The Impact of Maryland Care Management Entity on Quality of Antipsychotic Medication Use and Clinical Outcomes

Abstract

Background: Care Management Entity (CME) using the wraparound practice is a type of care delivery model for youth with severe mental/behavioral disorders. The CME provides coordinated, child-centered services that aim to improve youth's clinical and functional outcomes. The impact of this care management on the quality of psychotropic medication treatment and outcomes following discharge is unknown. The goals of this dissertation are to examine the quality of antipsychotic use and mental health-related outcomes between CME-enrolled and non-CME youth. Methods: Data comprised Medicaid claims linked with the CME administrative records anytime from December 2009 through December 2013. A difference-in-difference design was used to estimate the odds ratio (OR) and the average marginal effect (AME) of antipsychotic use, concomitant antipsychotic use, higher-than-recommended antipsychotic dose, and metabolic monitoring among inverse probability of treatment weighting-adjusted CME and non-CME youth. To avoid loss of the sample due to missing information on length of stay (LOS) in CME services, methods for imputing LOS in CME care were conducted and cross-validated. Building on the data imputation, two-part models were used to examine the mental health-related emergency department (ED) visits, hospitalizations, and outpatient visits within one-year post discharge between CME and non-CME youth. Results: Among the 3,493 IPTW-adjusted cohort (679 CME and 2,814 non-CME youth), the CME-served youth had a significant decrease in any concomitant antipsychotic use relative to non-CME youth (AME= -3.28%, 95% CI= -4.19% to -2.38%). However, there was no difference in antipsychotic dosing or metabolic monitoring between the two groups. In the methodological study, the multiple imputation was preferred over single imputation because it produced smaller errors and similar LOS distribution. In the outcome analyses, the CME care model resulted in a lower likelihood of receiving any mental health-related service (mental health-related ED visits: OR=0.65, 95%CI=0.46 to 0.93; hospitalizations: OR=0.60, 95%CI=0.40 to 0.89; outpatient visits OR=0.46, 95%CI= 0.32 to 0.66) post discharge. Conclusions: Future optimization of this care model may benefit from 1) greater attention to improving antipsychotic monitoring, 2) stronger prescriber engagement in the wraparound practice, and 3) further research to identify potential risk factors that associated with mental health services utilization among youth in public health insurance programs.