Eligibility-Based Psychotropic Polypharmacy Trends and Patterns Among Youth Enrolled in Ohio Medicaid, 2002-2008
Research has documented substantially higher rates of psychotropic medication use for children in foster care compared to other low-income groups; however, little is known about patterns of polypharmacy over time and variations across Medicaid enrollment groups. This is especially critical, given a growing body of research documenting disparities in mental health service use and quality of care across Medicaid eligibility groups, with lower quality of care for children in foster care. The objective of this study was to examine polypharmacy patterns and rates over time among Medicaid enrolled youth, comparing three enrollment groups (foster care (FC), disabled (ABD), and low-income (CFC) youth).
Methods: A serial cross-sectional analysis of Medicaid claims data was conducted to examine trends in polypharmacy for children and adolescents between 2002 and 2008 stratified by the 3 Medicaid program eligibility categories: children in foster care (FC), disabled children (ABD), and low-income children (CFC). The study population included 129,893 youths 17 years of age and younger who were continuously enrolled in Ohio Medicaid for a 1-year period during fiscal years 2002 through 2008 and prescribed one or more psychotropic medications. Primary outcome measures were any polypharmacy (≥ 3 or more psychotropic medications) and multi-classpolypharmacy (≥3 or more psychotropic medications from different drug classes). Generalized estimated models were used to estimate odds ratios for medication receipt with each one year increase in time. Models were adjusted for demographic (age, race/ethnicity, gender) and clinical characteristics (primary diagnosis, psychiatric and medical comorbidities, prior service history).
Results: By 2008, approximately a quarter of FC (27.3%) and ABD youth (24.9%) and 11.5% of CFC youth were prescribed three or more medications. Approximately one in five FC (22.4%) and ABD (19.5%) enrollees were prescribed medications from three or more drug classes. Controlling for demographics, clinical characteristics and current mental health service, both any and multiclass polypharmacy significantly increased for youths in each eligibility category over time. For all eligibility groups the odds of being prescribed three medications increased for each year by 12% for CFC, 11% for ABD youth and by 9% for FC youth. For multi-class polypharmacy, the odds increased for each year by 10% for CFC, 9% for ABD, and 6% for FC youth. Prescription of two or more stimulants and two or more antipsychotic increased significantly for all eligibility groups, and these increases remained significant in adjusted models. There was also a significant increase in medication combinations involving stimulants and/or antipsychotics but decrease in combinations involving antidepressants
Conclusions and Implications:
In this large statewide Medicaid program, rates of psychotropic polypharmacy increased across all Medicaid eligibility groups between 2002 and 2008. However, rates of polypharmacy were consistently higher for children in foster care compared to those children who were disabled or those in poverty no matter how polypharmacy was defined. Overall, study findings underscore the need for oversight and monitoring of psychotropic medication use for children in foster care.