Quality of Care Treatment for Youth With Bipolar Disorder
An increasing number of children and adolescents are being diagnosed with bipolar disorder in the United States, with estimated prevalence rates ranging from 0.04% to 6% (JAACAP, 2007). Evidence based treatments for medication and psychotherapy are readily available for bipolar disorder, however, suboptimal treatment is well-documented and remains a common problem in both adult and pediatric populations. For example, Morrato and colleagues (2010) recently found that two-thirds of children prescribed an antipsychotic did not receive metabolic screenings. This study adds to the research on quality of care for youth with bipolar by addressing two primary aims: (1) to examine the rates of conformance to quality of care measures among youth with bipolar disorder and (2) to identify individual and clinical factors associated with variations in conformance to guidelines.
Methods:
A retrospective, longitudinal cohort design was used to achieve study objectives. The study population included all youth aged 5 to 18 who were newly diagnosed with bipolar disorder between 2006 and 2010 and continuously enrolled in Ohio’s Medicaid program during the 6 months prior to and 19 months following the initial diagnosis (N=4,047). Information on demographic and clinical characteristics was abstracted from Medicaid claims/eligibility files. The primary outcome measures captured various dimensions of quality of care for bipolar disorder: (1) appropriate medication (treatment with mood stabilizers or anticonvulsants); (2) blood level monitoring (for those prescribed a mood stabilizer); (3) side effect monitoring (for those prescribed a mood stabilizer); (4) screening for hyperglycemia and hyperlipidemia (for those prescribed an atypical antipsychotic); and (5) follow-up outpatient visits (≥ 6 visits during the acute phase). Logistic regression was used to assess the associations between demographic, clinical, and quality of care.
Results:
Of those youth with a new diagnosis of bipolar disorder, nearly two-thirds (65%) were prescribed either a mood stabilizer and/or an antipsychotic medication within 84 days (12 weeks) of their initial diagnosis, in accordance with practice guidelines. A similar proportion of youth received six or more follow-up visits with a mental health provider during the acute phase. However, most children diagnosed with bipolar did not received medical monitoring. Among youth prescribed either lithium or anticonvulsants, only about one-fifth received appropriate laboratory tests for blood levels or side effect monitoring (21% and 20% respectively), and less than a tenth of those youth prescribed an atypical antipsychotic received metabolic screening (e.g. glucose and lipids testing) (8%). Logistic regression analyses indicate that youth who are female, non-white, eligible through foster care or disability, and living in a rural area have lower odds of conforming to the quality of care guidelines, except for follow-up visits, where foster care and non-white youth had higher odds of conformance.
Conclusions and Implications:
Among Medicaid youth with bipolar, conformance rates for quality of care are below recommended guidelines. Most room for improvement lies in guidelines related to metabolic screenings, which aligns with previous research. Study findings underscore the need for quality improvement efforts to be directed towards vulnerable subpopulations, particularly racial/ethnic minorities, females and those living in rural areas.