Correlates of psychopharmacologic treatment outcomes for schizophrenia
Abstract
Schizophrenia is a severe and persistent mental illness that affects upwards of two million Americans and its treatment is estimated to cost {dollar}32 billion annually. Although pharmacotherapy represents the mainstay of treatment for schizophrenia, recent pharmacoepidemiologic data on practice patterns in large U.S. populations are limited. To address this need, a study was conducted with the following aims: (1) to characterize the patterns of pharmacologic management of schizophrenia and its demographic and clinical correlates in typical clinical practice settings; (2) to develop analytic models to examine the associations between characteristics of drug therapy and outcomes; and (3) to look for evidence of behavioral toxicity of antipsychotic medications. The data from this study were derived from a patient survey supplemented with medical record information of 719 participants recruited from inpatient and outpatient psychiatric facilities in two states for the Schizophrenia Patient Outcomes Research Team (PORT) study. The final study samples consisted of 224 inpatients and 358 outpatients that met eligibility criteria and had valid medical record data. Ethnic disparities in prescribing were identified, such that non-white patients received fewer newer antipsychotic medications, more long-acting injectable (depot) antipsychotic medications, higher average daily antipsychotic doses, and fewer adjunctive medications than their white counterparts, regardless of treatment setting. Geographic variations in prescribing patterns, in which newer antipsychotics and adjunctive medications (inpatients only) were prescribed more frequently in rural areas of State A and in urban areas of State B, and depot antipsychotics were prescribed more often in urban areas of State A and rural areas of State B, were also noted. The hypothesized model of an indirect relationship among pharmacotherapy and outcomes variables (functioning and satisfaction) that is mediated by symptoms and medication side effects was not supported by the data in either treatment setting. Also, evidence of behavioral toxicity of antipsychotics was not identified. Pronounced variations in the pharmacologic management of schizophrenia were revealed. Investigations of the outcomes of pharmacotherapy and the behavioral toxicity of antipsychotic medications should be undertaken, utilizing different measurement scales and a prospective, longitudinal study design.Description
University of Maryland, Baltimore. Pharmacy Administration. Ph.D. 1999Keyword
Health Sciences, Mental HealthHealth Sciences, Pharmacy
Health Sciences, Public Health
Psychology, Clinical
Antipsychotic Agents
Schizophrenia--drug therapy
Identifier to cite or link to this item
http://hdl.handle.net/10713/1240Related items
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The impact of the state of Maryland's Medicaid mental health carve-out on access-to-care for patients in a suburban health care systemIn recent years, providing care for individuals with severe mental illness has consumed increasing state and federal financial resources, with State Medicaid systems bearing the heaviest burden. Managed care strategies have been initiated by public mental health systems as a mechanism to control expenses. The state of Maryland implemented a mental health carve-out on July 1, 1997. The purpose of the present study is to describe the effects of the carve-out on access-to-care for individuals using emergency department services in one suburban health care system. Data for this study included all episodes of emergency crisis care in pre-implementation (1996-1997) and post-implementation (1998-1999) time periods. These data were examined within the context of the Behavioral Model of Health Service Use (Andersen, 1995) to describe the interrelationships among external environment, predisposing characteristics, and enabling resources on use of health services. Use of health services was operationalized by four outcomes: disposition, length of stay, number of visits, and recidivism. There were a total of 2986 episodes, initiated by 1928 individuals. Logistic regression demonstrated that when controlling for predisposing characteristics and enabling resources, the likelihood of inpatient admission did not change after initiation of the program. Moreover, there was not a significant change in the number of emergency visits. The assessment of recidivism demonstrated that only psychotic disorders (a predisposing characteristic) were a significant predictor of 30-day repeat visits. Multiple regression models examining the impact of the carve-out on length of stay demonstrated a significant increase in the emergency department length of stay (F = 5.47, p = .05) following the implementation of the carve-out. While benefits associated with improved coordination of services might be expected with the implementation of the carve-out, there was not a change in inpatient admissions, number of emergency visits, or recidivism. Additionally, there was a significant increase in the amount of time required to assess patients and to provide an appropriate disposition. The limited study sample and data prohibit generalizability. Considering that evaluations of mental health carve-outs are limited, this study reflects that anticipated benefits have not been experienced in emergency departments.
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Costs, outcomes and estimation of the cost-effectiveness of abciximab in the prevention of ischemic events over six months of follow-upAbciximab is an antiplatelet inhibitor used in conjunction with percutaneous revascularization procedures to decrease the risk of ischemic complications such as death, nonfatal MI or subsequent revascularization procedures like angioplasty or CABG. Although the efficacy of abciximab is rarely disputed based on evidence from three large clinical trials, the cost-effectiveness of the drug when used during routine practice has been questioned since it costs approximately $1,350 per patient treated. This study was undertaken to estimate the effectiveness of abciximab in patients treated at University of Maryland Medical System (UMMS) and to estimate the incremental cost-effectiveness ratio (ICER) defined as the cost per event avoided. The composite endpoint consisted of death, MI or subsequent revascularization procedure over 6-months of follow-up. Proportional hazards regression revealed that abciximab was associated with a lower risk of ischemic events among patients with more severe angiographic morphology. Patients who received a shortened infusion of the drug (<10 hours) were at a greater risk of experiencing an event than those who received an infusion for 10-14 hours. Also, patients who underwent coronary stenting were less likely to have an event while patients with multivessel disease or a history of a percutaneous revascularization procedure were at a higher risk of experiencing an event. The cost-effectiveness analysis was performed for a subgroup of patients with more severe coronary morphology using a matched cohort design. The point estimate of the ICER revealed that it cost about $20,680 to prevent an ischemic event over six months in high-risk patients treated with abciximab. Confidence intervals for the ICER were computed using Taylor series approximation, Fieller's theorem and bootstrapping, and were graphically represented with ellipses of equal probability. Overall, the data were consistent with a wide range of plausible estimates due to a relatively small denominator in the ICER.
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Development of a measure of the content and quality of prenatal care services in a Medicaid populationStatement of the problem. The purpose of this study was to develop an instrument to measure the content and quality of prenatal care services in a population of low income women. Dimensions of performance as proposed by the Joint Commission on Accreditation of Healthcare Organizations were used to define the quality of prenatal care. The United States Public Health Service Expert Panel Guidelines on the Content of Prenatal Care were used as the standard for the content of care. Methods. The Content and Quality of Prenatal Care Measure (CQPM), a prenatal care record review measure, was developed in this study. An assessment of content validity and intra- and inter-rater reliability was completed. Data collected for the validity sample of 163 records at two county health department sites was scored by content area. The Adequacy of Prenatal Care Utilization Index (APNCU) developed by Kotelchuck was used to categorize each record in the validity sample. Criterion-related validity was assessed with ANOVA using the CQPM scores as the dependent variable and the APNCU groups as the independent variable and by discriminant function analysis using the CQPM content scores as predictors for group membership in APNCU groups. Results. The mean percent agreement for each of the content areas for intra- and inter-rater reliability ranged from 72% to 95% with medical risk assessment having the highest reliability and health promotion having the lowest. Intra and inter-rater percent agreement for items ranking the quality of care was 70% and 51.6%. A significant difference between the groups was found in ANOVA, F(3,157):16.23, p < .00001, confirming criterion-related validity. The discriminant function analysis found an overall Lambda =.451941 (chi2 = 110.79, df 15, p < .00001). The prediction equation accounted for 62% of grouped cases being correctly classified also confirming criterion-related validity. Discussion. These results show that the Content and Quality of Prenatal Care Measure is reliable and valid and may be used to monitor care provided to low income populations and to conduct research on the content of prenatal care. Further research on weighting each item score in the CQPM and the reliability of items for special populations may be indicated.