Disclosure Statement. Learning Objectives. Background. Background 4/26/2016

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1 Disclosure Statement Implementation of Education plus Provider- Specific Prescribing Reports and the Effects on Antipsychotic Polypharmacy in Children and Adolescents with Mental Illness in an Outpatient Behavioral Health Center Lesley Rogers, PharmD, MPH PGY1 Pharmacy Resident Billings Clinic Billings, Montana IRB Status: Exempt status approved Co-investigators: Michelle Blair, BA, PharmD Eric Arzubi, MD, Department Chair Psychiatry Julie Schaaf, Consultant, Operational Excellence Valerie Hatton, CPhT, Healthcare Informaticist Melanie Townsend, PharmD, BCPS Conflicts of Interest: None Sponsorship: None 2 Learning Objectives Discuss the impact of education and psychiatric provider-specific prescribing reports on antipsychotic polypharmacy in children and adolescents with mental illness Describe the challenges of implementing a multiinterventional project design to impact provider prescribing habits bed hospital + multiple clinics Department of Psychiatry Inpatient: 4 psychiatrists 2 midlevels Outpatient: 4 adult psychiatrists 5 pediatric psychiatrists 1 midlevel Outpatient Behavioral Health Center Child and adolescent population: ~ 4,000 visits annually 4 Background Background Psychiatric polypharmacy is on the rise in the child and adolescent population Up to 52% outpatients and 85% inpatients on 2 psychotropic medications Consequences of polypharmacy Increased adverse events Increased costs Decreased compliance American Academy of Child and Adolescent Psychiatry (AACAP) 2009 practice parameters Lack of evidence to support combining medications from the same class AACAP. J Am Acad Child Adolesc Psychiatry. 2009;48 (9): Fontanella CA, et al. Psychiatr Serv. 2014;65(11): Few studies aimed at reducing psychotropic polypharmacy Hospital Based Inpatient Psychiatric Services (HBIPS) Targeted intervention: antipsychotics Polypharmacy = 2 antipsychotics DEBIT trial Inpatient intervention Education + reminder systems + cognitive behavioral techniques Reduced antipsychotic polypharmacy (p = 0.028) Gören et al. Inpatient intervention Educational seminars + prescriber-specific feedback to reduce antipsychotic polypharmacy 2 antipsychotics % prevalence decline: 33.9% 12.1% Thompson A, et al. Psychol Med. 2008;38(5): Gören JL, et al. J Manag Care Pharm. 2010;16(6):

2 Purpose To evaluate the impact of education and provider-specific prescribing reports on antipsychotic polypharmacy in children and adolescents with mental illness in an outpatient behavioral health center Methods: Study Design Prospective, interventional, single-center study with a historical control group Study Timeline data: Sept 15 Dec 15, 2015 Educational seminar: Dec 16, 2015 data: Jan 1 Mar 31, Methods: Eligibility Criteria Methods: Eligibility Criteria Psychiatrists Inclusion criteria Practice in the outpatient behavioral health center (BHC) Encounter with qualifying patient during study time frame Exclusion criteria None Patients Inclusion criteria: Age 17 years Seen in BHC during study time frame 1 psychotropic medication listed as active medication within 24 hours of encounter discharge Exclusion criteria: None 9 10 Methods: Provider-Specific Prescribing Report Methods: Provider-Specific Prescribing Report

3 4/26/2016 Methods: Outcomes Methods: Statistics Primary: % change in patients prescribed 2 antipsychotics upon encounter discharge Secondary % change in patients prescribed 2 antidepressants upon encounter discharge % change in patients prescribed 3 antiattention deficit hyperactivity disorder (ADHD) medications upon encounter discharge 13 Sample Size Psychiatrists = 4 Children/adolescents = all meeting eligibility criteria Baseline prevalence rate of children/adolescents prescribed 2 antipsychotics: 1 Estimated proportional change of 6, alpha = 0.05, power of 8, and 2% error rate Target sample size = 625 patient encounters Statistical Tests Descriptive statistics Chi-square test 14 Results: Baseline Patient Characteristics Characteristics Gender, n (%) Group (n=1,115) Group (n=1,190) Male 695 (62.3%) 711 (59.7%) Female 420 (37.7%) 479 (40.3%) Age (years) All patients, mean ± SD 12.7 ± ± 3.3 Ages 0-12, n (%) 532 (47.7%) 562 (47.2%) Ages 13-17, n (%) 583 (52.3%) 628 (52.8%) Results: Antipsychotics Encounters with Patients on Antipsychotics p = % 14.84% 85.16% 92.03% 2 antipsychotics 1 antipsychotic 15 n = 337 n = Results: Antipsychotics Results: Antidepressants 2 18% 16% 14% 12% 1 8% 6% 4% 2% with 2 Antipsychotics 2 Antipsychotics 14.84% 7.97% 17 Encounters with Patients on Antidepressants p = < % 18.7% % 89.31% n = 738 n = Antidepressants 1 Antidepressant 18 3

4 4/26/2016 Results: Antidepressants Results: ADHD Medications 2 18% 16% 14% 12% 1 8% 6% 4% 2% with 2 Antidepressants 18.7% 10.69% 2 Antidepressants Encounters with Patients on ADHD Medications p = < % 12.21% 38.48% 49.31% n = % 61.01% n = ADHD Medications 2 ADHD Medications 1 ADHD Medication 20 Results: ADHD Medications Results by Age Category 2 18% 16% 14% 12% 1 8% 6% 4% 2% with 3 ADHD Medications 12.21% 5.26% 3 ADHD Medications 21 Age 0-12 years 2 Antipsychotics 2 Antidepressants 3 ADHD Medications 10.66% 15.97% 15.67% 8.16% 6.84% 6.15% % Difference 2.5% 9.13% 9.52% p-value < < Age years 2 Antipsychotics 2 Antidepressants 3 ADHD Medications 17.21% 20.44% 7.83% 7.84% 13.13% 4.02% % Difference 9.37% 7.31% 3.81% p-value Discussion Discussion 1 st study to examine impact of education + provider-specific prescribing reports on psychotropic polypharmacy in the outpatient child and adolescent population with mental illness Antipsychotics Change in 2 antipsychotics prevalence Statistically significant difference of p = Absolute % reduction of 6.87% is less than similar studies Proportional % decrease of 46.3% Antidepressants and ADHD medications Statistically significant differences in control group and intervention group Suggests interventional methods contributing to changes in prescribing practices

5 Limitations Conclusions Small group of providers Short time frame Department barriers prevented additional education Mechanism for dissemination of reports Unable to ascertain physicians actually utilized the prescribing reports Education + provider-specific prescribing reports may decrease polypharmacy in children and adolescents in an outpatient behavioral health center (BHC) Further studies needed to verify results of pilot project Future Directions Provider-specific prescribing reports Distributed monthly to evaluate performance Expansions to inpatient pediatric and adult providers Education/case-based teaching Reinforce best practices 27 Acknowledgements Co-investigators Michelle Blair, BA, PharmD Eric Arzubi, MD, Department Chair Psychiatry Valerie Hatton, CPhT, Healthcare Informaticist Julie Schaaf, Consultant, Operational Excellence Melanie Townsend, PharmD, BCPS Statistical analysis Nicholas Coombs, MS, Research Data Analyst 28 Supplemental: Results Chi-Square Analyses Summary Questions? lrogers@billingsclinic.org All Encounters Summary: Antipsychotics, Antidepressants, ADHD Medications Medication Class Absolute % Difference P-value 2 Antipsychotics 14.84% 7.97% % Antidepressants 18.7% 10.69% % < ADHD Medications 12.21% 5.26% % <

6 Supplemental: Total Patients and Average Encounter Number Total Patients, n Patients with 2 encounters, n (%) 287 (37.5%) 296 (37.6%) For patients with 2 encounters: mean # of encounters (range) 2.21 (2-6) 2.36 (2-8) 31 6