title: Second opinions improve ADHD prescribing in a medicaid-insured community population.
abstract: OBJECTIVE
  The appropriate use of psychotropic medications in youths is an important public health concern. In this article, we describe a review process developed to monitor the use of stimulants and atomoxetine for attention-deficit/hyperactivity syndrome (ADHD) in youths receiving fee-for-service Medicaid services.
  
  
  METHODS
  Washington State Medicaid developed threshold safety parameters for ADHD medications through a process involving the community. A second opinion was mandated when safety thresholds based on dose, combination therapies, or age was exceeded. Use and cost were compared 2 years before and after the program began.
  
  
  RESULTS
  From May 2006 to April 2008, 5.35% of ADHD prescriptions exceeded safety thresholds, resulting in 1,046 second-opinion reviews. Of those, 538 (51.4%) resulted in a prescription adjustment. Adjustments were made to primary care physician (52%), psychiatrist (50%), nurse practitioner (54%), and physician assistant-written (51%) prescriptions. When the preperiod and postperiod were compared, second opinions reduced ADHD medication at high doses (53%), in combinations (44%), and for patients 5 years of age and younger (23%). The review process resulted in a savings of $1.2 million, with 538 fewer patients exceeding safety thresholds. This was a 10:1 return over administrative costs; however, the overall Medicaid expenditures for ADHD medication still increased because of higher unit costs and the preferential use by clinicians of newer brands entering the market.
  
  
  CONCLUSIONS
  A statewide second-opinion process reduced outlier ADHD medication prescription practices and was cost-effective. Suggestions for process and quality improvements in prescribing to children diagnosed with ADHD are discussed.
authors.affiliation: Dr. Thompson, Mr. Kwan, and Mr. Lee are with the Washington State Department of Social and Health Services; and Drs. Varley, McClellan, Hilt, Trupin, and Lee are with the University of Washington. Electronic address: ThompJ@dshs.wa.gov.
authors.forename: Jeffery N
authors.initials: JN
authors.lastname: Thompson
authors.affiliation: Dr. Thompson, Mr. Kwan, and Mr. Lee are with the Washington State Department of Social and Health Services; and Drs. Varley, McClellan, Hilt, Trupin, and Lee are with the University of Washington.
authors.forename: Christopher K
authors.initials: CK
authors.lastname: Varley
authors.affiliation: Dr. Thompson, Mr. Kwan, and Mr. Lee are with the Washington State Department of Social and Health Services; and Drs. Varley, McClellan, Hilt, Trupin, and Lee are with the University of Washington.
authors.forename: Jon
authors.initials: J
authors.lastname: McClellan
authors.affiliation: Dr. Thompson, Mr. Kwan, and Mr. Lee are with the Washington State Department of Social and Health Services; and Drs. Varley, McClellan, Hilt, Trupin, and Lee are with the University of Washington.
authors.forename: Robert
authors.initials: R
authors.lastname: Hilt
authors.affiliation: Dr. Thompson, Mr. Kwan, and Mr. Lee are with the Washington State Department of Social and Health Services; and Drs. Varley, McClellan, Hilt, Trupin, and Lee are with the University of Washington.
authors.forename: Terry
authors.initials: T
authors.lastname: Lee
authors.affiliation: Dr. Thompson, Mr. Kwan, and Mr. Lee are with the Washington State Department of Social and Health Services; and Drs. Varley, McClellan, Hilt, Trupin, and Lee are with the University of Washington.
authors.forename: Alan C
authors.initials: AC
authors.lastname: Kwan
authors.affiliation: Dr. Thompson, Mr. Kwan, and Mr. Lee are with the Washington State Department of Social and Health Services; and Drs. Varley, McClellan, Hilt, Trupin, and Lee are with the University of Washington.
authors.forename: Taik
authors.initials: T
authors.lastname: Lee
authors.affiliation: Dr. Thompson, Mr. Kwan, and Mr. Lee are with the Washington State Department of Social and Health Services; and Drs. Varley, McClellan, Hilt, Trupin, and Lee are with the University of Washington.
authors.forename: Eric
authors.initials: E
authors.lastname: Trupin
mesh_terms: D000293:Adolescent; D018759:Adrenergic Uptake Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics; D000069445:Atomoxetine Hydrochloride; D001289:Attention Deficit Disorder with Hyperactivity / Q000175:diagnosis / Q000188:drug therapy* / Q000191:economics; D000697:Central Nervous System Stimulants / Q000191:economics / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D017046:Cost Savings / Q000706:statistics & numerical data; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D016527:Drug Costs / Q000706:statistics & numerical data; D064420:Drug-Related Side Effects and Adverse Reactions / Q000191:economics; D019317:Evidence-Based Medicine; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008484:Medicaid / Q000191:economics; D011437:Propylamines / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics; D012017:Referral and Consultation / Q000191:economics; D016896:Treatment Outcome; D014481:United States; D014861:Washington
chemical_list: D018759:Adrenergic Uptake Inhibitors; D000697:Central Nervous System Stimulants; D011437:Propylamines; D000069445:Atomoxetine Hydrochloride