Results Summary
What was the research about?
Doctors sometimes give children medicine called antipsychotics that can affect mood and behavior. Antipsychotics can have long-term risks, like heart attack and diabetes, but they help treat serious conditions like schizophrenia. But children may also receive antipsychotics to treat other conditions, like attention deficit hyperactivity disorder. The Food and Drug Administration, or FDA, has not approved antipsychotics for these types of mental health problems. Children in foster care get these medicines more often than children not in foster care.
States are responsible for children in foster care, including what medicines they get. In this study, the research team looked at policies to improve antipsychotic use in four states:
- In some Ohio counties, doctors got prescribing guidance that included reducing the use of multiple antipsychotics at once.
- In some Wisconsin counties, a policy improved coordination of medical and mental health care.
- In Washington, the state required doctors to get approval from psychiatrists to prescribe antipsychotics.
- In Texas, doctors got guidance on prescribing antipsychotics. The guidance also suggested testing for side effects of antipsychotics.
The team looked at how the state policies and programs affected antipsychotic use for children in foster care.
What were the results?
Overall, the policies improved appropriate use of antipsychotics for children in foster care.
Ohio
- There were reductions in use of more than one antipsychotic at the same time. Children in foster care had the largest reductions
Wisconsin
- Rates of recommended blood tests improved for children in foster care
Washington
- Before the state required reviews by psychiatrists, rates of antipsychotic medicines in Washington were similar to other states. Two years after the new policy, rates declined in Washington but stayed the same in the comparison states. Rates went down more among children in foster care than children not in foster care
Texas
- Compared with adopted children, those in foster care with less severe conditions where the FDA does not recommend antipsychotic treatment were less likely to get those prescriptions
- Treatment rates didn’t change for children with more severe problems, where the FDA does recommend treatment.
- Rates of blood tests for safety monitoring increased among children in foster care and adopted children.
What did the research team do?
The team looked at states with policies that affect how children in foster care get antipsychotics. All children had Medicaid. Using health records, the team identified which medicines children in foster care got. The team also looked at whether children in Texas and Wisconsin had blood tests for antipsychotics side effects.
Young adults who were once in foster care, caregivers of children in foster care, social workers, and doctors gave input on the study.
What were the limits of the study?
The study looked at policies in four states. Results may differ for other states and policies. Findings may have differed if the research team used interviews or surveys instead of health records.
Future research could look at policies in other states, or at other kinds of information from children, like quality of life.
How can people use the results?
Policymakers can use these results when considering how to improve antipsychotic prescribing for children in foster care.
Professional Abstract
Objective
To examine the effects of state antipsychotic prescription strategies for children in foster care (FC)
Study Design
Design Elements | Description |
---|---|
Design | Observational: mixed methods study |
Population | Children in foster care in Ohio and Wisconsin (selected counties), Washington, and Texas, with selected comparisons to children not exposed to the state policies of interest |
Interventions/ Comparators |
Before and after implementing State antipsychotic prescription monitoring strategies in Ohio, Wisconsin, Washington, and Texas |
Outcomes | Selected outcomes include: Prevalence of antipsychotic polypharmacy (multiple concurrent antipsychotics) in children in FC (Ohio); antipsychotics prescribed to children in FC (Texas and Washington); metabolic testing rates for those children in (Texas and Wisconsin) |
Timeframe | Up to 9-year follow-up for study outcomes |
Researchers examined interventions that monitor antipsychotic prescriptions for children in FC implemented in four states:
- Ohio: Minds Matter, a multi-component quality improvement program that included provider education and a guide for providers on antipsychotic prescribing. The program’s quality improvement targets included use of multiple antipsychotics
- Wisconsin: Integration of medical and mental health services for children in FC
- Washington: Prior authorization for antipsychotic prescriptions for children in FC based on review from child psychiatrists
- Texas: A multi-modal specialized managed care program for children in FC, supported by prescribing parameters that included metabolic monitoring requirements
The intervention groups included children in foster care, eligible for Medicaid, treated with antipsychotics; comparisons were with children not in foster care, except in Texas, where comparisons were with adopted children. Researchers examined Medicaid claims data before and after the implementation of state interventions to identify differences in outcomes among children exposed to interventions. Outcomes examined and specific comparison groups varied by state.
Young adults who were once in FC, caregivers of children in FC, social workers, and doctors helped plan and execute the study.
Results
Ohio
- After implementation of Minds Matter, antipsychotic polypharmacy rates fell to lower levels that were sustained over time, with the largest changes observed among children in FC.
Wisconsin
- Metabolic testing rates improved significantly for children in FC on antipsychotics in pilot counties from pre- to post-implementation.
- Rates were stable in non-pilot counties.
Washington
- Within two years of policy implementation, prevalence decreased from 6.17 per 1000 to 4.04 in Washington and remained stable (6.21) in comparison states.
- Initially, compared with children not in FC, antipsychotic use rates declined less for children in FC. However, in year two, rates declined significantly more quickly among children in FC.
Texas
- After program implementation, prescribing for conditions without an FDA-approved indication for use was reduced relative to a comparison population. Antipsychotic use did not significantly change among individuals with diagnoses carrying FDA-approved indications for use.
- Compared with children in FC treated with antipsychotics in Ohio (where the intervention did not focus on metabolic monitoring), children in FC treated with antipsychotics in Texas had significantly greater increases in metabolic monitoring.
- Addition of metabolic monitoring to state prescribing parameters was followed by an increase in both the level and trend of monitoring rates among youth in FC.
Limitations
Researchers examined antipsychotic prescription monitoring strategies in four states. Results may differ in other states and systems. Findings may have differed if researchers measured outcomes using self-reported data instead of administrative data.
Conclusions and Relevance
Overall, the antipsychotic policies studied improved appropriate use of antipsychotics for children in FC. State and local policymakers can use this research when considering antipsychotic prescription strategies for children in FC.
Future Research Needs
Future research could study the effects of antipsychotic prescription strategies in other states. Studies could also use self-reported data and different client-centered outcomes such as quality of life.
Final Research Report
View this project's final research report.
Journal Citations
Results of This Project
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers expressed concern that the study described itself as a comparative effectiveness study of state interventions, but most of the analyses involved changes within individual states’ medication oversight programs. The reviewers asked the researchers to acknowledge the limited amount of comparisons they could make across states given the observational nature of this study. The researchers agreed that there were limitations in what comparative conclusions they could draw, and noted that a more experimental model, where children in foster care would be assigned randomly to different interventions, was not feasible. The researchers pointed out that the topic and need for better information would benefit from the type of large-scale data collection, quasi-experimental studies like this one. They expanded the report’s discussion to describe the types of inferences about between-state comparisons that could and could not be made in this type of study.
- The reviewers questioned the report’s description of patient and stakeholder engagement. They asked for clarification on the role of stakeholders in developing the project and interpreting results. They asked why stakeholders were not listed as authors of the report. The reviewers also questioned why current children in foster care were not included as study stakeholders. The researchers said they involved patients and families extensively in developing research aims, choosing and prioritizing outcomes, and interpreting results. The researchers said they did not engage stakeholders in writing the report because the writing took place after the budget period of the project. Further, the researchers noted that there were state policy issues with having minors in foster care participate in research studies related to guardianship. In addition, the researchers hesitated to involve minors in the study given the sensitive topics that would be raised in discussions. The researchers ultimately felt that choosing to work with foster care alumni was more appropriate as well as more feasible while still providing a high level of insight into the foster care experience.