Improving Value of Publicly Funded Mental Health Care

 说明(申请人提供)：抗精神病药物是治疗精神分裂症的主要药物，对治疗双相I型障碍和难治性严重抑郁障碍具有重要价值。二十多年前推出的第二代抗精神病药物[SGAs]深刻地改变了美国的精神卫生保健。在1995至2008年间，年度抗精神病药物治疗人次翻了一番以上，在此期间，SGA所占抗精神病药物的份额从16%上升到93%。医疗补助和医疗保险承担了与SGA使用率增长相关的很大一部分经济负担，因为这些支付者为美国大多数精神疾病患者提供保险。令人惊讶的是，关于这种增长的贡献者的信息很少-有多少是由于抗精神病药物的过度使用(多药、非标签使用)，对支付者的经济影响是什么，或者增长如何在地理或时间上变化。对于具有双重资格的受益人来说，信息尤其稀少，他们是一个需求复杂、利用率很高的群体。公众支付者的经济负担可能不仅限于药品的购买成本。尽管与一些SGA相关的过度代谢风险的证据导致了FDA级别的警告，并呼吁改善处方做法，但被发现具有更高风险的抗精神病药物在严重精神疾病患者的治疗中仍然很受欢迎[SMI]。重要的是，我们知道的主要是过度代谢风险对健康的短期影响；我们对糖尿病和心血管疾病的了解很少，这些疾病需要更长的时间才能形成，也不知道与这种风险相关的公共支付者的经济负担。我们提出了一项研究计划，使用六个地理位置不同的州参加联邦医疗补助和/或联邦医疗保险计划的成年人的纵向(2007-2013)联邦医疗补助和医疗保险数据，以填补这些关键证据空白。在目标1中，我们评估了过度使用对国家和地区抗精神病药物使用和采购成本趋势的贡献。在目标2中，我们使用边际结构模型来量化SMI受益者累积纵向使用抗精神病药物对健康和经济的影响。在……里面 目的3我们使用微观模拟模型，结合来自全国调查、Delphi收集的专家意见以及医疗补助和医疗保险数据，量化旨在提高SMI受益者抗精神病药物治疗价值的策略的6年和终生健康和经济影响。我们采用的数据和方法允许通过经验地结合基于队列的观察、全国调查答复和使用当代统计和微观模拟建模方法的德尔福过程的结果来进行多方面的价值评估。

 DESCRIPTION (provided by applicant): Antipsychotic drugs are the mainstay of the treatment of schizophrenia and are valuable in the treatment of bipolar I disorder and treatment-resistant major depressive disorder. The introduction of second-generation antipsychotics [SGAs] over two decades ago profoundly changed mental health care in the U.S. Annual antipsychotic treatment visits more than doubled between 1995 and 2008, a period during which the share of antipsychotics that was SGA rose from 16% to 93%. Medicaid and Medicare bear a large portion of the economic burden associated with the growth in SGA utilization because these payers provide coverage to the majority of mentally ill people in the U.S. Surprisingly little information exists on contributors to this growth - how much is due to antipsychotic overuse (polypharmacy, off-label use), what are the economic implications to payers, or how growth varies geographically or temporally. Information is particularly thin for dually eligible beneficiaries, a population with complex needs and high utilization. The economic burden to public payers may not be limited to the drugs' purchasing costs. Although evidence on the excess metabolic risk associated with some SGAs led to a FDA class warning and calls for improved prescribing practices, antipsychotics identified to have higher risk remain popular in the treatment of people with serious mental illness [SMI]. Importantly, what we do know largely pertains to short-term health impacts of excess metabolic risk; we know little about diabetes and cardiovascular disease that take longer time to develop or about the economic burden to public payers associated with this risk. We propose a program of research that uses longitudinal (2007- 2013) Medicaid and Medicare data for adults enrolled in Medicaid, Medicare, or both programs in six geographically diverse states to fill in these critical evidence gaps. In Aim 1 we assess the contribution of overuse to state and regional trends in antipsychotic utilization and purchasing costs. In Aim 2 we use marginal structural models to quantify the health and economic impacts of cumulative longitudinal antipsychotic utilization in beneficiaries with SMI. In Aim 3 we use microsimulation modeling with inputs from a national survey, Delphi-gathered expert opinion, and Medicaid and Medicare data to quantify the 6-year and lifetime health and economic impacts of strategies aimed at enhancing value of antipsychotic treatment in beneficiaries with SMI. The data and the methodology we adopt permit a multi-faceted assessment of value by empirically combining cohort-based observations, national survey responses, and results from a Delphi process using contemporary statistical and microsimulation modeling approaches.