Youth Indicator Set July 2010 Technical Specifications NYS Office of Mental Health
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.
Youth Indicators Documentation 3 Youth Five Years and Younger on Psychotropics Technical Specifications PSYCKES DAWG TEAM
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
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 2010. 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)
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
Youth Indicators Documentation List of Antipsychotic Drugs by Maximum Dose and Source: 7 Antipsychotic Drugs Maximum Dose Generic Brand Source Age < 13 Age (13.1 17.9) Aripiprazole Abilify PDR 15 30 Asenapine Maleate Saphris PDR Chlorpromazine Thorazine, Chlorpromaz, Ormazine PDR 500 1000 Clozapine Clozaril, Fazaclo PDR 300 600 Fluphenazine Permitil, Prolixin TEXT 10 10 Haloperidol Haldol PDR 3 6 Iloperidone Fanapt PDR 24 24 Loxapine Loxitane FDA 100 100 Molindone* Moban PDR 150 150 Olanzapine Zyprexa PORT 12.5 20 Paliperidone Invega FDA 15 15 Perphenazine Amitriptyline, Trilafon PORT 64 64 Pimozide Orap FDA 10 10 Prochlorperazine** PDR 25 40 Quetiapine Fumarate Seroquel TEXAS 300 600 Risperidone Risperdal PDR 3 6 Thioridazine Mellaril PDR 120 210 Thiothixene Navane PDR 50 50 Trifluoperazine* Eskazinyl, Eskazine, Jatroneural, Modalina, Stelazine, Terfluzine, Trifluoperaz, Triftazin PDR 15 15 Ziprasidone Geodon TEXT 160 160 * Drug not available in the United States **
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
Youth Indicators Technical Specifications List of Antidepressant Drugs by Maximum Dose and Source: Antidepressant Drugs Generic Brand Source Amitriptyline Maximum Dose Age < 13 Age (13.1 17.9) Elavil, Endep, Enovil, Vanatrip PDR 150 150 Amoxapine Asendin PDR 400 400 BuPROPion HBr Aplenzin NO FDA 278 522 Bupropion Hcl Budeprion Sr, Wellbutrin Xl TEXAS 240 450 Bupropion Hcl (Smoking Deter) Zyban, Buproban PDR 300 300 Citalopram Hydrobromide Celexa TEXAS 40 60 Clomipramine Anafranil PDR 200 200 Norpramin, Thsc Desipramine Desipramine Hcl FDA 150 150 Desvenlafaxine Succinate Pristiq PDR 400 400 Prudoxin, Zonalon, Adapin, Doxepin Sinequan FDA 300 300 Duloxetine Cymbalta NO FDA 120 120 Escitalopram Oxalate Lexapro PDR 20 20 Fluoxetine Prozac, Rapiflux PDR 60 60 Fluvoxamine Luvox PDR 200 300 Imipramine Tofranil PDR 100 100 Isocarboxazid Marplan NO FDA 60 60 Maprotiline Ludiomil FDA 150 150 Mirtazapine Remeron TEXT 30 30 Nefazodone Serzone TEXT 600 600 Nortriptyline Aventyl, Pamelor PDR 50 50 Paroxetine Paxil TEXAS 40 40 Paroxetine Paxil Cr TEXAS 40 40 Phenelzine Nardil FDA 90 90 Protriptyline Vivactil FDA 60 60 Selegiline Emsam NO FDA 0 12 Sertraline Zoloft PDR 200 200 Tranylcypromine Parnate FDA 60 60 Trazodone Desyrel, Oleptro TEXT 200 200 Trimipramine Surmontil PDR 100 100 Venlafaxine Effexor TEXAS 120 225 Venlafaxine Effexor Xr TEXAS 120 225 9
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
Anxiolytic Drugs Maximum Dose Generic Brand Source Age < 13 Age (13.1 17.9) Alprazolam Niravam, Xanax TEXT 4 4 Buspirone Buspar, Vanspar MICROMEDEX 50 50 Butabarbital Sodium* Butabarbital PDR 100 100 Chloral Hydrate Aquachloral, Noctec, Somnote FDA 1500 1500 Chlordiazepoxide Calmium, Chlordiazep, H Tran, Librium, Lipoxide, Spaz 5, Mitran FDA 30 30 Clonazepam Ceberclon, Klonopin FDA 4 4 Clorazepate Dipotassium Diazepam Gen Xene, Tranxene Sd, Tranxene T FDA 60 60 D Val, Di Tran, Diastat, Valium, Valrelease, Zetran PDR 12 14 Estazolam Prosom FDA 2 2 Eszopiclone Lunesta NO FDA 3 3 Flurazepam Dalmane, Flurazepam FDA 30 30 Hydroxyzine Atarax, Atazine, Neucalm, Qys, Rezine, Vistacon, Vistacot, Vistaject, Vistaril PDR 100 100 Lorazepam Ativan, Lorazepam PDR 4 4 Mephobarbital* Mebaral PDR 256 256 Meprobamate Equanil, Miltown, Meprospan FDA 600 600 Meprobamate Aspirin Equagesic, Micrainin FDA 600 1075 600 1075 Oxazepam Oxazepam, Serax FDA 120 120 Phenobarbital Aspirbar, Solfoton PDR 270 400 Ramelteon Rozerem NO FDA 8 8 Secobarbital Sodium Lanabarb, Seconal PDR 100 100 Temazepam Temazepam FDA 30 30 Triazolam Halcion FDA 0.5 0.5 Zaleplon Sonata PDR 20 20 Zolpidem Tartrate Ambien, Edluar PDR 10 10 Zolpidem Tartrate CR Ambien Cr PDR 12.5 12.5 * Drug not available in the United States NYS Office of Mental Health
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
Mood Stabilizer Drugs Maximum Dose Generic Brand Source Age < 13 Age (13.1 17.9) Carbamazepine Atretol, Carbatrol, Epitol, Tegretol, Tegretol Xr PDR 1000 1000 Divalproex Sodium Depakote FDA 2400 4200 Gabapentin Gabarone, Neurontin FDA 2000 3600 Lamotrigine Lamictal FDA 200 400 Lithium Carbonate Eskalith, Lithobid, Lithonate FDA 1800 1800 Lithium Citrate Lithium Citrate FDA 1800 1800 Oxcarbazepine Trileptal PDR 1500 2100 Topiramate Topamax, Topiragen PDR 1600 1600 Valproic Acid Depakene, Stavzor FDA 2400 4200 NYS Office of Mental Health
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
ADHD Drugs Generic Brand Source Maximum Dose Age < 13 Age (13.1 17.9) Amphetamine Dextroamphetamine Adderall PDR 40 40 Amphetamine Dextroamphetamine XR Adderall Xr PDR 30 30 Armodafinil Nuvigil PDR 250 250 Atomoxetine Strattera PDR 100 100 Clonidine** Catapres TEXAS 0.4 0.4 Dexmethylphenidate Focalin PDR 20 20 Dexmethylphenidate Focalin Xr PDR 20 30 Dextroamphetamine Sulfate Das, Dexedrine, Dextrostat, Liquadd, Procentra PDR 40 40 Guanfacine ** Intuniv, Tenex TEXAS 4 4 Lisdexamfetamine Dimesylate Vyvanse FDA 70 70 Methylphenidate Metadate Cd, Methylin, Ritalin FDA/TEXAS 60 60 Methylphenidate Concerta FDA/TEXAS 54 72 Modafinil Provigil NO FDA 200 200 Phentermine ** Not included in Adult Dose Indicator Adipex, Atti Plex, Fastin, Obe Mar,Obenix, Obephen, Panshape M, Phentercot, Phentride, Zantryl PDR 37.5 37.5 NYS Office of Mental Health
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
Youth on Longterm Psychotropic Polypharmacy PSYCKES DAWG TEAM NYS Office of Mental Health
Youth Indicators Technical Specifications 18
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 2008. 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.
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