Foster care, externalizing disorders, and antipsychotic use among Medicaid-enrolled youths.
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ABSTRACT:
SUBMITTER: Vanderwerker L
PROVIDER: S-EPMC4489136 | biostudies-literature | 2014 Oct
REPOSITORIES: biostudies-literature
Publications
Foster care, externalizing disorders, and antipsychotic use among Medicaid-enrolled youths.
Vanderwerker Lauren L Akincigil Ayse A Olfson Mark M Gerhard Tobias T Neese-Todd Sheree S Crystal Stephen S
Psychiatric services (Washington, D.C.) 20141001 10
<h4>Objectives</h4>The authors investigated the extent to which clinical diagnoses of externalizing disorders explain higher rates of antipsychotic use by foster care youths.<h4>Methods</h4>Medicaid claims data from 44 states for 2009 for youths in foster care (N=301,894) and those not in foster care (N=5,092,574) were analyzed, excluding those with schizophrenia, bipolar disorder, autism, and major depressive disorder. Logistic regressions assessed the relationship between foster care, external ...[more]
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| S-EPMC10873764 | biostudies-literature
Project description:The disproportionate prescribing of high-risk antipsychotic medication for youth in foster care is a significant social problem across the U.S. This qualitative study examined stakeholder perceptions of prescribing, being prescribed, or overseeing prescriptions for youth in foster care. Interviews and focus groups were conducted with clinicians, child welfare caseworkers, foster caregivers, and foster care alumni. The overall aim was to systematically explore their understanding of and experiences with the Informed Consent to treatment and shared decision-making processes related to prescribing and monitoring of antipsychotic medications for youth in foster care. Participants were recruited from around the country; data collection using structured interview or focus group guides occurred via telephone and web-based formats. This study is rooted in the lived experiences of stakeholders in addressing recent federal legislative mandates and guidelines for the oversight and co-ordination of mental health service delivery to youth in foster care. Numerous themes emerged that provide context in employing a team-based approach for youth engaged with multiple child-serving systems. Eight themes emerged that illustrate the necessary components of successfully implementing Informed Consent and shared decision-making as well as the barriers and concerns germane to this process. The findings address the nuanced complexity of and tensions with the trade-offs inherent in delivering mental health care to youth involved in foster care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
| S-EPMC8404191 | biostudies-literature
Project description:ObjectiveThis study examined polypharmacy patterns and rates over time among Medicaid-enrolled youths by comparing three enrollment groups (youths in foster care, with a disability, or from a family with low income).MethodsSerial cross-sectional trend analyses of Medicaid claims data were conducted for youths age 17 and younger who were continuously enrolled in Ohio Medicaid for a one-year period and prescribed one or more psychotropic medications during fiscal years 2002 (N=26,252) through 2008 (N=50,311). Outcome measures were any polypharmacy (three or more psychotropic medications from any drug class) and multiclass polypharmacy (three or more psychotropic medications from different drug classes).ResultsBoth types of polypharmacy increased across all three eligibility groups. Any polypharmacy increased from 8.8% to 11.5% for low-income youths (adjusted odds ratio [AOR]=1.12, 99% confidence interval [CI]=1.10-1.13), from 18.0% to 24.9% for youths with a disability (AOR=1.11, CI=1.09-1.13), and from 19.8% to 27.3% for youths in foster care (AOR=1.09, CI=1.07-1.11). Combinations associated with positive increases were two or more antipsychotics, two or more stimulants, and antipsychotics with stimulants.ConclusionsPolypharmacy increased across all enrollment groups, with the highest absolute rates for youths in foster care. Both the overall prevalence and increases in prescriptions for drug combinations with limited evidence of safety and efficacy, such as the prescription of two or more antipsychotics, underscore the need for targeted quality improvement efforts. System oversight and monitoring of psychotropic medication use appears to be warranted, especially for higher-risk groups, such as youths in foster care and those from low-income households who were prescribed multiple antipsychotics.
| S-EPMC4539016 | biostudies-literature
Project description:ImportanceYouths with sickle cell anemia (SCA) are at risk of pain crises, stroke, and early death. Complications can be reduced by the oral disease-modifying medication hydroxyurea, and in 2014, the National Heart, Lung, and Blood Institute published revised guidelines that hydroxyurea should be offered to youths aged 9 months and older with SCA regardless of disease severity.ObjectiveTo describe changes in hydroxyurea use among youths with SCA before and after release of the National Heart, Lung, and Blood Institute guidelines.Design, setting, and participantsThis cross-sectional study was conducted using administrative data from 2010 to 2018 from Michigan and New York State (NYS) Medicaid programs. The study population included youths aged 1 to 17 years with SCA enrolled in the Michigan or NYS Medicaid programs for at least 1 year (Michigan: 2010-2018; NYS: 2012-2018). Youths with SCA were identified using validated claims-based definitions. Data were analyzed from June to October 2020.Main outcomes and measuresThe main outcome was hydroxyurea use characterized as mean annual counts of days' supply of filled hydroxyurea prescriptions. Rates of hydroxyurea use over time were assessed using regression models (Michigan: zero-inflated negative binomial; NYS: negative binomial). Models included indicators for periods before and after guideline release.ResultsA total of 4302 youths with SCA (2236 males [52.0%]; 2676 born 2005-2017 [62.2%]; 150 Hispanic [3.5%], 2929 non-Hispanic Black [68.0%], and 389 non-Hispanic White [9.0%]) contributed 12 565 person-years. The mean (SD) annual days' supply of hydroxyurea was 47.2 (93.6) days per youth in Michigan and 97.4 (137.0) days per youth in NYS. In Michigan, there was an increase in the odds of having nonzero days' supply after the guidelines were released (odds ratio, 1.52; 95% CI, 1.07-2.14). In NYS, no change was seen in the mean days' supply of filled hydroxyurea.Conclusions and relevanceThese findings suggest that hydroxyurea was substantially underused among youths with SCA, despite establishment as the primary disease-modifying therapy for SCA, and that there was incomplete clinician or patient uptake of newly released guidelines. Results suggest that expanding use of hydroxyurea may require a multifaceted approach that includes addressing multiple system- and patient-level barriers.
| S-EPMC10313146 | biostudies-literature
Project description:Importance:Urgent care (UC) centers are a growing option to address children's acute care needs, which may cause unanticipated changes in health care use. Objectives:To identify factors associated with high UC reliance among children enrolled in Medicaid and examine the association between UC reliance and outpatient health care use. Design, Setting, and Participants:A retrospective cohort study used deidentified data on 4?133?238 children from the Marketscan Medicaid multistate claims database to calculate UC reliance and outpatient health care use. Children were younger than 19 years, with 11 months or more of continuous Medicaid enrollment and 1 or more UC, emergency department (ED), primary care provider (PCP; physician, advanced practice nurse, or physician assistant; well-child care [WCC] or non-WCC), or specialist outpatient visit during the 2017 calendar year. Statistical analysis was conducted from November 11 to 26, 2019. Exposures:Urgent care, ED, PCP (WCC and non-WCC), and specialist visits based on coded location of services. Main Outcomes and Measures:Urgent care reliance, calculated by the number of UC visits divided by the sum of total outpatient (UC, ED, PCP, and specialist) visits. High UC reliance was defined as UC visits totaling more than 33% of all outpatient visits. Results:Of 4?133?238 children in the study, 2?090?278 (50.6%) were male, with a median age of 9 years (interquartile range, 4-13 years). A total of 223?239 children (5.4%) had high UC reliance. Children 6 to 12 years of age were more likely to have high UC reliance compared with children 13 to 18 years of age (adjusted odds ratio, 1.07; 95% CI, 1.06-1.09). Compared with white children, black children (adjusted odds ratio, 0.81; 95% CI, 0.81-0.82) and Hispanic children (adjusted odds ratio, 0.61; 95% CI, 0.60-0.61) were less likely to have high UC reliance. Adjusted for age, sex, race/ethnicity, and presence of chronic or complex conditions, children with high UC reliance had significantly fewer PCP encounters (WCC: adjusted rate ratio, 0.60; 95% CI, 0.60-0.61; and non-WCC: adjusted rate ratio, 0.41; 95% CI, 0.41-0.41), specialist encounters (adjusted rate ratio, 0.31; 95% CI, 0.31-0.31), and ED encounters (adjusted rate ratio, 0.68; 95% CI, 0.67-0.68) than children with low UC reliance. Conclusions and Relevance:High UC reliance occurred more often in healthy, nonminority, school-aged children and was associated with lower health care use across other outpatient settings. There may be an opportunity in certain populations to ensure that UC reliance does not disrupt the medical home model.
| S-EPMC7203605 | biostudies-literature
Project description:ImportancePostpartum Medicaid eligibility extensions are likely to shift enrollees from commercial to Medicaid coverage in the postpartum year; however, the potential implications for health care use and spending are unknown.ObjectiveTo compare health care use and spending among individuals with a Medicaid-paid birth who had continuous Medicaid vs continuous commercial insurance during months 3 to 12 post partum.Design, setting, and participantsCross-sectional study using linked all-payer claims, birth records, and income data for Medicaid-paid births in the Colorado All Payer Claims Database from 2014 to 2019 to estimate the association between continuous Medicaid vs commercial insurance and health care use and spending during months 3 to 12 post partum.ExposureContinuous enrollment in Medicaid vs commercial insurance during months 3 to 12 post partum.Main outcomes and measuresPrimary outcomes were the rate and number of primary care and outpatient visits, and total out-of-pocket spending during months 3 to 12 post partum. Secondary outcomes were the rate and number of emergency department visits and hospitalizations during months 3 to 12 post partum.ResultsThe 44 471 individuals in the sample had a mean (SD) age of 26.8 (5.50) years. Self-reported race and ethnicity included 1279 (2.9%) Asian individuals, 4028 (9.1%) Black individuals, 33 534 (75.4%) White individuals, as well as 5630 (12.7%) individuals of other race and ethnicity (American Indian or Alaskan Native; Other Pacific Islander; and unspecified). Of these, 19 337 (43.5%) self-identified as Hispanic individuals. The sample included 42 989 individuals continuously enrolled in Medicaid and 1482 individuals continuously enrolled in commercial insurance during months 3 to 12 post partum. Compared with those continuously enrolled in Medicaid, commercially insured enrollees were older (32.2% of commercial enrollees were between the ages of 30-39 vs 27.5% of Medicaid enrollees, P < .001), less likely to be Hispanic (38.9% in commercial vs 43.7% in Medicaid, P < .001) or born in the US (15.6% in commercial vs 19.6% in Medicaid, P < .001), and more likely to be married (62.8% in commercial vs 54.8% in Medicaid, P < .001), have completed college (32.9% in commercial vs 16.5% in Medicaid, P < .001), and initiated early prenatal care (79.7% in commercial vs 72.5% in Medicaid, P < .001). In multivariable models, individuals with commercial insurance were 2.46 percentage points (95% CI, 2.12-2.79 percentage points; P < .001) more likely to attend a primary care visit and had 0.81 (95% CI, 0.70-0.92; P < .001) additional primary care visits total during months 3 to 12 post partum. Individuals enrolled in commercial insurance were 7.92 percentage points (95% CI, -8.44 to -7.40 percentage points; P = .006) less likely to visit an emergency department compared with those enrolled in Medicaid. Total adjusted per person spending was $1110 (95% CI, $509-$1710; P < .001) higher, and total out-of-pocket spending per person was $796 (95% CI, $754-$838; P < .001) higher for those enrolled in commercial insurance vs Medicaid.Conclusions and relevanceIn this study, primary care use was higher and emergency department use was lower among those continuously enrolled in commercial vs Medicaid insurance during months 3 to 12 post partum. Medicaid rather than commercial insurance was associated with decreased exposure to out-of-pocket costs during months 3 to 12 postpartum for individuals with low income.
| S-EPMC8933732 | biostudies-literature
Project description:ObjectiveLittle is known about the role of primary care safety-net clinics, including federally qualified health centers and rural health clinics, in providing mental health services to youths. This study examined correlates and quality of mental health care for youths treated in these settings.MethodsMedicaid claims data (2008-2010) from nine states were used to identify youths initiating medication for attention-deficit hyperactivity disorder (ADHD) (N=6,433) and youths with an incident depression diagnosis (N=13,209). The authors identified youths who received no ADHD or depression-related visits in a primary care safety-net clinic, some (but less than most) visits in these clinics, and most visits in these clinics. Using bivariate and regression analyses, they examined correlates of mental health treatment in these settings and whether mental health visits in these settings were associated with quality measures.ResultsOnly 13.5% of the ADHD cohort and 7.2% of the depression cohort sought any ADHD- or depression-related visits in primary care safety-net clinics. Residence in a county with a higher (versus lower) percentage of residents living in an urban area was negatively associated with receiving the majority of mental health visits in these settings (p<0.05). Compared with youths with no visits in these settings, youths who received most of their mental health treatment in these settings received lower-quality care on five of six measures (p<0.01).ConclusionsAs investment in the expansion of mental health services in primary care safety-net clinics grows, future research should assess whether these resources translate into improved mental health care access and quality for Medicaid-enrolled youths.
| S-EPMC8052634 | biostudies-literature
Project description:Youth aging out of the foster care system in the US are a vulnerable population. When in foster care, youth are eligible for their state's Medicaid program, but they lose eligibility when they age out of foster care. The Affordable Care Act (ACA) has the potential to address some of the health care needs of former foster youth through the Medicaid eligibility expansion to low-income adults and by extending Medicaid eligibility up to age twenty-six for former foster youth. Using the 2011-18 National Youth in Transition Database, we found that Medicaid expansion increased Medicaid coverage among former foster youth by 10.1 percentage points, and the age extension increased coverage by 3.4 percentage points. There is suggestive evidence of positive spillovers for both policies. Our findings imply that the ACA improved Medicaid coverage among former foster youth, with the largest effects from Medicaid expansion. The modest effects of the Medicaid age extension may imply a need to revise enrollment, recertification, outreach, and eligibility determination processes to further increase Medicaid coverage among former foster youth.
| S-EPMC8588631 | biostudies-literature
Project description:ObjectiveThe study aims were to investigate secular trends in antiepileptic drug (AED) use in women during pregnancy, and to compare the use of first- and second-generation AEDs.MethodsStudy participants consisted of female Florida Medicaid beneficiaries, older than 15 years, and pregnant within the time period 1999 to 2009. Fifteen AEDs were categorized into first and second generation of AEDs. Continuous use of AEDs was defined as at least 2 consecutive AED prescriptions totaling more than a 30-day supply. Polytherapy was defined as 2 or more AEDs continuously used for at least 30 overlapping days. Annual prevalence was estimated and compared.ResultsWe included 2,099 pregnant women who were enrolled in Florida Medicaid from 1999 to 2009 and exposed to AEDs during pregnancy. Although there were fluctuations, overall AED use in the study cohort did not increase from 2000 to 2009 (? ± standard error [SE]: -0.07 ± 0.06, p = 0.31). The use of first-generation AEDs decreased (? ± SE: -6.21 ± 0.47, p < 0.0001), whereas the use of second-generation AEDs increased (? ± SE: 6.27 ± 0.52, p < 0.0001) from 2000 to 2009. AED use in polytherapy did not change through the study period. Valproate use reduced from 23% to 8% in the study population (? ± SE: -1.61 ± 0.36, p = 0.0019), but this decrease was only for women receiving an AED for epilepsy and was not present for other indications.ConclusionThe second-generation AEDs are replacing first-generation AEDs in both monotherapy and polytherapy. Valproate use has declined for epilepsy but not other indications. Additional changes in AED use are expected in future years.
| S-EPMC4351665 | biostudies-literature
Project description:ObjectiveTo examine the relationship between federally qualified health center (FQHC) use and hospital-based care among individuals dually enrolled in Medicare and Medicaid.Data sourcesData were obtained from 2012 to 2018 Medicare claims.Study designWe modeled hospital-based care as a function of FQHC use, person-level factors, a Medicare prospective payment system (PPS) indicator, and ZIP code fixed effects. Outcomes included emergency department (ED) visits (overall and nonemergent), observation stays, hospitalizations (overall and for ambulatory care sensitive conditions), and 30-day unplanned returns. We stratified all models on the basis of eligibility and rurality.Data extraction methodsOur sample included individuals dually enrolled in Medicare and Medicaid for at least two full consecutive years, residing in a primary care service area with an FQHC. We excluded individuals without primary care visits, who died, or had end-stage renal disease.Principal findingsAfter the Medicare PPS was introduced, FQHC use in rural counties was associated with fewer ED and nonemergent ED visits per 100 person-years among both age-eligible (-14.8 [-17.5, -12.1]; -6.6 [-7.5, -5.6]) and disability-eligible duals (-11.3 [-14.4, -8.3]; -6 [-7.4, -4.6]) as well as a lower probability of observation stays (-0.8 pp age-eligible; -0.4 pp disability-eligible) and unplanned returns (-2.1 pp age-eligible; -1.9 pp disability-eligible). In urban counties, FQHC use was associated with more ED and nonemergent ED visits per 100 person-years (10.6 [8.4, 12.8]; 4.0 [2.6, 5.4]) among disability-eligible duals (a decrease of more than 60% compared with the pre-PPS period) and increases in the probability of hospitalization (1.1 pp age-eligible; 0.8 pp disability-eligible) and ACS hospitalization (0.5 pp age-eligible; 0.3 pp disability-eligible) (a decrease of roughly 50% compared with the pre-PPS period).ConclusionsFQHC use is associated with reductions in hospital-based care among dual enrollees after introduction of the Medicare PPS. Further research is needed to understand how FQHCs can tailor care to best serve this complex population.
| S-EPMC9441286 | biostudies-literature