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Effect of a mental health "carve-out" program on the continuity of antipsychotic therapy.
N Engl J Med. 2003 May 08; 348(19):1885-94.NEJM

Abstract

BACKGROUND

On July 1, 1996, as a cost-containment strategy, Tennessee's expanded Medicaid program, TennCare, rapidly shifted the provision of mental health services to a fully capitated, specialty "carve-out" program, TennCare Partners. We studied the effect of this transition on the continuity of antipsychotic therapy among patients with severe mental illness who had previously adhered to treatment.

METHODS

Study patients were 21 to 64 years of age, were enrolled throughout the study period, and had adhered to antipsychotic therapy during a 6-month base-line period that preceded the 12 months of study follow-up. The study population included 4507 patients whose follow-up began on the day the change was implemented (the post-transition cohort) and 3644 patients whose follow-up began one year earlier (the pretransition cohort). We compared the two cohorts in terms of the loss of continuity of antipsychotic therapy (missed treatment for more than 60 days during follow-up) and the mean number of days of antipsychotic therapy during follow-up.

RESULTS

As compared with the pretransition cohort, the post-transition cohort had increased odds of loss of continuity (a multivariate odds ratio of 1.18 [95 percent confidence interval, 1.07 to 1.30], P=0.001) and a shorter mean duration of antipsychotic therapy (a mean reduction of 4.2 days [95 percent confidence interval, 1.7 to 6.7], P=0.001) during follow-up. This difference was most pronounced among high-risk patients (those requiring the administration of extended-release [depot] injections of antipsychotic medications or who had been hospitalized for psychosis) at base line, for whom continuity was most important (odds ratio for loss of continuity, 1.79 [95 percent confidence interval, 1.45 to 2.22]; P<0.001; mean reduction in the number of days of antipsychotic therapy, 14.4 days [95 percent confidence interval, 9.4 to 19.4]; P<0.001). These patients had decreased use of antipsychotic drugs immediately after the transition; the lower level persisted throughout the 12 months of follow-up.

CONCLUSIONS

These findings underscore the need to ensure that shifts to widely used carve-out programs, which are designed primarily to contain costs, do not adversely affect clinical outcomes.

Authors+Show Affiliations

Division of Pharmacoepidemiology, Department of Preventive Medicine, Nashville Veterans Affairs Medical Center, Nashville, USA. cindy.naron@mcmail.vanderbilt.eduNo affiliation info availableNo affiliation info available

Pub Type(s)

Evaluation Study
Journal Article
Research Support, U.S. Gov't, P.H.S.

Language

eng

PubMed ID

12736282

Citation

Ray, Wayne A., et al. "Effect of a Mental Health "carve-out" Program On the Continuity of Antipsychotic Therapy." The New England Journal of Medicine, vol. 348, no. 19, 2003, pp. 1885-94.
Ray WA, Daugherty JR, Meador KG. Effect of a mental health "carve-out" program on the continuity of antipsychotic therapy. N Engl J Med. 2003;348(19):1885-94.
Ray, W. A., Daugherty, J. R., & Meador, K. G. (2003). Effect of a mental health "carve-out" program on the continuity of antipsychotic therapy. The New England Journal of Medicine, 348(19), 1885-94.
Ray WA, Daugherty JR, Meador KG. Effect of a Mental Health "carve-out" Program On the Continuity of Antipsychotic Therapy. N Engl J Med. 2003 May 8;348(19):1885-94. PubMed PMID: 12736282.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Effect of a mental health "carve-out" program on the continuity of antipsychotic therapy. AU - Ray,Wayne A, AU - Daugherty,James R, AU - Meador,Keith G, PY - 2003/5/9/pubmed PY - 2003/5/15/medline PY - 2003/5/9/entrez SP - 1885 EP - 94 JF - The New England journal of medicine JO - N Engl J Med VL - 348 IS - 19 N2 - BACKGROUND: On July 1, 1996, as a cost-containment strategy, Tennessee's expanded Medicaid program, TennCare, rapidly shifted the provision of mental health services to a fully capitated, specialty "carve-out" program, TennCare Partners. We studied the effect of this transition on the continuity of antipsychotic therapy among patients with severe mental illness who had previously adhered to treatment. METHODS: Study patients were 21 to 64 years of age, were enrolled throughout the study period, and had adhered to antipsychotic therapy during a 6-month base-line period that preceded the 12 months of study follow-up. The study population included 4507 patients whose follow-up began on the day the change was implemented (the post-transition cohort) and 3644 patients whose follow-up began one year earlier (the pretransition cohort). We compared the two cohorts in terms of the loss of continuity of antipsychotic therapy (missed treatment for more than 60 days during follow-up) and the mean number of days of antipsychotic therapy during follow-up. RESULTS: As compared with the pretransition cohort, the post-transition cohort had increased odds of loss of continuity (a multivariate odds ratio of 1.18 [95 percent confidence interval, 1.07 to 1.30], P=0.001) and a shorter mean duration of antipsychotic therapy (a mean reduction of 4.2 days [95 percent confidence interval, 1.7 to 6.7], P=0.001) during follow-up. This difference was most pronounced among high-risk patients (those requiring the administration of extended-release [depot] injections of antipsychotic medications or who had been hospitalized for psychosis) at base line, for whom continuity was most important (odds ratio for loss of continuity, 1.79 [95 percent confidence interval, 1.45 to 2.22]; P<0.001; mean reduction in the number of days of antipsychotic therapy, 14.4 days [95 percent confidence interval, 9.4 to 19.4]; P<0.001). These patients had decreased use of antipsychotic drugs immediately after the transition; the lower level persisted throughout the 12 months of follow-up. CONCLUSIONS: These findings underscore the need to ensure that shifts to widely used carve-out programs, which are designed primarily to contain costs, do not adversely affect clinical outcomes. SN - 1533-4406 UR - https://www.unboundmedicine.com/medline/citation/12736282/Effect_of_a_mental_health_"carve_out"_program_on_the_continuity_of_antipsychotic_therapy_ DB - PRIME DP - Unbound Medicine ER -