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Articles   |    
A+KIDS, a Web-Based Antipsychotic Registry for North Carolina Youths: An Alternative to Prior Authorization
Robert B. Christian, M.D.; Joel F. Farley, Ph.D.; Brian Sheitman, M.D.; Jerry R. McKee, Pharm.D.; David Wei, Ph.D.; John Diamond, M.D.; Alan Chrisman, M.D.; Larry Jarrett Barnhill, Jr., M.D.; Lynn Wegner, M.D.; Guy Palmes, M.D.; Troy Trygstad, Pharm.D., Ph.D.; Trista Pfeiffenberger, Pharm.D.; Steven E. Wegner, J.D., M.D.; Randell Best, M.D.; Linmarie Sikich, M.D.
Psychiatric Services 2013; doi: 10.1176/appi.ps.002762012
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Dr. Christian is affiliated with the Carolina Institute for Developmental Disabilities, CB 7255, Chapel Hill, NC 27599-7255 (e-mail: rob.christian@cidd.unc.edu). Dr. Christian is also with the Department of Psychiatry, University of North Carolina (UNC) Chapel Hill School of Medicine, Chapel Hill, where Dr. Sheitman, Dr. Barnhill, and Dr. Sikich are affiliated. Dr. Farley is with the UNC Eshelman School of Pharmacy, Chapel Hill, where Dr. Wei was formerly affiliated. Dr. Wei is now with North Carolina Community Care Networks, Raleigh, where Dr. McKee, Dr. Trygstad, and Dr. Pfeiffenberger are affiliated. Dr. Diamond is with the Department of Psychiatry, East Carolina University Brody School of Medicine, Greenville, North Carolina. Dr. Chrisman is with the Department of Psychiatry, Duke University School of Medicine, Durham, North Carolina. Dr. Lynn Wegner is with the UNC Department of Pediatrics, Chapel Hill. Dr. Palmes is with the Department of Psychiatry, Wake Forest University, Winston-Salem, North Carolina. Dr. Steven Wegner is with AccessCare North Carolina, Morrisville. Dr. Best is with the North Carolina Department of Medical Assistance, Raleigh.

Copyright © 2013 by the American Psychiatric Association

Abstract

Objective  The rise in use of antipsychotics among U.S. children is well documented. Compliance rates with current safety-monitoring guidelines are low. In response, the North Carolina Division of Medical Assistance established the Antipsychotics—Keeping It Documented for Safety (A+KIDS) registry. The initial objectives of the project were to successfully establish a Web-based safety registry and to obtain and evaluate clinical information derived from the registry.

Methods  In April 2011, A+KIDS began asking prescribers of antipsychotics for children age 12 and under to respond to a set of questions regarding dose, indication, and usage history. Antipsychotic registrations were examined by linking North Carolina Medicaid prescription claims to registry entries. Prescribers were classified into different types, and the number of patients and registrations per prescriber were examined.

Results  In the initial six months, 730 prescribers registered 5,532 patients, 19% below age seven. By month 6 of the registry, 72% of all fills were registered with the program. Top diagnosis groups for registry patients were unspecified mood disorders, autism spectrum disorders, and disruptive behavior disorders. Top target symptoms were aggression (48%), irritability (19%), and impulsivity (11%). Psychosis accounted for 5% of the target symptoms. Twenty-eight percent of children were receiving no form of psychotherapy. Twenty-five percent of all A+KIDS prescribers were responsible for 81% of the registrations.

Conclusions  The A+KIDS registry initiative has been successful, as measured by rapid uptake, and is providing clinical information not available from claims data alone. Future efforts will allow for detailed examinations of antipsychotic utilization and further safety improvement.

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Figure 1 Timeline of the number of antipsychotic fills surrounding A+KIDS medication registration datea

aA+KIDS, Antipsychotics—Keeping It Documented for Safety program; 74 (2%) and 21 (1%) A+KIDS registry entries were not accompanied by an antipsychotic fill before or after the medication was authorized online or via fax, respectively.

Figure 2 Antipsychotic prescription use among Medicaid pediatric patientsa

aPatients were ages 0–12. A prescription was considered registered if it was filled on or after the registration date of the medication. E-registered, online registration

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Table 1Patient, prescriber, and treatment characteristics for children taking antipsychotic medication, by age groupa
Table Footer Note

a The highest-ranking diagnosis registration was used for instances of multiple registrations for the same patient. [The ranking scheme is available online in appendix C of the data supplement to this article.]

Table Footer Note

b Data are from the North Carolina Medicaid eligibility file. A total of 1,056 of the children ages ≤6 and 4,470 of those ages 7–12 were matched successfully to the registry (>99.9%).

Table Footer Note

c N=994 for the ≤6 population because of 66 nonresponses; N=4,219 for the 7–12 population because of 253 nonresponses.

Table Footer Note

d N=873 for the ≤6 population because of 187 nonresponses; N=3,801 for the 7–12 population because of 671 nonresponses.

Table Footer Note

e N=582 for the ≤6 population and N=2,778 for the 7–12 population

Table Footer Note

f Included paliperidone, asenapine, iloperidone, lurasidone, and olanzapine-fluoxetine

Table Footer Note

g Included chlorpromazine, haloperidol, pimozide, perphenazine, fluphenazine, trifluoperazine, and thioridazine

Table Footer Note

h Included paliperidone and risperidone

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Table 2Characteristics of prescribers entering prescriptions in the first six months of the Antipsychotics—Keeping It Documented for Safety registry
Table Footer Note

a A patient was counted multiple times if he or she obtained registrations for the same medication from multiple prescribers (5,532 total patients versus 6,033 counts in the table).

Table Footer Note

b Repeat registrations were not excluded if a medication was previously registered for the same patient by other prescribers (6,072 unique registrations versus 6,473 counts in the table).

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Table 3Target symptom being treated by antipsychotic medication across clinical diagnosis groupsa
Table Footer Note

a Based on symptoms and diagnoses for each of the 5,532 patients in A+KIDS (Antipsychotics—Keeping It Documented for Safety). For the purposes of illustration, 18 diagnoses were condensed into the eight listed diagnostic groups, mainly covering the following diagnoses: mood, for unspecified mood disorder, bipolar disorder, and depressive disorder; autism spectrum disorder or developmental disability, for autistic disorder, pervasive developmental disorder not otherwise specified, Asperger’s disorder, and developmental disability; disruptive behavior, for oppositional behavioral disorder, conduct disorder, and disruptive behavior disorder not otherwise specified; trauma, for posttraumatic stress disorder (PTSD) and reactive attachment disorder; psychosis and schizophrenia, for psychotic disorders and schizophrenia; anxiety, for any anxiety disorder except PTSD. Tourette’s and attention-deficit hyperactivity disorder did not encompass additional disorders.

Table Footer Note

b Percentages reflect totals for target symptoms across diagnostic groups, with 5,532 as the denominator.

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