Antipsychotic adherence and emergency department utilization among patients with schizophrenia
Introduction
Patients with schizophrenia and other severe and persistent mental illnesses have high rates of costly acute care utilization (Billings and Mijanovich, 2007; Billings and Raven, 2013; Shim et al., 2014). Mental illness is among the most significant predictors of frequent emergency department (ED) use (Booth et al., 2011; Lin et al., 2015). However, patients with schizophrenia also have higher rates of ED and hospital utilization for non-psychiatric conditions than the general public (Jackson et al., 2015; Shim et al., 2014). These patients suffer from a disproportionate burden of undiagnosed and/or undertreated chronic illness, creating extremely complex health care needs (Hansen, 2012; Institute of Medicine (US) Committee on Crossing the Quality Chasm: Adaption to Mental Health and Addictive Disorders, 2006).
Adherence to an antipsychotic medication regimen is of particular concern for these patients, given that a large majority of experience gaps in medication use (Mojtabai et al., 2002). Non-adherent and partially adherent patients have predictably worse outcomes (Acosta et al., 2014; Weiden and Olfson, 1995). Multiple studies have shown that non-adherence is associated with higher rates of readmission, longer length of stay, and higher costs (Jiang and Ni, 2015; Offord et al., 2013; Weiden et al., 2004). The results are similar for psychiatric admissions and all-cause admissions. Less is known, however, about the relationship between non-adherence and the risk of visiting the emergency department for medical, non-psychiatric complaints. This link between poorly controlled mental illness and high acute-care medical utilization is becoming increasingly important for state Medicaid agencies as they seek to control costs through greater integration of care (Nardone et al., 2014). Given that an estimated 8.5% of Medicaid patients carry a schizophrenia diagnosis, efforts to increase integrated care management for such patients is greatly warranted (Boyd et al., 2010).
Community Care of North Carolina (CCNC) is an enhanced primary care case management program for Medicaid enrollees throughout the state of North Carolina. CCNC has already been successful at reducing unnecessary ED and hospital utilization for patients with schizophrenia through careful coordination with community-based infrastructure, and is continually working to improve care for these patients (Jackson et al., 2015). In this study, we evaluate the relationship between antipsychotic medication adherence and ED utilization among CCNC-enrolled Medicaid patients with schizophrenia.
Section snippets
Study design and population
This retrospective cohort study used available CCNC data for patients with schizophrenia enrolled in the program between January and December 2015. These data were taken from monthly reports derived from Medicaid claims and compiled by the CCNC behavioral health administrative team. They include the number of antipsychotic prescriptions each patient had filled in the past year, the number of medical and psychiatric ED visits and hospitalizations in the past year, and an array of demographic and
Patient characteristics
A total of 7851 Medicaid patients enrolled in CCNC met criteria for inclusion in this study. Table 1 displays the patient characteristics. Patients had a mean age of 44.6 ± 12.4 years, and 52.2% were male. Rates of chronic diseases, particularly diabetes and hypertension, were quite high across patients. Seventy-five percent of all patients had visited a primary care provider, 12.8% had at least one medical hospitalization, and 8.2% had at least one psychiatric hospitalization during the study
Discussion
This study examines the relationship between antipsychotic medication adherence and emergency department utilization among Medicaid patients with schizophrenia. Interestingly, this study found that the overwhelming majority of ED utilization among patients with schizophrenia is categorized as medical rather than psychiatric, and that partial and non-adherence to antipsychotics are associated with increased ED utilization for medical conditions, but not necessarily psychiatric conditions. In
Conclusions
This study demonstrates a clear association between antipsychotic use and ED utilization, highlighting the importance of antipsychotic medication adherence in patients with schizophrenia. From a population health standpoint, it also highlights the important link between behavioral health care and medical utilization among Medicaid patients with schizophrenia. More research is needed understand the causes for non-adherence among Medicaid patients with schizophrenia, as well as the best methods
Conflicts of interests
Morgan Hardy—none.
Carlos Jackson—none.
Jennie Byrne—none.
Contributors
Morgan Hardy conducted all of the analyses and wrote the manuscript. Carlos Jackson procured the data, developed the concept for the study, provided statistical expertise, and edited the manuscript. Jennie Byrne served as a research mentor to Morgan Hardy, helped develop the concept of the study, edited the manuscript, and provided logistical support. All authors contributed to and have approved the final manuscript.
Funding body agreements and policies
This study was conducted with approval from the North Carolina Department of Medical Assistance. No grants or other source of funding were used.
Acknowledgements
The authors would like to acknowledge Troy Trygstad, Vice President of Pharmacy Programs for CCNC and Theodore Pikoulas, Associate Director of Behavioral Health Pharmacy Programs for CCNC, for their consultation and assistance with this evaluation. Jill Ruppenkamp, CCNC behavioral health program analyst, assisted in data collection and analysis.
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