Youth Indicator Set. Technical Specifications. July NYS Office of Mental Health

Transcription

1 Youth Indicator Set July 2010 Technical Specifications NYS Office of Mental Health

2 Youth Indicators Documentation 2 The PSYCKES Youth Indicators Technical Specifications Youth Psychotropic Prescribing Proposed Indicator Set (YPP): A total of 8 indicators are proposed: Youth 5 Years and Younger on Psychotropics; Three or More Psychotropics; and Higher than Recommended Dose Indicator (Summary and by Drug Class): 6 indicators were created to reflect psychotropic dosing that exceeds the recommended maximums*: 1. Antipsychotics; 2. Antidepressants; 3. Anxiolytics & Anti Anxiety; 4. Mood Stabilizers; 5. Stimulant & ADHD Medications; and the overall 6. High Dose Summary. In the following document, the technical specification for each indicator is described. The technical specifications provide the definitions used to calculate each indicator using the NYS Medicaid Mental Health population.

3 Youth Indicators Documentation 3 Youth Five Years and Younger on Psychotropics Technical Specifications PSYCKES DAWG TEAM

4 Youth Indicators Documentation 4 Indicator: Description: Youth Five Years and Younger on Psychotropics The proportion of Medicaid enrollees younger than five prescribed any psychotropic within 35 days of the report date, among all Medicaid enrollees younger than 18. Eligible Population: Age: Under 18. Inclusion Criteria: Exclusion Criteria: Medicaid enrollee who is prescribed any active psychotropic within 35 days of the report date. None. Specification: Numerator: Denominator: Enrollees (from the denominator) currently on a psychotropic who are 5 years of age or younger, as of 35 days of the report date. Eligible Population

5 Youth Indicators Documentation 5 The PSYCKES adult dose indicators are based on the Federal Drug Administration (FDA) s maximum dose, as indicated by the Physician s Desk Reference (PDR) at the start of The decision rules were created by two psychiatrists: the PSYCKES Medical Director (Dr. Matt Perkins) and the Director of the PSYCKES Project (Dr. Molly Finnerty). It is expected that the dose maximum values will be reviewed each quarter for potential changes. Given the lack of FDA approvals of many psychotropic medications in the youth population, a slightly different set of decision rules were created for the youth dose indicators. Specifically, the decision rules regarding which dose to set as the maximum may be found in the table below: To identify the maximum Youth dose When there is an FDA approval for use in a pediatric population, use the associated/extrapolated 1 dose for children under 13 years and those 13 to 18 as the PDR suggests. When there are multiple indications in youth, use the maximum dose for the psychiatric indication (PDR) If there is no FDA indication for the pediatric population, use the guidelines proposed by the 2 Texas report regarding the care of Foster Children (TEXAS) In the absence of both the FDA indication and guidance from the Texas report, then the dosing parameters set forth in Appendix 1 of Pediatric Psychopharmacology: Principles and Practice 3 (2003) Editors Andres Martin, Lawrence Scahill, Dennis S. Charney, and James F. Leckman Oxford University Press (TEXT; Revised edition expected in 2010 will be used to update the recommendations) In the case that none of the above sources set forth any guidance, then the adult PDR Maximum 4 will be used (see Adult Dose Specifications for Rules: Identified by PDR MAX, Notes: WEIGHT BASED Dose: In the case of a weight based dose, dosages for the under 10 group will be based on a 40 kg 10 year old boy and the dosages will be based on a 70 kg 17 year old boy to set the maximums. This document details the technical specifications for the Youth Dose Indicators. Appendix X in the Adult Dose documentation presents the full and extensive clinically guided review that was conducted to inform these technical specifications. With the exception of the set maximum doses, the youth population was not reviewed separately. In sum, the dose indicators reflect the five major drug classes (Antipsychotics, Antidepressants, Anxiolytics/Hypnotics, Mood Stabilizers, and ADHD Medications) and a combined summary indicator, allowing for three levels above the recommended dose (>1 times the maximum, >1.5 times the maximum, and >2 times the maximum dose)

6 Youth Indicators Documentation 6 Indicator: Description: Higher than Recommended Dose, Antipsychotics The proportion of Medicaid enrollees on any antipsychotic who are prescribed a dose exceeding the recommended maximum (>1 times the recommended maximum). Three additional levels are provided: >1 times higher than the recommended maximum; >1.5 times higher than the recommended maximum; and >2.0 times higher than the recommended maximum. Eligible Population: Age: Younger than 18. Inclusion Criteria: Exclusion Criteria: Medicaid enrollee who is prescribed any active antipsychotic within 35 days of the report date. None. Specification: Numerator: Denominator: Enrollees (from the denominator) currently on a dose exceeding the recommended maximum by a factor of >1.0, >1.5; >2.0 times, as of 35 days of the report date. Eligible Population

7 Youth Indicators Documentation List of Antipsychotic Drugs by Maximum Dose and Source: 7 Antipsychotic Drugs Maximum Dose Generic Brand Source Age < 13 Age ( ) Aripiprazole Abilify PDR Asenapine Maleate Saphris PDR Chlorpromazine Thorazine, Chlorpromaz, Ormazine PDR Clozapine Clozaril, Fazaclo PDR Fluphenazine Permitil, Prolixin TEXT Haloperidol Haldol PDR 3 6 Iloperidone Fanapt PDR Loxapine Loxitane FDA Molindone* Moban PDR Olanzapine Zyprexa PORT Paliperidone Invega FDA Perphenazine Amitriptyline, Trilafon PORT Pimozide Orap FDA Prochlorperazine** PDR Quetiapine Fumarate Seroquel TEXAS Risperidone Risperdal PDR 3 6 Thioridazine Mellaril PDR Thiothixene Navane PDR Trifluoperazine* Eskazinyl, Eskazine, Jatroneural, Modalina, Stelazine, Terfluzine, Trifluoperaz, Triftazin PDR Ziprasidone Geodon TEXT * Drug not available in the United States **

8 Indicator: Description: Higher than Recommended Dose, Antidepressants The proportion of Medicaid enrollees under 18 on any antidepressant who are prescribed a dose exceeding the recommended maximum (>1 times the recommended maximum). Three additional levels are provided: >1 times higher than the recommended maximum; >1.5 times higher than the recommended maximum; and >2.0 times higher than the recommended maximum. Eligible Population: Age: Younger than 18. Inclusion Criteria: Exclusion Criteria: Medicaid enrollee who is prescribed any active antipsychotic within 35 days of the report date. None. Specification: Numerator: Denominator: Enrollees (from the denominator) currently on a dose exceeding the recommended maximum by a factor of >1.0, >1.5; >2.0 times, as of 35 days of the report date. Eligible Population NYS Office of Mental Health

9 Youth Indicators Technical Specifications List of Antidepressant Drugs by Maximum Dose and Source: Antidepressant Drugs Generic Brand Source Amitriptyline Maximum Dose Age < 13 Age ( ) Elavil, Endep, Enovil, Vanatrip PDR Amoxapine Asendin PDR BuPROPion HBr Aplenzin NO FDA Bupropion Hcl Budeprion Sr, Wellbutrin Xl TEXAS Bupropion Hcl (Smoking Deter) Zyban, Buproban PDR Citalopram Hydrobromide Celexa TEXAS Clomipramine Anafranil PDR Norpramin, Thsc Desipramine Desipramine Hcl FDA Desvenlafaxine Succinate Pristiq PDR Prudoxin, Zonalon, Adapin, Doxepin Sinequan FDA Duloxetine Cymbalta NO FDA Escitalopram Oxalate Lexapro PDR Fluoxetine Prozac, Rapiflux PDR Fluvoxamine Luvox PDR Imipramine Tofranil PDR Isocarboxazid Marplan NO FDA Maprotiline Ludiomil FDA Mirtazapine Remeron TEXT Nefazodone Serzone TEXT Nortriptyline Aventyl, Pamelor PDR Paroxetine Paxil TEXAS Paroxetine Paxil Cr TEXAS Phenelzine Nardil FDA Protriptyline Vivactil FDA Selegiline Emsam NO FDA 0 12 Sertraline Zoloft PDR Tranylcypromine Parnate FDA Trazodone Desyrel, Oleptro TEXT Trimipramine Surmontil PDR Venlafaxine Effexor TEXAS Venlafaxine Effexor Xr TEXAS

10 Youth Indicators Technical Specifications Indicator: Description: Higher than Recommended Dose, Anxiolytic/Hypnotics The proportion of Medicaid enrollees on any anxiolytic/hypnotic who are prescribed a dose exceeding the recommended maximum (>1 times the recommended maximum). Three additional levels are provided: >1 times higher than the recommended maximum; >1.5 times higher than the recommended maximum; and >2.0 times higher than the recommended maximum. 10 Eligible Population: Age: Younger than 18. Inclusion Criteria: Exclusion Criteria: Medicaid enrollee who is prescribed any active antipsychotic within 35 days of the report date. None. Specification: Numerator: Denominator: Enrollees (from the denominator) currently on a dose exceeding the recommended maximum by a factor of >1.0, >1.5; >2.0 times, as of 35 days of the report date. Eligible Population

11 Anxiolytic Drugs Maximum Dose Generic Brand Source Age < 13 Age ( ) Alprazolam Niravam, Xanax TEXT 4 4 Buspirone Buspar, Vanspar MICROMEDEX Butabarbital Sodium* Butabarbital PDR Chloral Hydrate Aquachloral, Noctec, Somnote FDA Chlordiazepoxide Calmium, Chlordiazep, H Tran, Librium, Lipoxide, Spaz 5, Mitran FDA Clonazepam Ceberclon, Klonopin FDA 4 4 Clorazepate Dipotassium Diazepam Gen Xene, Tranxene Sd, Tranxene T FDA D Val, Di Tran, Diastat, Valium, Valrelease, Zetran PDR Estazolam Prosom FDA 2 2 Eszopiclone Lunesta NO FDA 3 3 Flurazepam Dalmane, Flurazepam FDA Hydroxyzine Atarax, Atazine, Neucalm, Qys, Rezine, Vistacon, Vistacot, Vistaject, Vistaril PDR Lorazepam Ativan, Lorazepam PDR 4 4 Mephobarbital* Mebaral PDR Meprobamate Equanil, Miltown, Meprospan FDA Meprobamate Aspirin Equagesic, Micrainin FDA Oxazepam Oxazepam, Serax FDA Phenobarbital Aspirbar, Solfoton PDR Ramelteon Rozerem NO FDA 8 8 Secobarbital Sodium Lanabarb, Seconal PDR Temazepam Temazepam FDA Triazolam Halcion FDA Zaleplon Sonata PDR Zolpidem Tartrate Ambien, Edluar PDR Zolpidem Tartrate CR Ambien Cr PDR * Drug not available in the United States NYS Office of Mental Health

12 Indicator: Description: Higher than Recommended Dose, Mood Stabilizer The proportion of Medicaid enrollees on any mood stabilizer who are prescribed a dose exceeding the recommended maximum (>1 times the recommended maximum). Three additional levels are provided: >1 times higher than the recommended maximum; >1.5 times higher than the recommended maximum; and >2.0 times higher than the recommended maximum. Eligible Population: Age: Younger than 18. Inclusion Criteria: Exclusion Criteria: Medicaid enrollee who is prescribed any active antipsychotic within 35 days of the report date. None. Specification: Numerator: Denominator: Enrollees (from the denominator) currently on a dose exceeding the recommended maximum by a factor of >1.0, >1.5; >2.0 times, as of 35 days of the report date. Eligible Population NYS Office of Mental Health

13 Mood Stabilizer Drugs Maximum Dose Generic Brand Source Age < 13 Age ( ) Carbamazepine Atretol, Carbatrol, Epitol, Tegretol, Tegretol Xr PDR Divalproex Sodium Depakote FDA Gabapentin Gabarone, Neurontin FDA Lamotrigine Lamictal FDA Lithium Carbonate Eskalith, Lithobid, Lithonate FDA Lithium Citrate Lithium Citrate FDA Oxcarbazepine Trileptal PDR Topiramate Topamax, Topiragen PDR Valproic Acid Depakene, Stavzor FDA NYS Office of Mental Health

14 Indicator: Description: Higher than Recommended Dose, ADHD Medications The proportion of Medicaid enrollees on any ADHD Medication who are prescribed a dose exceeding the recommended maximum (>1 times the recommended maximum). Three additional levels are provided: >1 times higher than the recommended maximum; >1.5 times higher than the recommended maximum; and >2.0 times higher than the recommended maximum. Eligible Population: Age: Younger than 18. Inclusion Criteria: Exclusion Criteria: Medicaid enrollee who is prescribed any active antipsychotic within 35 days of the report date. None. Specification: Numerator: Denominator: Enrollees (from the denominator) currently on a dose exceeding the recommended maximum by a factor of >1.0, >1.5; >2.0 times, as of 35 days of the report date. Eligible Population NYS Office of Mental Health

15 ADHD Drugs Generic Brand Source Maximum Dose Age < 13 Age ( ) Amphetamine Dextroamphetamine Adderall PDR Amphetamine Dextroamphetamine XR Adderall Xr PDR Armodafinil Nuvigil PDR Atomoxetine Strattera PDR Clonidine** Catapres TEXAS Dexmethylphenidate Focalin PDR Dexmethylphenidate Focalin Xr PDR Dextroamphetamine Sulfate Das, Dexedrine, Dextrostat, Liquadd, Procentra PDR Guanfacine ** Intuniv, Tenex TEXAS 4 4 Lisdexamfetamine Dimesylate Vyvanse FDA Methylphenidate Metadate Cd, Methylin, Ritalin FDA/TEXAS Methylphenidate Concerta FDA/TEXAS Modafinil Provigil NO FDA Phentermine ** Not included in Adult Dose Indicator Adipex, Atti Plex, Fastin, Obe Mar,Obenix, Obephen, Panshape M, Phentercot, Phentride, Zantryl PDR NYS Office of Mental Health

16 Youth Indicators Technical Specifications 16 Indicator: Description: Higher than Recommended Dose, Summary The proportion of Medicaid enrollees on any psychotropic who are prescribed a dose exceeding recommended maximum (>1 times the recommended maximum). Three additional levels are provided: >1 times higher than the recommended maximum; >1.5 times higher than the recommended maximum; and >2.0 times higher than the recommended maximum. Eligible Population: Age: Younger than 18. Inclusion Criteria: Exclusion Criteria: Medicaid enrollee who is prescribed any active antipsychotic within 35 days of the report date. None. Specification: Numerator: Denominator: Enrollees (from the denominator) currently on a dose exceeding the recommended maximum by a factor of >1.0, >1.5; >2.0 times, as of 35 days of the report date. Eligible Population

17 Youth on Longterm Psychotropic Polypharmacy PSYCKES DAWG TEAM NYS Office of Mental Health

18 Youth Indicators Technical Specifications 18

19 Youth Indicators Technical Specifications 19 Psychotropic polypharmacy in youth (three or more) (3PP(Y)) Description: The percentage of enrollees younger than 18 years old currently on three or more psychotropic medications among youth currently on any psychotropic medication Eligible Population Age: Inclusion Criteria: Exclusion Criteria: Event/Diagnosis: Younger than 18 years old. Medicaid enrollee who is prescribed at least 1 psychotropic medication. Current Medicare enrollee (dual eligibility). An enrollee is included in the eligible population if the enrollee has been prescribed a Psychotropic medication for longer than 90 days* as of the report date. Specification: Numerator: Denominator: Enrollees (from the denominator) currently on three or more concurrent psychotropic medications for longer than 90 days (as of the report date). Eligible Population * Note: This indicator was initially implemented in August The algorithm measures time exposed to multiple agents and not the specific regimens. Individual agent trials are created, allowing for a possible 32 day gap between the last day with medication and the next pick up date of the same agent (assuming less than perfect adherence and possible short inpatient stays). Polypharmacy trials are created by counting the number of agents available each day (constructed via the agent trials) and assigning corresponding start and end dates. A built in allowance for polypharmacy trial gap of 15 days is permitted to allow for short periods of fewer medications, if enrollee returns to the same or higher status.

20 Youth Indicators Technical Specifications List of Psychotropic Drugs by Drug Class: 20 Drug Class Drug Class Generic Name Brand Name Antidepressants alprazolam Xanax Subclass Generic Name Brand Name amobarbital*** Amytal TCAs amitriptyline Elavil buspirone Buspar amoxapine Asendin butabarbital*** Butisol clomipramine Anafranil chloral hydrate Somnote desipramine Norpramin chlordiazepoxide Librium doxepin Sinequan clonazepam Klonopin imipramine Tofranil clorazepate Tranxene nortriptyline Pamelor diazepam Valium protriptyline Vivactil estazolam Prosom SSRIs trimipramine Surmontil esczopiclone Lunesta citalopram Celexa flurazepam Dalmane escitalopram Lexapro halazepam*** Paxipam fluoxetine Prozac Anxiolytics hydroxyzine Vistaril fuvoxamine Luvox lorazepam Ativan paroxetine Paxil mephobarbita***l Mebaral SNRIs sertraline Zoloft meprobamate Miltown duloxetine Cymbalta oxazepam Serax desvenlafaxine Pristiq pentobarbital*** Nembuta MAOIs venlafaxine Effexor phenobarbital Lumina isocarboxazid Marplan prazepam*** Centrax phenelzine Nardil quazepam Doral Others tranylcypromine Parnate rameleton Rozerem bupropion Wellbutrin secobarbital Seconal maprotiline Ludiomil temazepam Restoril mirtazapine Remeron triazolam Halcion nefazodone Serzone zaleplon Sonata selegiline (transdermal) Ensam patch zolpidem Ambien Drug Class 1 st Generation trazodone* Desyrel Drug Class Generic Name Brand Name Generic Name Brand Name carbamazepine Tegretol chlorpromazine Thorazine divalproex Depakote, Depakote ER fluphenazine Prolixin gabapentin Neurontin fluphenazine decanoate Prolixin Depot Mood Stabilizers lamotrigine Lamictal haloperidol Haldol lithium Eskalith haloperidol decanoate Haldol Depot oxcarbazepine Trileptal loxapine Loxitane topiramate Topamax molindone*** Moban valproic acid Depakene,Valproate perphenazine Trilafon Drug Class Generic Name Brand Name pimozide Orap amphetaminedextroamphetamine Adderall, Adderall XL prochlorperazine Compazine thioridazine Mellaril atomoxetine Strattera thiothixene Navane clonidine** Catapres trifluoperazine*** Stelazine dexmethylphenidate Focalin triflupromazine*** Vesprin dextroamphetamine Dexedrine Drug Class Generic Name Brand Name Stimulants/ guanfacine** Tenex 2 nd Generation aripiprazole Abilify ADHD lisdexamfetamine Vyvanse clozapine Clozaril methamphetamine Desoxyn iloperidone Fanapt olanzapine Zyprexa methylphenidate paliperidone Invega modafinil Provigil quetiapine Seroquel pemoline Cylert risperidone Risperdal phentermine Adipex P risperidone microspheres Risperdal Consta ziprasidone Geodon Combinations: Olanzapine-Fluoxetine HCl (Symbyax) Perphenazine-Amitriptyline (Etrafon, Triavil (various)) Ritalin, Concerta, Daytrana, Metadate, Methylin *not counted as an antidepressant for antidepressant polypharmacy, but counted as a psychotropic for psychotropic polypharmacy **only counted as psychotropic in children and adolescents Note: SSRIs and SNRIs are considered as part of the same subclass by PSYCKES *** No longer available in the US