We observed changes over time in schizophrenia treatment quality. Independent of these changes, quality was low. Also, there were phase-specific differences. Cross-sectional measures (i.e., receiving any antipsychotic or mental health visit) were higher in maintenance phase, likely reflecting its longer time window (up to 365 days vs. 12 weeks for acute phase). Longitudinal measures (i.e., continuity of treatment,) were lower in maintenance phase, likely reflecting the challenges of either adherence and/or barriers to care over time.
While overall treatment quality remained the same, there were changes in the likelihood of receiving components of quality. Overall medication quality improved, driven by a higher percentage of patients receiving an antipsychotic. However, the likelihood of receiving continuous outpatient visits declined, as did the likelihood of receiving a continuous supply of antipsychotic medications in acute phase. These results likely reflect increasing pressure for Medicaid cost containment. For example, during the study period the inflation adjusted Florida Medicaid fees for psychosocial treatments declined.14
Further, our observation that patients were more likely to receive antipsychotics, but less likely to receive psychosocial treatments is consistent with other research examining trends in mental health treatment utilization.15-21
The PORT examined quality at the person level, whereas we do so at the treatment phase level. Still, finding some reasonable comparison between the studies would be useful. Ninety percent of the patients with a maintenance phase in our study had only one per year, which provides an opportunity for some approximate comparison with PORT results. A lower proportion of maintenance phases in our sample included an antipsychotic (65.4-73.7% vs. 92% of PORT respondents in maintenance phase). However, there was higher excessive dosing in the PORT (31% vs. approximately 22%). Approximately 65% of PORT respondents reported receiving help with at least one life problem and 45% of the treatment plans indicated the patients were receiving psychotherapy. We found that 74.5-77.8% of maintenance phases included at least one mental health visit, but much lower rates of at least monthly psychotherapy (11.9%-7.3%).
There are other ways in which our data are not directly comparable to the PORT. We rely upon administrative data and the PORT utilized a combination of chart review and patient interview. Also, the PORT measured the proportion prescribed an antipsychotic, whereas our data reflect the proportion that actually filled a prescription. Further, our estimate of medication dosing is based upon a calculation of the average daily dose over a treatment phase based on prescription claims, rather than relying on charts or patient self report.
We found treatment quality differences associated with age and gender (and consistent with prior literature22, 23
), but co-occurring substance use disorders were more strongly associated with a disparity in treatment quality. While consistent with other literature describing worse adherence in patients with co-occurring schizophrenia and substance use disorders,24-28
we cannot determine if decreased quality or adherence is related to patient factors, provider/system factors or both. Also, our finding that these patients were similarly likely to receive appropriate prescribed antipsychotic doses is consistent with prior literature.23
Still, our results demonstrate the importance of additional policy or service system changes aimed at engaging and maintaining this population in treatment, such as increasing the capacity for integrated co-occurring treatment. However, it is also notable that while we found persons with co-occurring substance use disorder were less likely in maintenance phase to fill an antipsychotic prescription, those who did were more likely to fill a continuous supply. These results suggest better quality for a subset of persons with co-occurring substance use disorders who received antipsychotic pharmacotherapy.
The greatest disparity in overall medication quality and visit continuity based on race/ethnicity was between Blacks and Hispanics, with Hispanics at times faring better than Whites. However, we also found a spottier quality record for the individual measures of treatment quality. Other research has also found that Blacks and Hispanics are less likely to receive a continuous supply of medication3, 4, 25, 28, 29
and that Blacks are less likely to have visit continuity.30
Our observation that Blacks were equally likely to meet the PORT dose standard is consistent with some,23
but not replicated in all,29, 31
prior literature. Although prior research has found no dosing appropriateness differences between Hispanics and Whites,23
we found excessive dosing more likely for Hispanics, in maintenance phase.
We also found additional relationships between quality, race/ethnicity and co-occurring substance use disorders. A co-occurring substance use disorder diagnosis typically was associated with worse quality outcomes for Blacks but some better quality outcomes for Hispanics. However, the confidence intervals for Hispanics tended to be large, suggesting less stable estimates. Further research is needed to clarify the relationship between quality disparities and co-occurring substance use disorders and race/ethnicity.
There are several limitations worth noting. One is that we could not directly observe clinical symptoms, therefore our definitions of acute or maintenance phase may not entirely correspond to the clinical scenario. Further, we rely upon claims data to determine race/ethnicity and concerns have been raised about the accuracy of the non-White categories in large databases.32
However, there is some evidence that misclassification biases in administrative data are small for Blacks, Whites and Hispanics, due to high positive predictive values within a racial/ethnic category. 33
The 2003 PORT update reflected increasing choices in second generation antipsychotics, as well as an updated evidence base regarding psychosocial treatments. We apply these standards to care delivered from July 1996 through June 2001. The updated PORT recommendations are reasonable to apply to these data for two reasons. First, the dosing recommendations of newer medications follow the manufacturers' recommendations (and therefore were accessible to clinicians prior to publication of the updated PORT). Second, the limited frequency in these data of psychosocial treatments specifically recommended by the PORT necessitated a very liberal definition of psychosocial treatment quality: namely continuity.
The maintenance phases typically lasted nine to twelve months (depending upon whether one considers the mean or median/mode). Over this duration, it may be reasonable for service utilization to decrease as patients become more stable over time. However, our quality standards represent a minimum threshold of care that should be maintained over time. For example, individuals with a chronic, debilitating illness such as schizophrenia, most of whom are disabled and on Supplemental Security Income, should receive at least one mental health visit in a 60 day period. Or, over a 1 year maintenance phase period patients should receive an antipsychotic, at an appropriate dose and without any medication disruption for more than 30 days.
We do not examine treatment quality beyond fiscal year 2001. Possibly, our data do not reflect the current state of quality in this Medicaid program. However, while not directly comparable, study by other investigators of this Medicaid program demonstrate that the penetration of inpatient and outpatient psychiatric service utilization remained constant from January 1, 2001- June 30, 2004 in the fee-for-service plans.34
Also, there were no changes in the financing of psychotropic medications. Thus, we think it reasonable to consider that the environment shaping mental health care changed little through at least 2004.
A further limitation is that we examined quality in one state Medicaid program. However, Florida has the 3rd largest Medicaid program in the United States. Additionally, the fiscal constraints facing Florida have been similar in other Medicaid programs, which also provide additional relevance of this study from a more general policy perspective.
A strength is that we examined multiple domains of quality in acute and maintenance phases of treatment, and also control for insurance status, socioeconomic level, illness severity and co-occurring illness. However, we cannot distinguish between drugs that were prescribed (i.e., recommended) versus what was received. Patients may have been prescribed treatments (either visits or medications) that were not received either because of patient preference or barriers to care. The distinction between differences due to preferences versus barriers is important when examining disparities.35
However, the observation that there were time trends in some of these quality decrements, independent of patient characteristics, suggests that barriers to care are likely to play a significant role in the quality shortfalls observed.
Our results demonstrate a mixed picture in terms of changes in quality and disparities of care in this Medicaid population during the study period. Less than 25% of the person-phases included treatment that met a minimum recommended standard of care. Over time, patients with schizophrenia were more likely to fill an antipsychotic prescription but less likely to meet continuity quality standard for visits with mental health professionals. These results highlight the importance measuring pharmacotherapy and psychosocial visit quality, as well as treatment phase specific quality, when conducting population-based quality assessment and improvement. They also highlight that the most significant disparities were associated with race/ethnicity and co-occurring substance use disorders. Such information provides policy guidance that identifies particular patient populations which could most benefit from system/programmatic quality improvement initiatives.