (e.g., within therapeutic dose range) for at least 4 consecutive weeks after initiation of medication

Denominator: The number of children (<18 years) with continuous enrollment, who were newly diagnosed with depression and

Depression can be treated effectively with antidepressant medications, but research has shown these agents to be most effective within the therapeutic range of dosages. Lower doses may lead to inadequate response, while higher doses may produce side effects without greater efficacy. Studies have shown that many patients receive sub-therapeutic


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prescribed antidepressant medication during the measurement period

See Appendix D for Dose Guidelines

dosages in clinical practice.

6. Recommended antidepressant medication

% of members 18 years of age or younger with a new episode of depression and treated with antidepressant medication who are prescribed SSRIs (e.g., fluoxetine, sertraline, citalopram, and escitalopram) during the 84-day (12 week) acute phase treatment

Numerator: Those members of the denominator who had a prescription fill for an SSRI medication.

Denominator: The number of children (<18 years) with continuous enrollment, who had a new episode of depression and were treated with an antidepressant medication during the 84 day (12 week) acute treatment phase.

SSRIs are considered the first line of pharmacological treatment for pediatric depressive disorders. SSRIs have a superior safety, tolerability, and effectiveness profile and research base than is currently available for other antidepressants. Fluoxetine (Prozac) and Escitalopram (Lexapro) are approved by the Food and Drug Administration (FDA) for the treatment of depression in children and adolescents. RCTs conducted with children and adolescents with MDD have shown SSRIs to be a well tolerated and effective treatment.


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Bipolar Measures7. Use of appropriate

medication% 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

Numerator: Those youths from the denominator who are prescribed a mood stabilizer and/or antipsychotic medication within the first 84-days (12 weeks) of the diagnosis

Denominator: The number of children (≤18 years) with continuous enrollment who were diagnosed with a new episode of bipolar disorder

See Appendix A for definitions.See Appendix E for recommended medications.

Mood stabilizers and antipsychotics are considered the first line of treatment for pediatric bipolar disorder. RCTs have shown the mood stabilizers - lithium, valproate, divalproex, and carbamazepine - to be well tolerated and effective at alleviating symptoms of bipolar disorder in youths and adolescents. Olanzapine, quetiapine and risperidone are recommended as the first-line of atypical antipsychotic treatment. Not enough RCTs have been done with children to determine which drug is best, so decisions can be made based on patient characteristics. Recent


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review of RCTs showed that children using atypical antipsychotics had larger effects than those using mood stabilizers alone; however, atypical have a higher side effect burden than mood stabilizers.

8. Blood levels for mood stabilizers

% 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)

Numerator: Those youths from the denominator who receive a serum medication blood level test within 84-days (12 weeks) of initiation of lithium or mood stabilizer (carbamazepine, divalproex sodium/valproic acid)

Denominator: The number of children (≤ 18 years) with continuous enrollment who are diagnosed with a new episode of bipolar disorder and treated with a lithium agent or mood stabilizer (carbamazepine, divalproex sodium/valproic acid)

Guidelines recommend monitoring of blood levels to reduce side effects and prevent toxicity and to ensure maximum effectiveness. Up to 75% of patients on lithium experience side effects, some of which can indicate toxicity. The narrow therapeutic index of lithium (.8 – 1.4 mmol/L) requires monitoring levels after initial dosage and dosage increases. Monitoring medication serum levels verifies that patients are treated within the therapeutic index while not being overdosed on a specific medication. A study of adult Medicaid patients showed that 36.5% of individuals diagnosed with bipolar and on lithium did not receive medication level blood tests.

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9. Side effect monitoring of mood stabilizers

% 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

Numerator: Those youths from the denominator who receive a thyroid or renal function test within 84-days (12 weeks) of initiation of lithium or who receive a liver test within 84-days (12 weeks) of initiation of valproic acid or carbamazepine

Denominator: The number of children (≤ 18 years) with continuous enrollment who are diagnosed with a new episode of bipolar disorder and

Mood stabilizers for bipolar disorder have potential for adverse drug effects on specific organ systems. Lithium can cause polyuria, renal dysfunction and hypothyroidism, giving rise to recommendations to monitor BUN, creatinine, and thyroid function via blood tests. Renal toxicity is likely to increase with medications, especially during long- term use. Monitoring can lead to early detection, changes in dosing


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treated with lithium, valproic acid or carbamazepine

or medication resulting in reduced impairment, and in some cases clinical intervention. A study of adult Medicaid patients showed that over half (54.1%) of lithium users did not receive a thyroid function test and less than 5% received renal function test.

10. Screening for hyperglycemia and hyperlipidemia when an atypical antipsychotic is prescribed

% 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

Numerator: Those youths from the denominator who are screened for evidence of hyperglycemia or hyperlipidemia within 112-days (16 weeks) of initiating an atypical antipsychotic agent

Denominator: The number of children (≤ 18 years) with continuous enrollment who are diagnosed with a new episode of bipolar disorder and treated with an atypical antipsychotic agent

See Appendix F for list of medications

Based on reviews of RCTs, treatment with antipsychotic medications has been associated with weight gain and impaired glucose metabolism, exacerbation of existing Type 1 and Type 2 diabetes, new onset of Type 3 diabetes and diabetic ketoacidosis. Monitoring of weight and plasma glucose levels can help indicate patients are at early risk for diabetes related diseases. Adjustments in treatments can be made on the individual patient level. Fasting Plasma Glucose level is the ideal method for monitoring glucose levels with a variety of alternatives when fasting is not possible.


A

11. Individual and group psychotherapy

% of enrollees 18 years of age or younger with ≥ 6 claims for any outpatient visits by a mental health practitioner within 84-days (12 weeks) of initial diagnosis

Numerator: Those youths from the denominator who had at least 6 claims for any outpatient visits by a mental health practitioner within 84-days (12 weeks) of diagnosis

Denominator: The number of children (≤ 18 years) with continuous enrollment with a new episode of bipolar disorder


Guidelines recommend follow-up visits and psychotherapy to monitor symptoms, functioning, and suicide risk, improve adherence, address psychosocial stressors, and educate parents and children about bipolar disorder. Reviews of recent studies have shown the majority of outcomes show reduced relapse rates, increased quality of life, improved functioning, and more favorable symptom outcomes. Patients, caregivers, and family

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members can all benefit from psychotherapy. A variety of treatments have been shown to be useful including CBT, family, and group therapy. Psychotherapy can help reduce symptoms of bipolar disorder and increase adherence to medication use.

Psychotropic Prescribing Measures

12. Psychotropic polypharmacy(> 4 medications)

(All diagnoses)

% of enrollees 18 years of age or younger on four (4) or more psychotropic medications for ≥ 30 days during the measurement year

Numerator: Those members from the denominator on four (4) or more psychotropic medications for 30 days or longer

Denominator: The number of children (≤18 years) who were prescribed at least one psychotropic medication for 30 days or longer during the measurement year

See Appendix F for listing of psychotropic medications

The use of multiple medications increases the risk for medication related adverse effects and drug-drug interactions, complicates the drug regimen making compliance more difficult, and potentially creates the need for more medications. In addition, polypharmacy substantially increases costs. There is also very little scientific evidence on the safety or efficacy of combination treatment. Despite the limited evidence and concerns about safety risks, prescribing of multiple medications is an increasing trend and common among Medicaid populations. According to a recent national study of office-based psychotropic prescription, rates of polypharmacy increased from 22% to 32% over a 12 year period.

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13. Antipsychotic polypharmacy(> 2 antipsychotics)

(All diagnoses)

% 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

Numerator: Those members in the denominator who are prescribed two (2) or more concomitant antipsychotic medications

Denominator: The number of children (≤ 18 years) who were prescribed at least one antipsychotic medication for

National trends suggest an increased use of antipsychotic polypharmacy in children and adolescents, driven in large part due to prescribing of antipsychotic medications for treatment of behavioral symptoms (e.g., impulsivity and aggression). For


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60 days or longer during the measurement


example, a retrospective cohort study of Medicaid enrolled children in a single state found that 42% of youth received antipsychotic polypharmacy. While there is some evidence from small, short-term clinical trials that antipsychotics and mood stabilizers can reduce behavioral symptoms in children with ADHD or autism and combination medications may be helpful for children with complex comorbid conditions, these practices need to be balanced with potential risks. Adverse events associated with antipsychotic medications 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


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


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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.

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 the measurement year

Numerator: Those member in the denominator who were prescribed two (2) or more amphetamine and methylphenidate-based stimulants concurrently for 60 days or more

Denominator: The number of children (≤ 18 years) who were prescribed at least one stimulant medication for 60 days or longer during the measurement year

See listing of types of stimulants

Treatment of behavioral symptoms associated with ADHD, disruptive disorders, and autism is a major driver of polypharmacy in children and adolescents. Research suggests that many children with ADHD and conduct problems are prescribed multiple agents because of suboptimal response to stimulants. However, the American Academy of Child and Adolescent Psychiatry recommends caution in prescribing multiple agents because of the lack of scientific evidence on effectiveness and safety concerns. Currently, there are no studies on the effectiveness of the use of multiple stimulants. A recent study regarding polypharmacy in youth with ADHD and aggression by Blader et al. suggests that aggression resolves in a substantial proportion of youth when the stimulant dose is titrated to maximum optimization.


C

16. Higher than recommended dose of antipsychotic medications

(All diagnoses)

% 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

Numerator: Those members in the denominator with evidence of a dose higher than the recommended maximum

Denominator: The number of

Currently there is little scientific evidence about the efficacy of high doses of antipsychotic medications for children and adolescents. Studies of second generation antipsychotics in youth have


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children (≤ 18 years) who were prescribed at least one antipsychotic medication for 30 days or more during the measurement year

See Appendix D for dose guidelines

demonstrated equal or worsening response when higher doses are compared to lower doses. Higher doses of psychotropic medications also increase the risk for serious side effects and problems with adherence.

ADHD Measures17. Follow-up care for

children prescribed ADHD medication-initiation phase

% of members age 6 to 18 with a new prescription for an ADHD medication who had ≥ 1 follow-up visit with a prescribing practitioner within 30 days of the index prescription date

Numerator: Those youths from the denominator who had ≥ 1 follow-up visit with the prescribing practitioner within 30 days of the index prescription date.

Denominator: Number of children age 6 to 18 with continuous enrollment with a new prescription for ADHD medication during the 1 year measurement period.See Appendices:

A for definitions B for diagnosis codes and

follow-up codes F for medication list

ADHD is one of the most common childhood mental disorders, affecting 3–7% of U.S. children and associated with costs of more than $42 billion. During the past decade, ADHD medication prescriptions have doubled. An estimated 6–42% of children are identified as having a mental health problem during a primary care visit, more than 70% of general pediatricians report being responsible for treating ADHD. However, studies suggest that follow-up care in primary care are substantially below recommended national guidelines. Medications used to treat ADHD have known side effects and need to be closely monitored by a practitioner with prescribing authority.


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18. Follow-up during continuation phase

% of members 6 to 18 years of age with a new prescription for ADHD medication who remained on the medication for at least 120 days and had at least two follow-up visits with a prescribing practitioner within 150 days (5 months) after the initiation phase ended.

Numerator: Members from the denominator who had at least two follow-up visits with a prescribing practitioner in the months subsequent to the initiation phase

Denominator: Number of children age 6 to 18 with a) a new prescription for ADHD medication and continuous enrollment during the 1 year

The annual cost of illness for ADHD in the U.S. is estimated to be more than $42 billion. ADHD may culminate in significant health care-related costs, including frequent unintentional injuries, co-occurring psychiatric conditions and productivity loss. Studies indicate that follow-up care for children and youths treated for ADHD in primary



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measurement period and b) were on the medication for ≥ 120 days (MPR = 80%) during the 5 months following the initiation phase.

See Appendices: A for definitions B for diagnosis codes and

follow-up codes F for medication list

care settings is poor (average 1 visit per year) and focused primarily on medication management. In contrast, children in specialty mental health care receive an average of 5 visits per month including medication management and psychosocial intervention. 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 attention-deficit/hyperactivity 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. Evidence-based 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.


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

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

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See Appendix D for ADHD dose guidelines

youth are particularly vulnerable to adverse effects of psychotropic medications. In children, high doses of stimulants can cause insomnia and appetite suppression.

Preschool Measures21. 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 non-psychopharmacological interventions (for up to 12 weeks) before starting psychopharmacological treatment due to the potential impact on their developing brains.


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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

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


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year in privately insured preschoolers more than doubled from 1999 to 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 Measures24. 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 short-term efficacy of SSRIs for the treatment of childhoodanxiety disorders, including: GAD, social phobia, and SAD. SSRIs are also well tolerated in children and adolescents with anxiety disorders.



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 mental health diagnosis with at least

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 medications other than SSRIs for



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one prescription fill for a benzodiazepine during the measurement year. Excluding children who were diagnosed with a seizure disorder

See Appendix F for listing of benzodiazapines

the treatment of childhood anxiety disorders have not been established. Benzodiazepines have not shown efficacy in controlled trials in childhood anxiety disorders or other psychiatric disorders. Adverse effects are also well documented including central nervous system depression, impaired psychomotor performance, amnesia, respiratory depression, and dependence and abuse potential.

26. Follow-up care for children with anxiety disorders

% of enrollees 18 years of age or younger with new diagnosis of anxiety disorder and prescribed an antianxiety agent (e.g., SSRI antidepressant) that receive ≥ 6 follow-up outpatient mental health visits (at least 2 of the 6 visits need to be with the prescribing physician) within 84 days (12 weeks) of the initial diagnosis

Numerator: Those children in the denominator with ≥ 6 outpatient mental health visits (at least 2 of the 6 need to be with the prescribing practitioner)

Denominator: The number of children (≤18 years) with continuous enrollment and who were diagnosed with new episode of anxiety disorder and treated with an antianxiety agent during the 84 day (12 week) acute treatment phase.

See Appendix C for follow-up codes

Follow-up care is necessary to monitor response to treatment, including symptoms, functioning, behavior, and potential side effects. Monitoring of medications is especially important for children and adolescents taking antidepressants given the FDA black box warning on the risk of pediatric suicidality with SSRIs. AACAP practice guidelines recommend multimodal treatment (psychotherapy and pharmacological interventions) for children and adolescents with moderate or severe anxiety disorders. Although combination pharmacological and psychological interventions have not been adequately studied, behavioral and psychological interventions that help promote mastery are important to prevent recurrence after discontinuation of medication. Numerous RCTs have documented the efficacy of CBT and behavioral therapies for the childhood anxiety



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disorders, whether delivered in individual, group, or family-based format. Little research has examined the effectiveness of differences in frequency of follow-up visits, although there is some evidence of improvement with 6-9 psychotherapy visits. AHRQ practice guidelines for major depression recommend 4-8 visits during the acute phase of treatment.

27. Higher than recommended dose of anxiolytic medication

% of enrollees 18 years of age or younger on anxiolytic medications (e.g., benzodiazepines) 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 ) who were prescribed an anxiolytic medication for 30 days or more during the measurement year

See Appendix D for dose guidelinesSee Appendix F for listing of anxiolytic medications

Little scientific evidence regarding high doses of medications exists for children and adolescents outside the FDA approval process; therefore, caution is needed when prescribing for pediatric populations. The few existing studies that have examined this issue suggest that high doses do not improve symptom control. Studies of second generation antipsychotics in youth have demonstrated equal or worsening response when higher doses are compared to lower doses. Studies of stimulants have shown that for some children, attention and hyperactivity symptoms remain. Benzodiazepines have a number of well documented adverse effects including central nervous system depression, impaired psychomotor performance, amnesia, respiratory depression, and dependence and abuse potential. Higher than recommended doses increase the risk of side effects.



B

All Diagnoses

28. Follow-up after emergency % of members 18 years of age Numerator: Those members in the A substantial proportion of young Medicaid Claims & Encounter B


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room visit

(All diagnoses)

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

denominator who received a follow-up 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


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.

Data

Eligibility Files Professional File

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


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

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30. Treatment engagement % of members of members 18 years of age or younger who had a mental health evaluation for treatment of depression and who had a second mental health visit within 30 days

Numerator: Those members from the denominator who had a mental health evaluation for depression and had a second outpatient mental health visit within 30 days of the initial assessment

Denominator: The number of continuously enrolled children (< 18 years of age) who had a new episode

Many patients discontinue treatment prematurely, resulting in failure to achieve remission or relapse. Studies have found that patients continuing medication for 4 to 9 months after remission are less likely to relapse than those who do not. Studies have found remission to occur after an average of 8 to 12 visits.

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of depression during the measurement period.


31. Provider continuity

(All Diagnoses)

% of members 18 years of age or younger with new episodes of depression who receive outpatient mental health visits through the same provider or facility during the acute phase of treatment

Numerator: The number mental health visits to the same provider or facility (Continuity of Care Index)

Denominator: The total number of outpatient mental health visits during the measurement period for members(< 18years) with continuous enrollment and diagnosed with a new episode of depression.


Continuity of care is critical for effective management of serious mental illness. Studies on pediatric populations have shown that continuity of care is associated with reduced emergency department and inpatient hospitalizations, and increased patient satisfaction.



B

32. Medical Checkup % of enrollees 18 years of age or younger with ≥ 1 medical visit by a primary care practitioner b within 1 year of starting any mental health treatment

Numerator: Those youths from the denominator who had at least 1 medical visit with a primary care practitioner

Denominator: The number of children (≤ 18 years) who are diagnosed with a mental health disorder during the measurement year

Psychotropic medications including antidepressants, stimulants, mood stabilizers and antipsychotics, prescribed alone or in combination, all have the potential for adverse side effects. Medical follow-up is needed to monitor potential adverse side effects (e.g. weight gain, metabolic changes, cardiovascular effects) to maintain good health.

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Acute Care Utilization33. High Utilization of

ED/Inpatient Services% of enrollees 18 years of age or younger with ≥ 4 ED visits or ≥ 2 inpatient psychiatric hospitalizations among those who are currently receiving mental health services

Numerator: Those in the denominator with ≥ 4 ED visits or ≥ 2 inpatient psychiatric hospitalizations for mental health problems

Denominator: The number of children (≤ 18 years of age) with a mental health diagnosis and ≥ 1 mental health service claim during the measurement year

Hospitalizations are costly, accounting for approximately 31% of the total health care expenditures. High utilization of emergency room (ER) and/or inpatient hospital services is generally considered an indicator of poor quality of care or poor transitions between different providers and settings or systemic failures (e.g., poor coordination, lack of services). Identifying high risk


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groups with frequent readmissions can provide opportunities for targeted quality improvement efforts.


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Table 2. Deleted Measures and Rationale

Name of Measure Description Clinical Condition Rationale for ExclusionDomain: Treatment

Optimal Provider contact-continuation phase

% of members 18 years of age or younger with a new episode of depression and treated with antidepressant medication who had at least monthly follow-up visits during the 180 day continuation phase of treatment

Depression Minimal research evidence. Only about 20% of children continue to take antidepressants for 6-9 months.

Adequate antidepressant monotherapy trial before using polypharmacy

% of members 18 years of age or younger with a new episode of depression who received an adequate trial (8-10 weeks of the initial antidepressant before adding another antidepressant (excluding trazodone for insomnia)

Depression Time period is too long. Not easy to reliably capture using Medicaid data.

Adequate psychotherapy trial before initiating antidepressant medications

% of children 3-5 years of age treated for major depression that received 12 weeks of outpatient psychotherapy before initiating antidepressant medications

Depression

(Preschoolers)

This measure has been revised. Panel states that 12 weeks of psychotherapy is not realistic given barriers in accessing services, particularly in rural areas.

Antidepressant polypharmacy % of members 18 years of age or younger who received 2 or more concomitant antidepressant medications in a single subclass —selective serotonin reuptake inhibitors, serotonin –norepinephrine reuptake inhibitors, tricyclics, and other antidepressants

Depression

Avoidance of antidepressant or stimulant monotherapy

% of enrollees 18 years of age or younger with ≥ 1 claim for an antidepressant or stimulant without a concurrent claim of a mood stabilizer and/or antipsychotic medication with 84 days of the initial bipolar diagnosis

Bipolar

Duration of ADHD medication treatment

% of members age 6 to 18 with a new ADHD prescription who received

ADHD Not reliable because many children go on drug "vacations" (stop taking stimulants) during holidays or


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continuous medication treatment for ≥ 144 days out of 180 days.

summer months

Stimulant medication for preschool-aged children

% of enrollees ≤ 5 who receive a new prescription fill for methylphenidate or amphetamine

ADHD

(Preschoolers)

Duplicate of measure # 20;

Antidepressant medication for preschool-aged children

% of enrollees ≤ 5 who receive a new prescription fill for fluoxetine

Depression

(Preschoolers)

This measure is based on research findings from older children and duplicates measure #6.

Family visits % of members 18 years of age or younger with a new episode of depression with 1 or more outpatient mental health visits that includes a family member for the 84 day period following the initial diagnosis

All diagnoses Not reliably coded in the Medicaid data

Domain: Care CoordinationDual diagnosis % of members 18 years of age or

younger discharge with a depression and substance abuse diagnosis that received 4 or more substance abuse visits within a 12 month period

All diagnoses Not accurately captured in the dataset. Availability of substance abuse treatment in Medicaid is lacking. Services are not always billed as substance abuse.

Case management for high users

% of members 18 years of age with ≥ 1 case management visit for individuals with ≥ 2 hospitalizations or ≥ 4 ED visits during a 12 month period

All diagnoses Not accurately captured in the dataset. Will capture a wider variety of services not just case management.

Follow-up after hospitalization-7 days

% of patient hospitalized for treatment of a mental health disorder, seen by a mental health provider within 7 days of discharge

All diagnoses Not realistic given barriers in accessing outpatient care (e.g., waiting lists, shortages of psychiatrists)

Domain: Access/Availability of CareSpecialty care % of children who say a clinician with

specialized training in the mental health care of children

All diagnoses


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Appendices


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Appendix A

Definition of Terms

Acute phase (Depression): The acute phase usually lasts 6–12 weeks, and the main goals of treatment are to achieve response and remission of the depressive symptoms.

Continuation phase (Depression): The continuation phase typically lasts 4–12 months, during which remission is consolidated to prevent relapses.

New episode of depression: Defined as: (1) a diagnosis of depression (identified by the International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes: 296.2, 296.3, 300.4, and 311); and (2) no history of depression (no claims) or antidepressant usage in the six-month pretreatment period prior to index prescription

Monotherapy: Defined as a drug regimen with a single antidepressant

Polypharmacy: Defined as drug regimen with two or more medications taken concomitantly

Index prescription: Defined as the first prescription of the antidepressant

Index date: Defined as the date of each patient’s first antidepressant prescription

Medication Possession Ratio: Defined as the sum of the number of days’ supply for all antidepressant prescriptions during the specified time period divided by the total number of days during the specified time period, theoretically ranging from 0% (no adherence) to 100% (perfect adherence)

Acute phase (Bipolar): The acute phase treatment lasts up to 12 weeks. The main goals for depressive episode are (1) remission of depressive symptoms and return to usual level of psychosocial functioning and (2) avoidance of mood destabilization and precipitation of hypomania or mania. The main goals for mania or mixed episodes are (1) rapid response to agitation, aggression and impulsivity and (2) remission of manic/mixed symptoms with return to usual level of psychosocial functioning.

New episode of bipolar disorder: Defined as: (1) a diagnosis of bipolar disorder (identified by the International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes: 296.0, 296.1, 296.4, 296.5, 296.6, 296.7-296.80, 296.89); and (2) no history of bipolar disorder (no claims) or usage of a mood stabilizer or antipsychotic medication in the six-month pretreatment period prior to initial diagnosis.

Extrapyramidal side effects: These are adverse effects upon movement, including akathisia, motor restlessness, muscle stiffness, tremor, and severe muscle spasms (dystonia), sometimes referred to as drug-induced Parkinson’s symptoms.

Tardive Dyskinesia: Impairment of control over ordinary muscle movement, spasmodic involuntary movements affecting the mouth, lips, tongue. Can affect trunk and other parts of the body.

Prolactin: A hormone produced by the pituitary gland.

Hyperglycemia: Abnormally high levels of glucose in the blood.

Creatinine: A lab test used to calculate an estimate of kidney function.


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BUN: Blood urea nitrogen test to calculate how well kidneys and liver are working.

New episode of ADHD or Anxiety: A period of 6 months (180 days) prior to the index prescription start date (IPSD) for during which time the child has no prescription fill for a stimulant medication (or Strattera) or anti-anxiety medication (e.g. antidepressants)

Index Prescription State Date (IPSD): The first prescription dispense date for ADHD

Initiation Phase (ADHD): The 30 day period following IPSD for ADHD medication

Continuation Phase (ADHD): The 31-150 days following the IPSD for ADHD medication


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Appendix B

Diagnostic Categories

Mental Health and Substance Abuse ICD-9-CM Codes

Diagnostic Category ICD-9-CM Procedure Code Description

Mental Health Diagnoses

Major depression and depressive disorders

296.20, 296.3, 298.0, 300.4, 311 Major depression single episode, major depression, recurrent episode, neurotic depression, and depressive disorder nos

Bipolar disorders 296.0, 296.1, 296.4-296.9 Bipolar I disorder, bipolar spectrum disorder, bipolar nos or manic affective disorder

Psychosis* 295, 297, 298 Schizophrenia; delusional disorders, other non-organic psychosis

Autism spectrum* 299.00 Pervasive developmental disorders; autism

Anxiety disorder 300.0-300.02, 300.09.300.2-300.39, 309.21, 309.81, 313

Overanxious disorder, separation anxiety disorder, panic disorder, simple phobia, social phobia, generalized anxiety disorder, post-traumatic stress disorder, anxiety state unspecified

Adjustment disorders* 308, 309 Adjustment and stress disorders

Personality disorders* 301

ADHD* 314 Attention deficit hyperactivity disorder

Conduct disorder 313.81, 312.0-312.9 Oppositional defiant disorder, disturbances of conduct, impulse control disorder

Other mental disorders* 302, 306, 310 Sexual and gender identify;

Special syndromes* 307 Eating disorders, tic disorders; movement disorders; sleep disorders; enuresis

Substance Abuse Diagnoses

Substance abuse* 291, 292, 303, 304, 305 Alcohol or drug disordersNote: * = includes all diagnoses that have the listed first three digits

Diagnostic Categories and ICD-9-CM Procedure Codes for Bipolar Disorder


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ICD-9 Diagnosis Code Description296.0x1 Bipolar I disorder, single manic/hypomanic episode296.40 Bipolar I disorder – most recent episode hypomanic296.4x Bipolar I disorder – most recent or current episode manic296.5x Bipolar I disorder – most recent or current episode depressed296.6x Bipolar I disorder – most recent or current episode mixed296.7x Bipolar I disorder – most recent or current episode unspecified296.80 Bipolar I disorder – Not Elsewhere Classified – includes

Bipolar Disorder NOS Manic-Depressive Syndrome NOS Manic-Depressive reaction NOS

296.89 Bipolar II disorder301.13 Cyclothymic disorder

1x= 5th digit used to specify severity (0=unspecified; 1=mild, 2=moderate, 3=severe-without mention of psychosis, 4=severe-with mention of psychosis, 5=in partial or unspecified remission, 6=in full remission).

Diagnostic Categories and ICD-9-CM Procedure Codes for ADHD

ICD-9-CM Diagnosis Code Description314.00 Attention-deficit disorder, without mention of hyperactivity314.01 Attention-deficit disorder, with mention of hyperactivity314.1 Hyperkinesis with developmental delay314.2 Hyperkinetic conduct disorder314.8 Other specified manifestations of hyperkinetic syndrome314.9 Unspecified hyperkinetic syndrome

Diagnostic Categories and ICD-9-CM Procedure Codes for Anxiety

ICD-9-CM Diagnosis Code Description300.02 Generalized anxiety disorder300.3 Obsessive compulsive disorder309.21 Separation anxiety disorder300.2 Specific Phobias300.21 Agoraphobia with panic300.23 Social Anxiety disorder (social phobia)309.81 Post Traumatic Stress disorder300.00 Anxiety Disorder NOS313.0 Overanxious disorder313.23 Selective Mutism300.01 Panic disorder300.81 Somatoform disorders


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Appendix C

Current Procedure Terminology (CPT) Codes by Service Types

Service Type CPT Codes CommentNon-PsychiatricEvaluation and Management

Office or other E/M codes 99201-99205; 99211-99215

Visit claim must include a mental health diagnostic codes (ICD-9 codes) or specialist (psychiatrist, psychologist)

Office or other outpatient consultation codes

99206-99210; 99241-99245

Prolonged physician visit codes 99354, 99355; 99358, 99359

Preventive medicine 99381-99387, 99391-99397

Preventive medicine counseling 99401-99404

Case management service codes 99361, 99362; 99371-99373

Diagnostic psychological/ developmental Assessment test codes

96100, 96110, 96115

Health Behavioral Assessment & Intervention (HBAI codes)

96150 – 96155

PsychiatricPharmacological management 90862, Z1831Mental health assessment 90801, H0002, H0031,

Z1832by a physician or non-physician

Diagnostic interview 90801, 90802, Z1832Individual psychotherapy 90804-90819, 90821-

90824, 90826-90829, 90889, H0004, Z1833

Group psychotherapy 90853, H0004, Z1834Family therapy 90846, 90847, 90849Other incidental services 90885, 90887, 90889Partial hospitalization Z1838, S0201Case management Z1840, Z1841, H0036Crisis intervention Z1837


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Appendix D

Dose Guidelines for Children and Adolescents

Antidepressant Medications

Type of Antidepressants Minimal

Daily Dose

Maximum

Daily Dose

Therapeutic Range

SSRIs

Fluoxetine 20 mg 60 mg 20-60 mg for children and adolescents

Sertraline 50 mg 200 mg 50-200 mg children and adolescents

Escitalopram 10 mg 20 mg 10-20 mg for children and adolescents

Citalopram 20 mg 40 mg 20-40 mg for children and adolescents

Paroxetine 20 mg 40 mg 20-40 mg

Paroxetine CR 20 mg 37.5 20-37.5 mg

Fluvoxamine 100 mg 300 mg 100-300 mg

Other antidepressantsa

Buproprion XL 100 mg 300 mg children

450 mg adolescents

100-300 mg for children

150-450 mg for adolescents

Trazodone 100 mg

25 mg (for sleep)

150 mg

100 mg

100-150 mg

25-100 mg for sleep

Mirtazapine 15 mg 45 mg 15-45 mg for children and adolescents

Venlafaxine 75 mg

50mg for children and adolescents <30kg

75mg for children and adolescents >30kg

225 mg 75-225 mg

Duloxetine 40 mg 60 mg 40-60 mg


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Tricyclics

Desipramine 25 mg 100 mg 5mg/kg for children based on TBW, 150mg for adolescents

Nortriptyline 30 50mg 30-50 mg

Clomipramine 200 mg 200 mg Amitriptyline 50 mg 100 mg

100 mg for adolescents

50-100 mg

Imipramine 30 mg 75 mg 25 mg-50mg for children30 mg-75mg for adolescents

Doxepin 75 mg 300 mg 75-300 mg for adolescents

Abbreviations: SSRIs = selective serotonin reuptake inhibitor aIncludes selective noradrenaline reuptake inhibitors, nonadrenaline-dopamine reuptake inhibitors and noradrenergic and specific serotonergic antidepressantSources: Clinical Manual of Child and Adolescent Psychopharmacology, Robert L. Findling MD, 2008. Pediatric Psychopharmacology Fast Facts, Daniel F. Connor MD, Bruce M Meltzer, 2006. Clinical Handbook of Psychotropic Drugs for Children and Adolescents 2nd Revision, Kalyna Z. Bezchlibnyk-Blutler, Adil S. Virani, 2007. Child and Adolescent Clinical Psychopharmacology 4th edition, Wayne Hugo Green, 2007.


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Antipsychotic Medications

Drug Name Drug Brand Name Maximum Dose Dose Source

CHILD (≤ 12)

ADOLESCENT (13-18)

Atypical

Aripiprazole Abilify 15mg 30mg FDA; Texas; PSYCKES

Clozapine Clozaril, Fazaclo 300mg 600mg Texas; PSYCKES

Olanzapine Zyprexa 12.5mg 20mg FDA; Texas; PSYCKES

Quetiapine Seroquel 300mg 800mg FDA; Texas; PSYCKES

Risperidone Risperdal 3mg 6mg FDA; Texas; PSYCKES

Ziprasidone Geodon 160mg 160mg Texas; PSYCKES

Typical

Chlorpromazine Thorazine 500mg 800mg FDA; PSYCKES

Haloperidol Haldol 6mg 10.5mg FDA; Texas; PSYCKES

Perphenazine Trilafon 6mg 64mg FDA; Texas; PSYCKES

Pimozide Orap 10mg 10mg FDA; PSYCKES

Thioridazine Hcl Mellaril 120mg 210mg FDA; PSYCKES

Thiothixene Navane 20mg 20mg Textbook

Abbreviations: FDA = U.S. Food and Drug Administration; Texas = Psychotropic Medication Utilization Parameters for Texas Foster Children; PSYCKES = New York State Office of Mental Health: Psychiatric Clinical Knowledge Enhancement System

Textbook references: Stahl SM. Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. 3 rd ed. New York: Cambridge University Press; 2008. Findling RL. Clinical Manual of Child and Adolescent Psychopharmacology. APP Inc; 2008. Green WH. Child and Adolescent Clinical Psychopharmacology. 4th ed. Lippincott Williams & Wilkins; 2007.

ADHD Medications


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Drug Name Drug Brand Name Maximum Dose Dose SourceCHILD

(≤ 12)

ADOLESCENT (13-18)

amphetamine-dextroamphetamine Adderall 40 40 FDA (Y) , PSYCKES

amphetamine-dextroamphetamine XR Adderall XR 30 30 FDA (Y), PSYCKES

armodafinil Nuvigil 250 250 FDA (A) , PSYCKES

atomoxetine Hcl Strattera 56 100 FDA (Y) - W , PSYCKES

clonidine Hcl Catapres 0.4 0.4 TEXAS , PSYCKES

clonidine Hcl Kapvay 0.4 0.4 TEXAS, PSYCKES

cloniine Hcl (Analgesia) Catapres 0.4 0.4 TEXAS , PSYCKES

dexmethylphenidate Hcl Focalin 20 20 FDA (Y), PSYCKES

dexmethylphenidate Hcl (Focalin XR) Focalin Xr 30 30 FDA (Y) , PSYCKES

dextroamphetamine sulfateDas, Dexedrine, Dextrostat, Liquadd, Procentra

40 40 FDA (Y), PSYCKES

guanfacine Hcl Intuniv, Tenex 4 4 FDA (Y), PSYCKES

lisdexamfetamine dimesylate Vyvanse 70 70 FDA (Y) , PSYCKES

methamphetamine Hcl Desoxyn 25 25 FDA (Y) , PSYCKES

methylphenidate Hcl Metadate Cd, Methylin, Ritalin 60 60 FDA (Y) , PSYCKES

methylphenidate Hcl (Concerta) Concerta 54 72 FDA (Y) , PSYCKES

modafinil Provigil 400 400 FDA (A) , PSYCKES

Abbreviations: FDA = U.S. Food and Drug Administration (Y) = Youth, (A) = Adult, (W) = dose based on weight; Texas = Psychotropic Medication Utilization Parameters for Texas Foster Children; PSYCKES = New York State Office of Mental Health: Psychiatric Clinical Knowledge Enhancement System


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Antianxiety Medications (Benzodiazepines)

Generic Brand Name Maximum Dose Dose SourceCHILD(≤ 12)

ADOLESCENT (13-18)

alprazolam Xanax 4 4 TEXT

chlordiazepoxide, Librax, Libritabs, Librium, CDP 30 30 FDA

clonazepam Klonopin, Ceberclon 3 3 TEXT

clorazepate dipotassium Azene, Tranxene 60 60 FDA

diazepam Valium 10 10 FDA

lorazepam Ativan, Lorazepam 4 4 FDA

oxazepam Serax 120 120 FDA

temazepam Restoril 30 30 FDA

hydroxyzine

Atarax, Vistaril, Atazine, Neucalm, Qys, Rezine, Vistacon, Vistacot, Vistaject

100 100 FDA

meprobamate Miltown, Equanil, Meprospan 1800 1800 FDA

meprobamate-aspirin Equagesic, Micrainin 2600 2600 FDAAbbreviations: FDA = U.S. Food and Drug Administration; TEXT = Stahl SM. Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. 3rd ed. New York: Cambridge University Press; 2008. Findling RL. Clinical Manual of Child and Adolescent Psychopharmacology. APP Inc; 2008. Green WH. Child and Adolescent Clinical Psychopharmacology. 4th ed. Lippincott Williams & Wilkins; 2007.


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Appendix E

Recommended Mood Stabilizers and Antipsychotics for Treatment of Pediatric Bipolar Disorder1,2

Mood stabilizers AntipsychoticsBrand Name Generic Brand Name Generic

Eskalith, Lithane Lithobid

lithium carbonate Zyprexa Olanzapine

Depakote Divalproex Seroquel Quetiapine

Tegretol Carbamazepine Risperdal Risperidone

Trileptal Oxcarbazepine Geodon Ziprasidone

Lamictal Lamotigine Abilify Aripiprazole

Topamax Topiramate Clozaril Clozapine

Neurontin Gabapentin

1. Kowatch RA, Strawn J, Sorter M. Clinical trials support new algorithm for treating pediatric bipolar mania. Current Psychiatry. 2009;8(1):19-34.

2. McClellan J, Kowatch R, Findling RL. Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry. 2007; 46 (1): 107-25.


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Appendix F

Listing of Psychotropic Medications by Drug Class

Drug Class Brand Name GenericAntidepressants TCAs

Elavil, Endep, Enovil, Vanatrip

amitriptyline Hcl

Asendin amoxapineAnafranil Clomipramine hclNorpramin, Pertofrane desipramine hclAdapin, Sinequan doxepinTofranil Imipramine hydrochloride (Hcl)Ludiomil Maprotiline HclAventyl, Pamelor, Nortrilen nortriptyline HclVivactil protriptyline HclSurmontil trimipramine

SSRIsLexapro® Escitalopram OxalateLuvox, Luvox CR Fluvoxamine MaleatePaxil, Paxil CR® paroxetine HclCelexa Citalopram HydrobromideZoloft Sertraline HclProzacSarafem

Fluoxetine Hcl

MAOIsMarplan isocarboxazidNardil Phenelzine SulfateParnate tranylcypromine sulfateDeprenyl selegiline

OtherWellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban

bupropion Hcl

Remeron mirtazapineDesyrel trazodone HclEffexor XR venlafaxine HclSerzone Nefazodone HclCymbalta Duloxetine Hcl

Combination Antipsychotic and Antidepressant

Symbyax (Prozac & Zyprexa)

Olanzapine-Fluoxetine Hcl

Antipsychotics Atypical

Abilify aripiprazoleSolian amisulprideClozaril clozapine


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Drug Class Brand Name GenericFanapt, Fanapta, Zomaril iloperidoneBuronil, Burnil, Eunerpan melperoneInvega paliperidoneZyprexa olanzapineSeroquel, Seroquel XR Quetiapine FumarateRisperdal risperidoneGeodon ziprasidone HclSerlect sertindole

TypicalThorazine Chlorpromazine HclTaractan chlorprothixenePermitil, Prolixin Fluphenazine HclHaldol haloperidolLoxitane loxapineTrilafon perphenazineLidone, Moban molindoneNavane thiothixeneMellaril thioridazine HclStelazine trifluoperazineCompazine, Buccastem, Stemetil

prochlorperazine

Orap pimozideClopixol zuclopenthixolSerentil mesoridazineVesprin trifluopromazineSparine promazine

Anticonvulsant MoodTegretol carbamazepineDepakote divalproex sodiumNeurontin gabapentinLamictal lamotrigineTopamax topimarateTrileptal oxcarbazepine

LithiumEskalith, Eskalith CR Lithane, Lithobid

lithium carbonate

Cibalith-S lithium citrateAlpha Agonists

Catapres, Duraclon, Kapvay

clonidine Hcl

Tenex, Intuniv Guanfacine HclStimulants

Adderall, Amphetamine-Dextroamphetamine, Amphetamine mixed salts,

Adderall XR Amphetamine-Dextroamphetamine XR


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Drug Class Brand Name GenericConcerta, Metadate, Ritalin, Ritalin SR, Ritalin LA, Metadate CD, Methylin, Methylin ER, Daytrana TD

Methylphenidate Hcl

Cylert pemolineDexedrine, Dexostat, Dexedrine Spansule

Dextroamphetamine Sulfate

Focalin, Focalin XR Dexmethylphenidate HclDesoxyn Methamphetamine HclVyvanse Lisdexamfetamine Dimesylate

Non-stimulantStrattera Atomoxetine Hcl

BenzodiazepinesXanax, Niravam alprazolamLibrium ChlordiazepoxideKlonopin clonazepamTranxene Clorazepate DipotassiumValium, Diastat diazepamProsom estazolamSerax oxazepamCentrax prazepamVersed midazolamRestoril temazepamHalcion triazolamDalman Flurazepam Hcl

Other anti-anxietyBuSpar buspirone

Hypnotics (sleep)Placidyl ethchlorvynolMiltown, Equanil meprobamateTrancopal chlormezanoneAmbien, ambien CR, Edluar zolpidem tartrate, zolpidem

tartrate CRParal paraldehydeUnisom, Aldex doxylamineLunesta eszopicloneRozerem ramelteonSonata zaleplonPrecedex dexmedetomidine

Abbreviations: TCAs = tricyclics; SSRIs = selective serotonin reuptake inhibitors; MOAIs = Monoamine oxidase inhibitors; CR = controlled release, LA = long acting, SR = sustained release


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Appendix G

Amphetamine and Methylphenidate Based Stimulants

Type of Stimulant Brand Name Generic NameAmphetamine-Based Stimulants

Adderall, Adderall XR amphetamineDexedrine, Dexostat, Dexedrine Spansule

dextroamphetamine

Desoxyn methamphetamineVyvanse lisdexamfetamine

Methylphenidate Based StimulantsConcerta, Metadate, Ritalin, Ritalin SR, Ritalin LA, Metadate CD, Methylin, Methylin ER, Daytrana TD

methylphenidate

Appendix H


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Measure Developers

MeasureNumber

Measure Name Developer

Measure 1 Antidepressant medication management - acute phase NCQA/HEDIS/AHRQMeasure 2 Antidepressant medication management - continuation phase NCQA/HEDIS/AHRQMeasure 3 Optimal medication provider contacts - acute phase** NCQA/HEDIS*/AHRQMeasure 4 Optimal psychotherapy provider contacts - acute phase** NCQA/HEDIS*/AHRQMeasure 5 Adequacy of antidepressant dosage APA/AHRQMeasure 6 Recommended antidepressant medication ResearchMeasure 7 Use of appropriate medication CQAIMH/STABLE/AACAP/APAMeasure 8 Blood levels for mood stabilizers CQAIMH/STABLE/ResearchMeasure 9 Side effect monitoring of mood stabilizers AACAPMeasure 10 Screening for hyperglycemia and hyperlipidemia when an atypical

antipsychotic is prescribedCQAIMH/STABLE

Measure 11 Individual and group psychotherapy Research/STABLEMeasure 12 Psychotropic polypharmacy (> 4 medications) PSYCKES/TEXASMeasure 13 Antipsychotic polypharmacy (> 2 antipsychotics) PSYCKES/TEXAS/MMDLN/Rutgers

CERTSMeasure 14 Mood stabilizer polypharmacy (> 3 mood stabilizers) PSYCKES/TEXASMeasure 15 Stimulant polypharmacy (> 2 stimulants) PSYCKES/TEXASMeasure 16 Higher than recommended dose of antipsychotic medications PSYCKESMeasure 17 Follow-up care for children prescribed ADHD medication-initiation

phaseNCQA

Measure 18 Follow-up during continuation phase NCQAMeasure 19 Use of a stimulant medication for ADHD APA/CQAIMHMeasure 20 Higher than recommended dose of ADHD medications PSYCKESMeasure 21 Psychotropic medication use for preschool-aged children** PSYCKES/TEXASMeasure 22 Psychosocial visits among preschool-aged children prescribed

psychotropic medications**PSYCKES/TEXAS

Measure 23 Use of antipsychotics in preschoolers PSYCKES/TEXAS/MMDLN/RutgersCERTS

Measure 24 Pharmacotherapy with SSRIs for anxiety disorders Research/AACAPMeasure 25 Chronic use of benzodiazepine ResearchMeasure 26 Follow-up care for children with anxiety disorders ResearchMeasure 27 Higher than recommended dose of anxiolytic medication PSYCKES/TEXASMeasure 28 Follow-up after emergency room visit ResearchMeasure 29 Follow-up after hospitalization 30 Days HEDIS/NCQAMeasure 30 Treatment engagement CQAIMH/ValueOptionsMeasure 31 Provider continuity ResearchMeasure 32 Medical Checkup ResearchMeasure 33 High Utilization of ED/Inpatient Services PSYCKES

*Adapted from original version **Measures divided after expert panel meetings


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