This section provides an overview of the safe and judicious use of antipsychotic medications in children and adolescents measure set, details about measure reporting, and general information on guidelines and recommendations.
The National Collaborative for Innovation in Quality Measurement (NCINQ), led by the National Committee for Quality Assurance (NCQA), developed a set of quality measures to assess the safe and judicious use of antipsychotic medications in children and adolescents. The measures were designed to encourage vigilant prescribing and developed using a multi-stakeholder consensus process, which included advisory panels, testing, and public comment. The measures were tested using data from 17 Medicaid managed care plans in a large, mid-Atlantic state, as well as data from 73 commercial plans nationwide. Consistent with previous research findings, testing results demonstrated gaps in care, particularly for the receipt of first-line psychosocial care and metabolic monitoring. The measures are presented in Table 1 and were adopted into the HEDIS Health Plan Measures Set in 2014 (for first-year reporting in 2015).17 The measure descriptions below are from HEDIS 2020. Updated specifications are published annually in HEDIS Volume 2: Technical Specifications for Health Plans which can be found at http://store.ncqa.org/index.php/ (fee required).
Table 1. HEDIS Safe and Judicious Use of Antipsychotic Medications in Children and Adolescents Measure Set
|Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics
|Percentage of children and adolescents with a new prescription for an antipsychotic medication and documentation of psychosocial care as first-line treatment.
|Denominator: Age 1-17 with a new prescription for an antipsychotic.
Numerator: Received psychosocial care 90 days prior to or within 30 days after starting an antipsychotic.
Exclusions: Diagnoses for which there is a Food and Drug Administration-indicated use of antipsychotics.
|Metabolic Monitoring for Children and Adolescents on Antipsychotics
|Percentage of children and adolescents with ongoing antipsychotic use who received annual metabolic testing.
|Denominator: Age 1-17 with at least two prescriptions for antipsychotics within a year.
Numerator: Received the following during the measurement year:
|Use of Multiple Concurrent Antipsychotics in Children and Adolescents
|Percentage of children and adolescents on two or more concurrent antipsychotic medications (lower rate indicates better performance).
|Denominator: Age 1-17 with at least 90 days of antipsychotic use.
Numerator: On two or more concurrent antipsychotic medications for at least 90 consecutive days during the year.
All three quality measures were incorporated into the Medicaid Child Core Set for voluntary state reporting during the time frames indicated below.
- The Use of Multiple Concurrent Antipsychotics in Children and Adolescents measure was included in the 2016 through 2019 Medicaid Child Core Set. This measure was subsequently removed from the 2020 Medicaid Child Core Set (refer to the section below for information on the retirement of this measure).
- The Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics measure was first added to the 2018 Medicaid Child Core Set and currently remains in the core set.
- The Metabolic Monitoring for Children and Adolescents on Antipsychotics measure was added to the 2020 Medicaid Child Core Set.
Since 2015, the Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics and the Metabolic Monitoring for Children and Adolescents on Antipsychotics measures have been reported annually to NCQA for HEDIS reporting. As previously noted, these measures are also currently reported for the Medicaid Child Core Set. The measures are calculated using administrative claims and pharmacy data. For reference, the most recent HEDIS measure specifications are available in the NCQA Store.
Retirement of the Use of Multiple Concurrent Antipsychotics in Children and Adolescents Measure for Health Plans
The Use of Multiple Concurrent Antipsychotics in Children and Adolescents measure, which targeted medication overuse by tracking youth on two or more antipsychotics concurrently for an extended period of time, was retired from HEDIS and the Medicaid Child Core Set in 2020. Since the inclusion of this measure in HEDIS in 2015, health plan performance rates improved. With this improvement, rates of youth on multiple concurrent antipsychotics became consistently low with minimal plan-to-plan variation. Consequently, the utility of this measure in making plan comparisons diminished over time. These changes reflected progress but also pointed to the need to retire the measure (NCQA Blog). While this measure is no longer used in reporting programs, it remains important for plans to continue to track antipsychotic prescribing and to maintain efforts to discourage use of these powerful medications unless necessary. Given this continued importance, this toolkit presents change ideas for this measure, shares tested strategies and outlines lessons learned.
Guidelines for the Safe and Judicious Use of Antipsychotic Medications in Children and Adolescents
Summary-level guidelines and recommendations on the safe and judicious use of antipsychotic medications in children and adolescents are provided below. For detailed information on specific guidelines or recommendations, refer to the section on Guidelines and Recommendations for the Safe and Judicious Use of Antipsychotic Medications in Children and Adolescents.
Recommendations Supporting Use of Psychosocial Interventions
Seven guidelines address psychosocial services in the context of antipsychotic prescribing for children.16 These guidelines recommend the use of psychotherapy as first-line treatment for children and adolescents diagnosed with a variety of conditions, including bipolar disorder, maladaptive aggression, and oppositional defiant disorder. The recommended type and duration of the psychotherapy intervention for first-line treatment varies by condition. The American Academy of Child & Adolescent Psychiatry (AACAP) also recommends psychotherapy as first-line treatment when using atypical antipsychotics.18
Recommendations for Metabolic Screening and Monitoring
Eight guidelines refer to glucose and lipid screening for children prescribed antipsychotics. These guidelines address metabolic screening for children and adolescents who are prescribed antipsychotics, with consensus that baseline and ongoing metabolic monitoring is a standard of care for this population. The specificity of recommendations for ongoing metabolic monitoring varies, with some guidelines recommending “appropriate” monitoring and others offering varying levels of detail about specific tests and follow-up intervals.16 The AACAP practice parameters endorse American Psychiatric Association (APA)/American Diabetes Association (ADA) recommendations for laboratory monitoring, including a fasting glucose and fasting lipid profile at baseline, three months, and 12 months. The Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMESA) calls for more frequent monitoring in youth—at baseline, three months, six months, 12 months, and additional monitoring of fasting insulin.
Recommendations for Avoiding Multiple and Concurrent Antipsychotic Use
Four guidelines address the concurrent use of two or more antipsychotics in children as a practice to be avoided.16 These guidelines express concern regarding the prescription of multiple and concurrent antipsychotics, with agreement that it should be generally avoided for initial or endpoint treatment for children and adolescents unless there is a clear rationale, after which a clinical review is recommended before prescribing, especially for children in foster care.