JAMA: With a concern about inappropriate prescribing of antipsychotic
medications to children, 31 states have implemented prior authorization
policies for atypical antipsychotic prescribing, mostly within the past 5
years, and with most states applying their policies to children younger
than 7 years of age, according to a study in the March 3 issue of JAMA.
Over the past two decades, antipsychotic prescribing to youth, almost
exclusively comprising atypical antipsychotic medications, was
estimated to have increased from 0.16 percent in 1993- 1998 to 1.07
percent in 2005-2009 in office-based physician visits. Antipsychotic use
is also 5-fold greater in Medicaid-insured youth than in privately
insured youth, and occurs mostly for indications not approved by the
U.S. Food and Drug Administration (FDA). In light of antipsychotic
treatment-emergent cardiometabolic adverse events, several government
reports called for efforts to improve pediatric psychotropic medication
oversight in state Medicaid agencies. Such efforts have included
agerestricted prior authorization policies, which require clinicians to
obtain preapproval from Medicaid agencies to prescribe atypical
antipsychotics to children younger than a certain age as a condition for
coverage, according to background information in the article.
Julie M. Zito, Ph.D., of the University of Maryland, Baltimore, and
colleagues reviewed antipsychotic-related Medicaid prior authorization
policies for youth (<18 years) in 50 states plus the District of
Columbia between June 2013 and August 2014 and characterized these
policies according to agerestriction criteria and whether a peer review
process was present. A subset of prior authorization policies,
classified as “peer review”, brings clinical expertise into the review
process by requiring contracted clinicians (peer reviewers) to
adjudicate antipsychotic prescriptions for children.
The researchers found that 31 states have implemented prior
authorization policies for atypical antipsychotic prescribing to
children, mostly within the past 5 years. Most states apply their
policies to children younger than 5, 6, or 7 years of age. Only 7 states
(Alabama, Kentucky, Maryland, Nevada, North Carolina, Pennsylvania,
Tennessee) apply their policies to Medicaid-insured youth up to age 18
years. Seven other states (California, Colorado, Georgia, Mississippi,
Nebraska, New York, Washington) have age-restriction criteria that vary
by drug entity.
Of the 31 states, 15 have incorporated a peer review process, wherein
the adjudication process usually involves a psychiatrist or other
physician specialty. The programs without a peer review process use
automated systems or nonphysician manual reviews for adjudication.
“The findings may inform pediatric research to assess the effect of
these policies on atypical antipsychotic use to ensure clinical
appropriateness and to minimize unintended consequences,” the authors
write.
They add that potential unintended consequences of these restrictive
policies include inadequate treatment, substitution of potentially
inappropriate, off-label psychotropic medication classes such as
anticonvulsant mood stabilizers and antidepressants, and administrative
burden on prescribers.
“Additionally, Medicaid oversight programs should be concerned not
only with unnecessary antipsychotic use, but also should ensure
adherence to appropriate cardiometabolic monitoring practices at
baseline and during antipsychotic treatment, and support access to
alternative evidence-based nonpharmacological treatments.”
(doi:10.1001/jama.2015.0763; Available pre-embargo to the media at http://media.jamanetwork.com)
Editor’s Note:
This study was funded by the U.S. Food and Drug Administration (FDA).
Mr. Schmid was supported in part by a fellowship administered by the Oak
Ridge Institute for Science and Education and funded by the U.S. FDA.
The authors have completed and submitted the ICMJE Form for Disclosure
of Potential Conflicts of Interest and none were reported.