Epidemiology, Exploration and Evaluation: Addressing potentially dangerous medications in Medicaid children with a mental health diagnosis

 描述(由申请人提供)：精神健康诊断在儿科实践中很常见。大量证据表明，许多用于治疗患有精神健康问题的儿童的药物是在不推荐使用的情况下或组合中开出的。这种使用可能会导致患者的伤害，如糖尿病或自杀念头的发作，以及可能避免的急诊科就诊和住院治疗。该项目建议(1)详细描述门诊护理环境中患者安全的流行病学，重点关注参加纽约州医疗补助计划的患有精神健康诊断的儿童的用药安全；(2)评估三项战略的程度：a)在国家质量保证委员会(NCQA)认可的以患者为中心的医疗之家(PCMH)接受初级保健；b)新的州政策(“分割”)将管理处方药保险福利的责任分配给管理型护理计划，而不是州医疗补助计划；C)更以患者为中心的一套全面的药物调节(Medrec)做法可以减少这些人群中潜在的危险药物使用或不良后果/患者伤害；以及(3)评估州卫生质量部门实施调查以评估整个Medicaid中的药物调节做法是否是提高此类做法绩效的有效方式。流行病学研究将对2014至2017年的每一年进行横断面、单变量、双变量和多变量分析，包括Logistic回归和回归风险分析。它将着眼于临床、患者、背景和实践特征，这些特征与潜在危险药物实践的使用和不良后果的使用越来越少和越来越多相关。它将描述已确定的差异，考虑到性别、种族/族裔、城乡居住地、寄养状况和家乡县的贫困程度等特征。倾向评分分析将有助于评估特定用药做法与不良结果和患者伤害的关联。对PCMH和MEDREC战略的评估将利用从流行病学分析期间开发的模型修改而来的倾向评分分析。该州于2011年底实施的分阶段政策将使用2008年至2016年中断的时间序列的分段回归分析进行评估。=药物对账做法将使用由AHRQ-CMS CHIPRA联邦儿科质量衡量计划中的卓越中心开发的调查工具进行评估。测量对医疗记录实践的影响将使用分级楔形设计的整群随机试验来评估，调查所有年份的三分之一的实践，第二年和第三年的第三年和第三年的三分之一，仅第三年的三分之一。该项目承诺提供更详细的洞察，既可以了解弱势人群在门诊环境中的重要患者安全风险，也可以了解几种策略在现实世界中如何很好地降低风险。

 DESCRIPTION (provided by applicant): Mental health diagnoses are common in pediatric practice. Abundant evidence demonstrates that many medications used to treat children with mental health conditions are prescribed in circumstances or combinations for which they are not recommended. Such use may lead to patient harms such as onset of diabetes or suicidal ideation, and potentially avoidable emergency department visits and hospitalizations. This project proposes (1) to describe in detail the epidemiology of patient safety in ambulatory care settings, focusing on medication safety in children with mental health diagnoses who are enrolled in New York State Medicaid ; (2) to assess the extent to which three strategies: a) receipt of primary care in a National Committee for Quality Assurance (NCQA)-recognized patient-centered medical home (PCMH); b) a new state policy ("carve-in") that assigns responsibility to manage the prescription pharmaceutical insurance benefit to managed care plans rather than the state Medicaid program; and c) a more patient-centered, comprehensive set of medication reconciliation (med rec) practices can reduce potentially dangerous medication use or undesirable consequences / patient harms in this populations; and (3) to assess whether or not a state Department of Health quality department's implementation of a survey to assess medication reconciliation in practices throughout Medicaid is an effective way to enhance the performance of such practices. The epidemiological study will use cross sectional, univariate, bivariate, and multivariable analyses for each year from 2014 to 2017, including logistic regression and regression risk analysis. It will look at clinical, patient, contextual, and practice characteristics that are associated with lower and higher uses of potentially dangerous medication practices and undesirable outcomes. It will describe identified disparities, considering characteristics such as gender, race/ethnicity, rural/urban residence, foster care status, and level of poverty in the home county. A propensity score analysis will help to assess the association of the specified medication practices with undesirable outcomes and patient harm. Assessment of the PCMH and med rec strategies will utilize propensity score analyses that are modified from the models developed during the epidemiological analysis. The state carve-in policy, implemented in late 2011, will be assessed using a segmented regression analysis of an interrupted time series from 2008 to 2016.=Medication reconciliation practice will be assessed using a survey instrument developed by an AHRQ- CMS CHIPRA Center of Excellence in the federal Pediatric Quality Measures Program. The impact of measurement on med rec practices will be assessed using a cluster randomized trial with a stepped wedge design, surveying one third of practices in all years, on third in years two and three and one thir in year three only. This project promises to provide more detailed insight both into an important patient safety risk in ambulatory settings for a vulnerable population and also into how well several strategies reduce risk in real world settings.