title: Prescribing of Clozapine and Antipsychotic Polypharmacy for Schizophrenia in a Large Medicaid Program.
abstract: OBJECTIVE
  Underuse of clozapine and overuse of antipsychotic polypharmacy are both indicators of poor quality of care. This study examined variation in prescribing clozapine and antipsychotic polypharmacy across providers, as well as factors associated with these practices.
  
  
  METHODS
  Using 2010-2012 Pennsylvania Medicaid data, prescribers were identified if they wrote antipsychotic prescriptions for ten or more nonelderly adult patients with schizophrenia annually. Generalized linear mixed models with a binomial distribution and a logit link were used to examine prescriber-level annual percentages of patients with clozapine use and with long-term (≥90 days) antipsychotic polypharmacy and associated characteristics of prescribers' patient caseloads, prescriber characteristics, and Medicaid payer (fee-for-service versus managed care plans).
  
  
  RESULTS
  The study cohort included 645 prescribers in 2010, 632 in 2011, and 650 in 2012. In 2012, the mean prescriber-level annual percentage of patients with any clozapine use was 7% (range 0%-89%), and the mean percentage of patients with any long-term antipsychotic polypharmacy was 7% (range 0%-45%) (similar rates were found during 2010-2012). Prescribers with high prescription volume, a smaller percentage of patients from racial or ethnic minority groups, and a larger percentage of patients eligible for Supplemental Security Income were more likely to use both clozapine and antipsychotic polypharmacy for treating schizophrenia. Prescriber specialty and Medicaid payer were also associated with prescribers' practices.
  
  
  CONCLUSIONS
  Considerable variation was found in clozapine and antipsychotic polypharmacy practices across prescribers in their treatment of schizophrenia. Targeting efforts to selected prescribers holds promise as an approach to promote evidence-based antipsychotic prescribing.
authors.affiliation: Dr. Tang, who was a doctoral student at the University of Pittsburgh when this work was conducted, is with RTI International, Research Triangle Park, North Carolina (e-mail: yantang@rti.org ). Dr. Horvitz-Lennon is with RAND Corporation, Boston. Dr. Gellad is with the U.S. Department of Veterans Affairs Pittsburgh Healthcare System and the Division of General Medicine, University of Pittsburgh, both in Pittsburgh. Dr. Lave and Dr. Donohue are with the Graduate School of Public Health and Dr. Chang is with the Department of Biostatistics, University of Pittsburgh. Dr. Normand is with Harvard Medical School, Boston.
authors.forename: Yan
authors.initials: Y
authors.lastname: Tang
authors.affiliation: Dr. Tang, who was a doctoral student at the University of Pittsburgh when this work was conducted, is with RTI International, Research Triangle Park, North Carolina (e-mail: yantang@rti.org ). Dr. Horvitz-Lennon is with RAND Corporation, Boston. Dr. Gellad is with the U.S. Department of Veterans Affairs Pittsburgh Healthcare System and the Division of General Medicine, University of Pittsburgh, both in Pittsburgh. Dr. Lave and Dr. Donohue are with the Graduate School of Public Health and Dr. Chang is with the Department of Biostatistics, University of Pittsburgh. Dr. Normand is with Harvard Medical School, Boston.
authors.forename: Marcela
authors.initials: M
authors.lastname: Horvitz-Lennon
authors.affiliation: Dr. Tang, who was a doctoral student at the University of Pittsburgh when this work was conducted, is with RTI International, Research Triangle Park, North Carolina (e-mail: yantang@rti.org ). Dr. Horvitz-Lennon is with RAND Corporation, Boston. Dr. Gellad is with the U.S. Department of Veterans Affairs Pittsburgh Healthcare System and the Division of General Medicine, University of Pittsburgh, both in Pittsburgh. Dr. Lave and Dr. Donohue are with the Graduate School of Public Health and Dr. Chang is with the Department of Biostatistics, University of Pittsburgh. Dr. Normand is with Harvard Medical School, Boston.
authors.forename: Walid F
authors.initials: WF
authors.lastname: Gellad
authors.affiliation: Dr. Tang, who was a doctoral student at the University of Pittsburgh when this work was conducted, is with RTI International, Research Triangle Park, North Carolina (e-mail: yantang@rti.org ). Dr. Horvitz-Lennon is with RAND Corporation, Boston. Dr. Gellad is with the U.S. Department of Veterans Affairs Pittsburgh Healthcare System and the Division of General Medicine, University of Pittsburgh, both in Pittsburgh. Dr. Lave and Dr. Donohue are with the Graduate School of Public Health and Dr. Chang is with the Department of Biostatistics, University of Pittsburgh. Dr. Normand is with Harvard Medical School, Boston.
authors.forename: Judith R
authors.initials: JR
authors.lastname: Lave
authors.affiliation: Dr. Tang, who was a doctoral student at the University of Pittsburgh when this work was conducted, is with RTI International, Research Triangle Park, North Carolina (e-mail: yantang@rti.org ). Dr. Horvitz-Lennon is with RAND Corporation, Boston. Dr. Gellad is with the U.S. Department of Veterans Affairs Pittsburgh Healthcare System and the Division of General Medicine, University of Pittsburgh, both in Pittsburgh. Dr. Lave and Dr. Donohue are with the Graduate School of Public Health and Dr. Chang is with the Department of Biostatistics, University of Pittsburgh. Dr. Normand is with Harvard Medical School, Boston.
authors.forename: Chung-Chou H
authors.initials: CH
authors.lastname: Chang
authors.affiliation: Dr. Tang, who was a doctoral student at the University of Pittsburgh when this work was conducted, is with RTI International, Research Triangle Park, North Carolina (e-mail: yantang@rti.org ). Dr. Horvitz-Lennon is with RAND Corporation, Boston. Dr. Gellad is with the U.S. Department of Veterans Affairs Pittsburgh Healthcare System and the Division of General Medicine, University of Pittsburgh, both in Pittsburgh. Dr. Lave and Dr. Donohue are with the Graduate School of Public Health and Dr. Chang is with the Department of Biostatistics, University of Pittsburgh. Dr. Normand is with Harvard Medical School, Boston.
authors.forename: Sharon-Lise
authors.initials: SL
authors.lastname: Normand
authors.affiliation: Dr. Tang, who was a doctoral student at the University of Pittsburgh when this work was conducted, is with RTI International, Research Triangle Park, North Carolina (e-mail: yantang@rti.org ). Dr. Horvitz-Lennon is with RAND Corporation, Boston. Dr. Gellad is with the U.S. Department of Veterans Affairs Pittsburgh Healthcare System and the Division of General Medicine, University of Pittsburgh, both in Pittsburgh. Dr. Lave and Dr. Donohue are with the Graduate School of Public Health and Dr. Chang is with the Department of Biostatistics, University of Pittsburgh. Dr. Normand is with Harvard Medical School, Boston.
authors.forename: Julie M
authors.initials: JM
authors.lastname: Donohue
mesh_terms: D000328:Adult; D014150:Antipsychotic Agents / Q000627:therapeutic use*; D003024:Clozapine / Q000627:therapeutic use*; D015331:Cohort Studies; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008484:Medicaid; D008875:Middle Aged; D010414:Pennsylvania; D019338:Polypharmacy; D012044:Regression Analysis; D012559:Schizophrenia / Q000188:drug therapy*; D014481:United States
chemical_list: D014150:Antipsychotic Agents; D003024:Clozapine
keywords: Drug treatment/psychopharmacology; Schizophrenia