Changes in ADHD prescribing after psychotropic medication training

1. Changes in ADHD prescribing after psychotropic medication training Marisa Elena Domino†, Charles Humble*, Peter Jensen‡, Chris Kratochvilэ, Alan Stiles¥ ,Treiste Newton*, Lynn Wegner¥ ‡, Steve Wegner* ¥ , *AccessCare †UNC-CH Department of Health Policy & Management ¥ UNC-CH Department of Pediatrics ‡Principal Investigator, Resource for Advancing Children’s Health (REACH) Institute эUniversity of Nebraska Medical Center APHA Annual Meeting, Mental Health Workforce 4135.0: October 30, 2012

2. Disclosure Statement I am qualified on the content of today’s report because of decades of experience in claims data research and 3 years of participation in the P3NC study. In the current study I have organized the claims-based empirical analysis. I have no relevant financial relationships that effect the findings presented here today.

3. Background for North Carolina Attention Deficit/Hyperactivity Disorder (ADHD) is the most common behavioral health problem in children and adolescents Over last 7 years access to North Carolina’s public mental health programs has been challenged by re-design and funding cuts.

4. Program Goals Give Primary Care Providers (PCP) and Pediatric Residents the knowledge, skills, and tools needed to properly diagnose and manage ADHD and other common behavioral health conditions in the Medical Home Assess the possible added impact of training Case Managers (CM) with the knowledge, skills and tools needed to evaluate response to management plans and optimize adherence to management plans for care of children with ADHD

5. Provider Education Primary Care Providers (PCP)(Nov 2009) 3-day training in diagnosis of pediatric behavioral problems and primary pediatric psychopharmacology management (PPPM) biweekly conference calls for 6 mo. Care Managers (Nov 2009) 1-day training in PPPM biweekly conference calls for 6 mo. Pediatric Residents (Aug & Sep 2010) 1-day training in PPPM

6. Training Agenda • Identify common ground and gaps between Primary Care & Child Psychiatry • Discuss what is required to change how PCPs practice; reinforce thru role playing • Review personal areas of need, set goals • Create Virtual Treatment Teams through bi-weekly conference calls

7. Identification of Trained practices in NC Medicaid claims Claims and enrollment data were obtained on all children under age 21 from one year prior to one year post-training Only children affiliated with a medical homes practice were included Practices with one or more providers that participated in the training were identified in the claims data (n=32)

8. Selection of control practices • 1165 potential control practices were identified in claims • Medical homes practices • Did not have an identified provider that participated in the training

9. Selection of control practices • 18 baseline practice level characteristics served as risk factors in propensity models of training participation • Provider type, number of Medicaid enrolled children at practice, and baseline aggregated measures from child-level claims data (e.g., % of Medicaid children with ADHD Dx, % male) • Nearest neighbor propensity score matching was used to identify control practices (n=30) matched to intervention practices (n=30) • Practices were balanced on all characteristics

10. Selected practice characteristics

11. Child-month outcomes • After identifying trained and control practices, claims data on Medicaid-enrolled children affiliated with those practices were selected • Only children ages 6-18 were included • 1,006,420 children in trained practices • 821,244 children in control practices • Outcomes analyzed for all children include ADHD diagnosis, ADHD prescription receipt • Outcomes analyzed for children with ADHD examine dosing and adherence to ADHD medications

12. Child-month Level characteristics

13. Empirical Methods Analysis of child-month observations used generalized estimating equations to accommodate the repeated observations on individuals. We generated the average marginal effect of training during the post period for each outcome and report delta-method standard errors.

14. Preliminary Results

15. Conclusions • Training resulted in greater identification of children with ADHD, but a decrease in the probability of receiving an ADHD medication prescription • Decreases in medication use may come from better targeting of medications or reductions in polypharmacy, since the number of medications per child was also reduced • We observe no difference in prescribing below guideline level dosing between children in trained and control practices, despite the 15% baseline rate • We found a greater rate of prescribing above dosing guidelines in the trained practices • Adherence and overall Medicaid expenditures were similar by training status of practices

16. Conclusions The short training course affect practice patterns such as diagnosis and treatments. Further research should examine the effects of training on child-centered health outcome measures such as quality of life, behavior change, and school outcomes .

17. Limitations Practice identifiers aggregate claims from trained and non-trained providers using the same practice billing code All outcomes are from Medicaid claims and may under report ADHD diagnoses

18. Study Significance One of the first studies to use Medicaid data to examine the effect of a psychopharmaceutical training Findings support the value of extended PCP training in guideline-level care for ADHD Findings are informing rollout of other Behavioral Health programs in NC’s Medicaid program May also influence use of REACH model in other states now adopting the Medical Home model for their Medicaid clients

19. Major support for this project comes from ARRA Grant # 1RC1MH088922-01 (Principal Investigator: P. Jensen)The authors thank Dr. Lisa Hunter, Melanie Louis, Courtney Sanderson, and Tim O’Brien for their many contributions to this program.