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Comparative effectiveness of state psychotropic oversight systems for children in foster care
Investigator (PI): Crystal, Stephen
Performing Organization (PO): (Current): Rutgers, The State University of New Jersey, Institute for Health, Health Care Policy and Aging Research / (848) 932-8413
Supporting Agency (SA): Patient-Centered Outcomes Research Institute (PCORI)
Initial Year: 2015
Final Year: 2019
Record Source/Award ID: PCORI/IHS-1409-23194
Funding: Total Award Amount: $2,032,074
Award Type: Contract
Award Information: PCORI: More information and project results (when completed)
Abstract: Background: Children and youth in foster care receive antipsychotic medication at much higher rates than other children. These patients often receive multiple medications; treatment patterns vary dramatically across states and communities. These powerful medications have a profound impact on the lives of vulnerable youth. Recent federal mandates require states to develop psychotropic oversight systems for foster youth. States have used contrasting strategies, ranging from consultative/educational to more restrictive (e.g., prior authorization). Policy makers and other stakeholders face difficult decisions in selecting policies. Limited evidence on benefits and drawbacks of alternative strategies and on concerns, preferences, and impacts on patients, caregivers, and other stakeholders exists. To better inform these decisions, a multidisciplinary team incorporating consumer investigators will examine patient/stakeholder impact of differing, innovative oversight systems in Texas, Wisconsin, Washington, and Ohio. Objectives: We will identify, document, and analyze oversight systems in the study states (aim 1); elicit perspectives and experiences of psychotropic medication with essential stakeholders including foster care alumni, caregivers, caseworkers, clinicians and pharmacists, and their prioritization of effectiveness measures important to patients and stakeholders (aim 2); and examine stakeholder-prioritized outcomes of policies using Medicaid data (aim 3). Methods: Our mixed-methods design will integrate qualitative and quantitative analysis of data from state documents and key informant interviews (aim 1); focus groups and interviews with foster-care alumni, caregivers, and other stakeholders (aim 2); and variation between and within states and over time in stakeholder-prioritized outcome measures from claims data (aim 3), building on consensus psychotropic metrics developed by a multistate consortium. We will focus particularly on outcomes of natural experiments created by policy changes such as Texas prescribing parameters and review flags in 2013 on polypharmacy and metabolic monitoring that will dramatically increase second-opinion reviews. Outcomes: Interview and survey data will identify stakeholder-reported impacts of policies. Patient outcome measures for claims data to be prioritized by stakeholders include well-developed and tested metrics for antipsychotic use by age, polypharmacy, dosage, and adherence; management of metabolic risks; mental health evaluation and services consistent with treatment; diagnosis consistent with treatment; and other practices, as well as hospitalization, emergency room use, and self-harm events. The overall intended study outcome is improved, evidence-based decision making on oversight policies, aligned with patient/stakeholder priorities, and supporting improved care and outcomes for children in foster care and other vulnerable youth. Results to date indicate that implementation of a specialized managed care model for youth in foster care reduced the proportion of youth prescribed antipsychotic medications without FDA-indicated conditions while not significantly affecting antipsychotic medications prescribed to youth with FDA-indicated conditions. The managed care strategy provided a multimodal intervention that included routine mental health screening, health passports, elective psychiatric consultation line, and retrospective drug utilization reviews. Results suggest that when these tools are employed jointly, they may be effective in encouraging safe and judicious antipsychotic use.
Abstract Archived: Background: More than one in four foster care youths receive psychotropic medications; about one in seven receives antipsychotics. These patients often receive multiple medications, and treatment patterns vary dramatically across states and communities. These powerful medications have a profound impact on the lives of vulnerable youth. Their appropriate management has generated much national controversy. Recent federal mandates require states to develop psychotropic oversight systems for foster youth. States have used contrasting strategies, ranging from consultative/educational to more restrictive (e.g., prior authorization). Policy makers and other stakeholders face difficult decisions in selecting policies. Limited evidence on benefits and drawbacks of alternative strategies and on concerns, preferences, and impacts on patients, caregivers, and other stakeholders exists. To better inform these decisions, a multidisciplinary team incorporating consumer investigators will examine patient/stakeholder impact of differing, innovative oversight systems in Texas, Wisconsin, Washington, and Ohio. Objectives: We will identify, document, and analyze oversight systems in the study states (aim 1); elicit perspectives and experiences of psychotropic medication with essential stakeholders including foster care alumni, caregivers, caseworkers, clinicians and pharmacists, and their prioritization of effectiveness measures important to patients and stakeholders (aim 2); and examine stakeholder-prioritized outcomes of policies using Medicaid data (aim 3). Methods: Our mixed-methods design will integrate qualitative and quantitative analysis of data from state documents and key informant interviews (aim 1); focus groups and interviews with foster-care alumni, caregivers, and other stakeholders (aim 2); and variation between and within states and over time in stakeholder-prioritized outcome measures from claims data (aim 3), building on consensus psychotropic metrics developed by a multistate consortium. We will focus particularly on outcomes of natural experiments created by policy changes such as Texas prescribing parameters and review flags in 2013 on polypharmacy and metabolic monitoring that will dramatically increase second-opinion reviews. Outcomes: Interview and survey data will identify stakeholder-reported impacts of policies. Patient outcome measures for claims data to be prioritized by stakeholders include well-developed and tested metrics for antipsychotic use by age, polypharmacy, dosage, and adherence; management of metabolic risks; mental health evaluation and services consistent with treatment; diagnosis consistent with treatment; and other practices, as well as hospitalization, emergency room use, and self-harm events. The overall intended study outcome is improved, evidence-based decision making on oversight policies, aligned with patient/stakeholder priorities, and supporting improved care and outcomes for children in foster care and other vulnerable youth.

MeSH Terms:
  • Caregivers
  • Child
  • Comparative Effectiveness Research
  • Emergency Service, Hospital
  • Evidence-Based Medicine
  • Foster Home Care /*legislation & jurisprudence
  • /organization & administration
  • Health Policy
  • Humans
  • Medicaid
  • Ohio
  • Outcome Assessment (Health Care)
  • Patient Participation
  • Psychotropic Drugs /*therapeutic use
  • Self-Injurious Behavior /prevention & control
  • State Government
  • Texas
  • Vulnerable Populations
  • Washington
  • Wisconsin
Country: United States
State: New Jersey
Zip Code: 08901
UI: 20153585
Project Status: Ongoing
Record History: ('2019: Abstract archived and replaced. 2017: Project extended to 2019',)