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THE ANTIPSYCHOTIC ATLAS:

MEDICARE USAGE OF ANTIPSYCHOTIC MEDICATIONS IN WASHINGTON STATE (PER CAPITA USE)

BRIEF BACKGROUND

About 4.3% of adults in Washington have serious mental illness, and significant portions of this population are current or recent users of antipsychotic medications. Antipsychotic medications are powerful tools for managing severe mental illness, but also carry risk of serious adverse effects, including cardiometabolic dysfunction, diabetes, cerebrovascular events, thromboembolism, and sudden cardiac death. The objective of this two-year study is to provide a detailed portrait of antipsychotic utilization in Washington at the regional support network (RSN) and county level.

RESEARCH OBJECTIVES

  • To calculate rates of antipsychotic medication use among Medicare D recipients in WA
  • To assess sociodemographic and socioeconomic differences in antipsychotic medication use
  • To distinguish between incident and prevalent users
  • To describe clinically significant patterns of antipsychotic use,  including excessive and subtherapeutic dosing, discontinuation, switching, and polypharmacy
  • To determine off-label use rates for antipsychotics
  • To compare adverse clinical outcomes by drug and patterns of use (metabolic syndrome, stroke, thromboembolism)

FUNDING

This research project is intended to benefit Washington residents with dementia, schizophrenia, bipolar disorder or diabetes and is funded by a $340,288 grant awarded from the Washington State Attorney General’s Office. The grant originated as part of a “cy pres,” or “next best use” of settlement monies, stemming from a 2012 settlement agreement between the Washington State Attorney General’s Office and Janssen Pharmaceuticals, Inc., concerning the marketing of antipsychotic drugs Risperdal, Risperdal Consta, Risperdal M-Tab and Invega. 

PROJECT METHODOLOGY

Research for The Antipsychotic Atlas requires use of research identifiable datasets (RIFs), which contain protected health information (PHI) on Washington Medicare beneficiaries. The PI prepared a data use agreement (DUA) with the assistance of the Research Data Assistance Center (ResDAC) at the University of Minnesota, and this was reviewed by the Privacy Board of the Centers for Medicare and Medicaid Services to ensure that the beneficiary’s privacy is protected and the need for identifiable data is justified. A Secure Data Facility was established on the WSU Spokane campus. Once the DUA was approved, WSU worked with the Chronic Condition Data Warehouse to create the following data sets:

1) Denominator file (N=477,310) – is comprised of all Washington State residents continuously enrolled in Medicare Part D or a Medicare Advantage plan in 2010 (decedents, and those who added or dropped managed care or prescription drug coverage during the 12 month observation period were not included). Specific variables were derived from:

a. The 2010 Master Beneficiary File – which includes basic sociodemographic and program enrollment data.

b. The 2010 Part D Prescription Drug Event (PDE) File – which includes all prescriptions filled in 2010, and allowed identification of all antipsychotic medication users in the study population.

2) Numerator file (N=29,973) – comprised of all Washington State residents continuously enrolled in Medicare Part D or a Medicare Advantage plan who filled one or more prescriptions for an antipsychotic medication in 2010. Specific variables were derived from:

a. The 2010 Master Beneficiary File – which includes basic sociodemographic and program enrollment data.

b. The 2010 and 2011 Part D Prescription Drug Event (PDE) Files – which includes all prescriptions filled by study population in 2010 and 2011, and allows investigation of patterns of psychiatric medication usage. Prescriptions will be categorized by class, agent and formulation. Prevalent users (those who filled an antipsychotic prescription during the first two months of 2010) were distinguished from incident users (those who filled their first antipsychotic prescription in the 3rd through 12th months of 2010), and a uniform 12 month observation period was established.

c. The 2010 and 2011 Inpatient, Outpatient and Carrier Claim files – which included all hospital and physician claims by patient ID and ICD-9 diagnostic codes. Antipsychotic users who do not have a diagnosis of schizophrenia or bipolar disorder in one inpatient claim or two outpatient claims will be classified as off-label users. Select mental and physical diagnoses will also be used to determine the number and type of co-morbid chronic conditions treated over the 12 month observation period (including evidence of metabolic syndrome). The primary diagnosis code from institutional claims files will also be used to identify hospital treatment for stroke and thromboembolism.

STUDY HIGHLIGHTS

Profile of Antipsychotic Users in Washington

The following are the number and proportion of Medicare Part D beneficiaries prescribed antipsychotic medications in 2010.

County N Percent
Pierce 4,007 8.3
Columbia 40 8.2
Kitsap 1,091 8.1
Whitman 178 8.0
Thurston 1,198 7.8
King 8,215 6.9
Spokane 2,664 6.8
Whatcom 1,049 6.4
Walla Walla 296 6.1
Snohomish 2,707 6.1
Cowlitz 619 5.7
Grays Harbor 426 5.6
Chelan 290 5.5
Benton 565 5.5
Clark 1,879 5.4
Skagit 548 5.2
Lewis 439 5.2
Yakima 947 5.0
Douglas 230 4.8
Franklin 172 4.8
Clallam 448 4.8
Asotin 120 4.7
Pacific 125 4.5
Grant 315 4.5
Jefferson 169 4.4
Mason 223 4.3
Kittitas 115 4.3
Skamania 28 4.0
Island 238 3.9
Okanogan 164 3.8
San Juan 65 3.6
Klickitat 84 3.6
Stevens 149 3.6
Ferry 26 3.5
Adams 31 3.4
Garfield 11 3.3
Pend Oreille 43 3.1
Wahkiakum 16 3.0
Lincoln 39 2.9

Data source: Centers for Medicare and Medicaid Services.
Analysis by Dr. Jae Kennedy.

Table 1. A comparison on antipsychotic users and nonusers in WA Medicare Part D and Medicare Advantage Plans in 2010

Population Attributes Antipsychotic Users N Antipsychotic Users % Antipsychotic Nonusers N Antipsychotic Nonusers %
Total 29,972 6.3% 447,294 93.7%
Age 21-64 17,659 19.1% 74,769 80.9%
65 or older 12,316 3.2% 372,525 96.8%
Male 12,617 6.3% 93.7% 96.8%
Female 17,355 6.3% 259,104 93.7%
White 25,465 6.2% 386,493 93.8%
Black 1,586 12.8% 10,806 87.2%
Asian 1,057 4.2% 24,031 95.8%
Hispanic 1,062 6.5% 15,379 93.5%
Native American 462 8.8% 4,813 91.2%
Urban 23,757 6.8% 326,255 93.2%
Rural 6,212 4.9% 120,988 95.1%
Medicare only 8,223 2.4% 329,876 97.6%
Dual eligible 21,749 15.6% 117,418 84.4%

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RESEARCH STAFF

Jae Kennedy, Co-PI, Professor

Health Policy & Administration, Washington State University, Spokane

JAE KENNEDY

Education:

Whitman College, Walla Walla, WA, B.A. 1981-1985, Psychology

Claremont Graduate School, Claremont, CA, M.S. 1985-1988, Applied Social Psychology

University of California, Berkeley, CA, Ph.D. 1992-1996 Health Services and Policy Analysis

Personal Statement:

I am a professor of Health Policy and Administration at Washington State University, and taught at the University of Illinois in Urbana-Champaign before coming to WSU in 2002. I have over 25 years of health services and policy research experience, with a primary focus on access barriers to prescription medicines, medical care, rehabilitation, and long-term services, with particular emphasis on at-risk groups, including persons with physical and psychiatric disabilities. I have received regular research funding since 1997, and recently completed a three-year, $599,491 grant from the National Institute on Disability and Rehabilitation Research on Medicare Part D. I also served as the policy director of the Program of Excellence in Rural Mental Health and Substance Abuse Treatment (RMHSAT), a five-year, $4,048,620 grant from the WA Life Sciences Discovery Fund. I have published over 45 peer-reviewed research articles, including seven recent articles on Medicare policy.


Sean Murphy Co-PI, Assistant Professor

Health Policy & Administration, Washington State University, Spokane

Sean Murphy

Education:

University of Montana, Missoula, MT, B.A. 12/01, Economics

University of Montana, Missoula, MT, M.A. 8/03, Economics

Washington State University, Pullman, WA, Ph.D., 08/08 Health Economics

Personal Statement:

I am a health economist by training, and an Assistant Professor in the Department of Health Policy and Administration at Washington State University. My primary area of expertise is disease/disorder management with a focus on substance abuse and mental health. I serve as the lead health economist for WSU’s Program of Excellence in Addictions Research (PEAR), which, in conjunction with the WSU Alcohol and Drug Abuse Research Program (ADARP), comprises the Translational Addiction Research Center (TARC). PEAR is housed in WSU’s College of Nursing, and currently oversees approximately $14 million in grant funding from a multitude of funding agencies. I am also a research faculty member in the Center for International Health Services Research and Policy at WSU, and serve as an expert reviewer for SAMHSA’s National Registry of Evidence-Based Programs and Practices. I have extensive econometrics training, which is reflected in the quantitative nature of my research, and am well versed in performing economic analyses.

I have published 16 peer-reviewed research articles, 14 as primary author, and have been awarded over $65,000 worth of grants as a principal investigator. I have also served, or am currently serving, as a co-investigator on an additional $2.7 million worth of grants and contracts. The NIH, CDC, Life Sciences Discovery Fund, Empire Health Foundation and Providence Foundation, among others, have funded my research.


Sterling McPherson, Co-PI, Assistant Professor

College of Nursing, Washington State University, Spokane

Sterling McPherson

​Education:

Whitworth University, Spokane, WA, B.A. 5/05, Psychology (with honors)

Whitworth University, Spokane, WA, B.A. 5/05, Sociology (with honors)

Washington State University, Pullman, WA, M.S., 5/08 Experimental
Psychology

Washington State University, Pullman, WA, Ph.D., 5/10 Experimental
Psychology

Washington State University, College of Nursing, Spokane, WA, Postdoctoral Fellow, Psychopharmacology and Substance Abuse

Personal Statement:

I am an Assistant Professor in the College of Nursing, Co-Director of the Translational Addictions Research Center (TARC), and Director of the Program of Excellence in Addictions Research (PEAR). PEAR currently manages over 14 million dollars in grant funding from a diverse set of funding agencies. I am a Co-I for the Pacific Northwest Node of the National Drug Abuse Treatment Clinical Trials Network (CTN; Co-PIs, Donovan and Roll). In addition, I am the Program Director for the (P20, NIH-funded) Collaborative Action Toward Community Health (CATCH) center of excellence wherein my primary role is to oversee the management of 3 randomized controlled trials in addition to co-leading the Research Methods Core of this center. This dual role is critical to providing day-to-day oversight of the 3 projects and provide ongoing methodological support to the cores/projects throughout the center. I am the PI on 2 current, human behavioral pharmacology studies focused on 1) pharmacokinetics and reinforcement efficacy of nicotine delivered through e-cigarettes among opioid and methamphetamine abusing participants, and 2) sleep actigraphy and psychomotor vigilance task performance among participants with methamphetamine and prescription opioid dependency. I have been the Principal Investigator on two biostatistical grants that investigated 1) innovative application of modern missing data methodologies in substance use research (i.e., selection and pattern-mixture modeling) and 2) longitudinal methods of analysis to substance abuse clinical trial data. I have published 30 peer-reviewed research articles on various topics, all related to mental health, psychopharmacology, and drug abuse. NIH, NSF, CDC, Department of Justice, Bureau of Justice Affairs, Life Sciences Discovery Fund, American Beverage Association, Community Pharmacy Association, Center for Advancing Longitudinal Drug Abuse Research, Alcohol and Drug Abuse Research Program, and the Bristol Myers Squibb Foundation have funded my work.


Matt Layton, Co-I, M.D., Clinical Associate Professor

Medical Sciences, Washington State University, Spokane

Matt Layton

Education:

University of Kansas, Lawrence, B.A., 1986, Chemistry

Kansas University Medical Center, M.D. 1990, Medicine

Kansas University Medical Center, Ph.D., 1993, Pharmacology

University of Washington, Residency, 1997, Psychiatry

Personal Statement:

In my role as Medical Director for the Washington State University Program of Excellence in the Addictions, I am responsible for addressing the medical and psychiatric sequelae of substance abuse and dependence disorders. I diagnose, interpret laboratory results, clear individuals as medically-appropriate for participation in research protocols, and prescribe medications to participants. I collaborate with other team members around development and conduct of protocols, including ongoing assessment, evaluation and reporting of adverse events

While I initially began an academic career at the University of Washington in Seattle, my interests evolved toward community mental health. I moved to Spokane and served as Medical Director for Spokane Mental Health, the primary public mental health and co-occurring disorders treatment facility for a population of approximately 450,000. Although I did not actively conduct research or contribute to the scientific literature during that time, I saw first-hand the devastating impact of addictions on individuals, families and communities. When I left community mental health to return to academics, I was reinvigorated to pursue more clinically-oriented, translational research opportunities in light of my “real world” experiences with the dire consequences of addictions, especially when combined with medical and psychiatric conditions.  I also have the privilege of teaching human behavior to first-year medical students, as well as psychiatry to third-year medical students and resident physicians. This provides opportunities not only for them to learn about the impacts of addictions and mental health problems on overall health, but also for them to engage in short-term, supervised research projects and experiences through the Program of Excellence.

My background as a clinician/educator has allowed me to establish a solid network of relationships throughout the community that I am certain will be of benefit as we conduct research with this challenging population. I have had the pleasure of working closely with law enforcement officers and agencies, correctional personnel and facilities, first-responders including crisis service providers, emergency medical technicians and emergency department personnel, primary care providers, and the courts to provide education and training about the effects of mental health and substance dependence on those with whom they frequently interact. I am also very familiar with the ethical questions that arise in working with individuals with addictions, since I am Chair of the Washington State University Institutional Review Board. In summary, I am committed to the goals of this work and to working with people with addictions. With my background and qualifications, I believe I can and will make significant contributions to this project.


Libby Forsyth, B.A., Senior Secretary, Assistant

Health Policy & Administration, Washington State University, Spokane

Libby Forsythe

Education:

Business Administration, B.A., Washington State University, Pullman

Personal Statement:

I am Assistant for the Department of Health Policy and Administration. I received my BA in Business Administration from Washington State University and am an avid Cougar fan. My first position was in computer sales in the mid-80’s, first for a retail store and later for a pharmacy software company. For most of my career, my husband and I owned and operated River City Marina, the original location of which was right on the river near the Riverpoint Campus. After a few years as a stay at home mom, I went to work for the American Heart Association. Last March, I jumped at the chance to take a position at WSU in HR and I started helping out in the HPA Department in August. I accepted the full time HPA position in November. When not working, my guilty pleasures are cooking, reading and fostering kittens for the Spokane Humane Society.


Cyndy Cole, B.A., Graduate Research Assistant,

Health Policy & Administration, Washington State University, Spokane

Cyndy Cole

Education:

University of Arizona, Tucson, B.A. 2003, Journalism, Political Science.

Currently seeking master's degree in Health Policy & Administration, Washington State University, Spokane

Personal Statement:

I am currently working toward a master's degree in Health Policy and Administration at Washington State University, Spokane. I formerly covered health care as a journalist, among other subjects, including changes related to the Affordable Care Act. I am most interested in working in policy, particularly on improving and expanding access to care.


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PUBLICATIONS

Poster for American Public Health Association 2014 Meeting

Gives use of typical, atypical antipsychotics by Washington Medicare beneficiaries. Provides descriptive findings, compares attributes of users, nonusers and examines concurrent antipsychotic use.


Preliminary descriptive findings (pdf) »

Poster

Poster for Inland Northwest
Health Symposium


Antipsychotic Atlas project overview April 2014 (PowerPoint) »

This research project is intended to benefit Washington residents with dementia, schizophrenia, bipolar disorder or diabetes and is funded by a $340,288 grant awarded from the Washington State Attorney General’s Office. The grant originated as part of a “cy pres,” or “next best use” of settlement monies, stemming from a 2012 settlement agreement between the Washington State Attorney General’s Office and Janssen Pharmaceuticals, Inc., concerning the marketing of Risperdal, Risperdal Consta, Risperdal M-Tab and Invega.  

Overview


WA AGO Proposal - Antipsychotic Atlas 2013 (PDF) »

APPLICATIONS FOR PROJECT THAT BENEFITS WASHINGTON RESIDENTS WHO SUFFER FROM DEMENTIA, SCHIZOPHRENIA, BIPOLAR DISORDER, OR DIABETES
Washington State Attorney General’s Office, Consumer Protection Division

PI: Jae Kennedy, PhD
Department of Health Policy and Administration, Washington State University

Co-Investigators:
Matt Layton, MD, PhD
Sterling McPherson, PhD
Sean Murphy, PhD
Washington State University

CONTACT US

Washington State University Health Policy & Administration office:

Libby Forsyth
Senior Administrative Assistant
Phone: (509) 358-7980
Email: libby.forsyth@wsu.edu

Cyndy Cole
Graduate Research Assistant
Email: cynthia.cole@wsu.edu