DUR: Atypical Antipsychotic Educational Project DUR Update
Collaborative Review of Prescribing Patterns
The Medi-Cal Drug Use Review (DUR) Board and the California Department of Health
Services (DHCS) have been leading a collaboration of professionals for the past
three years in reviewing prescribing patterns of atypical antipsychotics in the
Medi-Cal population. This review is necessary due to the high cost of these
medications and the complex nature of their use. (From a list of more than 1700
drugs, Olanzapine has the highest expenditures in fee-for-service Medi-Cal, with
risperidone second and quetiapine eighth).
In addition to the DUR Board members and DHCS pharmacists, the group includes representatives from the Medi-Cal Fiscal Intermediary, EDS, and industry representation from Janssen Pharmaceutica, Eli Lilly and Company, Pfizer Inc, and AstraZeneca LP, with the later addition of Abbott Laboratories and Bristol-Myers Squibb Company. Furthermore, a faculty of 15 practitioners and a panel of seven independent reviewers have provided integral assistance and support.
Project Goals
The project has two main goals. The first goal is to determine the prescribing
patterns of atypical antipsychotics in the California Medi-Cal population and
identify problematic prescribing practices. Using this information, educational
programs are developed and presented to encourage effective and economical
application of antipsychotic therapy. The data gathered is the foundation of a
broad-based program that includes printed materials, a CD-ROM, continuing
education lectures delivered throughout California, as well as at national and
international professional forums.
The second goal of this project is to develop a new method for pharmaceutical industry support of drug use review, one that uses a multiple-manufacturer collaborative approach to reduce potential biases that may occur with single sponsor funding. This cooperative method allows data and information resources to be shared, encourages objective critical thinking and may result in analyses that could not be performed without the financial and intellectual resources that manufacturers can provide.
Characteristics of the Study:
- Based on California Medi-Cal pharmacy claims from May 1999 through August 2000.
- Included recipients who received one of the three available atypical
antipsychotics (risperidone, olanzapine or quetiapine) for more than 60
days. No restriction on diagnosis
was included. - Did not include ziprasidone, which was not yet on the market during this time period.
- A total of 116,114 recipients were reviewed for whom one or more claims
for these drugs
were submitted during the time period.
The literature research resulted in the identification of high-cost, low-evidence practices for treating psychosis. Consequently, three major directions for investigation resulted from the Medi-Cal data analysis.
- High Dose – In this group, recipients received high doses of
atypical antipsychotics (as described by package insert or individual
manufacturer recommendations), with a breakout by age and gender of
recipients along a continuum of daily dose. Frequency of high dose use was 8
percent for risperidone (>6 mg/day), 7 percent for olanzapine (>20 mg/day)
and 1 percent for quetiapine (>800 mg/day). Evidence provides little support
for this costly treatment strategy.
- Polypharmacy – In this group, recipients received atypical antipsychotic polypharmacy, defined as two or more atypical antipsychotics administered concomitantly for 60 or more days in any 75-day period during the study. This is a very costly approach to therapy and there is virtually no evidence to support it. In this study, 79 percent of the total study group received only monotherapy with one of the three agents, but 21 percent received two or more of these three atypical antipsychotics at some point during the 16-month period, although not necessarily concurrently. A total of 4.1 percent of all recipients received long-term atypical antipsychotic polypharmacy for greater than 60 days. An additional analysis showed that polypharmacy with any two antipsychotics (either atypicals or conventionals) occurred in 11 percent of the recipient cases.
- Augmentation – In this group, recipients received augmentation of atypical antipsychotic drugs with drugs that were not antipsychotics themselves, such as divalproex, gabapentin, etc. The evidence for the various augmenting drugs varies, with drugs such as gabapentin showing little supportive evidence and drugs such as divalproex showing substantial support. Analysis showed that 11 percent of recipients taking antipsychotics also received concurrent therapy with valproic acid or one of its salts for at least 60 days.
Analysis Results
The data supports a conclusion that there is an opportunity to improve
prescribing practices of atypical antipsychotics in the Medi-Cal population. The
data also supports the effectiveness of this collaborative analysis process. The
project has demonstrated that the participation and cooperation of organizations
that are traditionally aligned in a competitive manner can produce a successful
program. The activity of this collaboration is expected to continue, performing
short and long-term outcome evaluations, developing manuscripts for publication
and Web-based distribution of program information, and coordinating
multi-pronged efforts to contact individual providers, as well as the community
of mental health care providers and advocates.
