Childhood Attention-Deficit/Hyperactivity Disorder Prescribing by Prescriber Type and Specialty in Oregon Medicaid

Abstract

Objective:

This study compares nurse practitioner (NP) and physician (MD/DO) prescribing patterns for treatment of children with an attention-deficit/hyperactivity disorder (ADHD)-related diagnosis covered by Oregon Medicaid from 2012 to 2013.

Methods:

This study is a limited data set review of Oregon pharmacy claims for youth aged 3–18 at time of prescription fill, who were continuously enrolled for at least 10 months of the index year. Claims with selected ICD-9 codes (n = 197,364) were further defined by 30-day prescriptions and prescription drug events (PDE) linked to each prescriber type of interest. Descriptive statistical analysis of variables included prescriber type (NP vs. physician) and specialty (generalist vs. specialist), child age, and controlled versus noncontrolled drug type.

Results:

A total of 82,754 complete 30-day prescriptions for 10,753 children from 1785 unique prescribers (78 NP specialists; 303 NP generalists; 162 physician specialists; and 1242 physician generalist prescribers) and 16,669 PDE were analyzed. Physicians prescribed more than 81% of all ADHD medications, and physician generalists prescribed nearly 60% of all prescriptions. Sixty-four percent of 30-day supply prescriptions (n = 52,678) were controlled substances. Generalists, both NPs and physician prescribers, prescribed controlled medications more often than specialists. Physician specialists consistently prescribed controlled substances for all age groups, while NP specialists prescribed more controlled substances as child age increased. Rates of controlled medications prescribed generally increased, as children got older, regardless of provider type.

Conclusion:

NPs overall prescribe in a similar pattern to physicians when given the authority to prescribe controlled substances for ADHD. Comparisons between prescriber types for controlled substance prescribing by age should be explored further to identify possible variance from national guidelines.

Introduction

Avariety of physician and nurse practitioner (NP) prescribers, including psychiatric, pediatric, and family practice providers, prescribe and manage psychotropic medications for children with attention-deficit/hyperactivity disorder (ADHD). Outpatient office visits with a diagnosis code for ADHD number 1,439,000 according to the 2011 National Hospital Ambulatory Medical Care Survey (Centers for Disease Control/National Center for Health Statistics 2011). ADHD is one of the top five diagnoses among psychiatric specialists in the ambulatory care setting. Children and adolescents under the age of 15 represent 11% of psychiatry visits, and 17% of patients seen by psychiatric specialists use Medicaid or the Children's Health Insurance Program (CHIP) as source of payment (Centers for Disease Control/National Center for Health Statistics 2010).

Recent comparative prescribing pattern studies evaluate psychotropic medication (Rettew et al. 2015), controlled substance prescribing (Paulozzi et al. 2014), and controlled substance prescribing by prescriber type (Levy et al. 2015). Most focus on opioid rather than stimulant prescribing. A comprehensive study of opioid prescribing trends from 2007 to 2012 examined comparisons between prescriber types, but aggregated NPs and physician assistants (PAs) together despite their differences in scope of practice (Levy et al. 2015). One large all-state commercial database comparison identified higher opioid and benzodiazepine prescribing in states with nonindependent prescribing for advanced practice nurses, with no significant differences in prescribing of long-acting or high-dose opioids (Schirle and McCabe 2016). State-based studies from Oregon compare prescribing data by prescriber type from prescription monitoring programs for opioids rather than stimulant prescribing (Kim et al. 2016) or explore database access patterns by prescribers (Irvine et al. 2014) rather than prescribing activities.

NPs in Oregon have broad scope prescribing authority, including prescribing of Schedule III-V drugs since the late 1970s. Since 2000, NPs in Oregon have had the authority to also write prescriptions for Schedule II drugs, which expanded their ability to prescribe ADHD medications in congruence with national guidelines. In 2008, the requirement that NPs prescribe according to a Board of Nursing-approved formulary was eliminated. Use of FDA-approved drugs remains the only requirement for prescribing. Off-label prescribing of medications is not limited under the Oregon Nurse Practice Act (Oregon State Board of Nursing 2011). NPs in Oregon therefore have the same authority to prescribe controlled substances as physicians, seeing a substantial number of Medicaid patients.

Little is known about NP prescribing of controlled and other medications for ADHD, particularly when compared to physician prescribers.

We examined and compared the prescribing patterns of medications prescribed for Oregon Medicaid patients aged 3–18 treated for ADHD in 2012, by physician and NP prescribers. An additional comparative analysis determined if prescribing differences exist among provider types when classified as generalists (family, pediatrics) or specialists (psychiatry), as well as by patient age, and whether a drug was controlled or noncontrolled.

Methods

This study was a limited dataset review. The institutional review boards at Washington State University, Pacific Lutheran University, and the Washington State IRB determined it was exempt from IRB review. Approval was also obtained through the Oregon Health Authority (OHA) who provided deidentified Medicaid encounter claims data and pharmacy claims data.

Sample

All eligible records with prescribing dates of service from January 1, 2012 to December 31, 2012 were requested. The sample was restricted to continuously covered children aged 3–18 with an encounter claim containing a provider diagnosis of ADHD within 730 days before the prescription date. To obtain all records with prescribing dates of service in 2012, pharmacy claims records from 2012 and 2013 were provided. This captured fill dates from 2013, which were prescribed in 2012. Continuous Medicaid eligibility was defined as at least 10 of 12 months in a given year. Diagnosis of ADHD was broadly defined using the following ICD-9 diagnostic codes: 314.0, 314.00, 314.01, 314.1, 314.2, 314.8, 314.9, V62.3, 313.83.

Each record in the pharmacy claims file (n = 197,364) included a unique child identifier (deidentified) with the age of the child at the time the prescription was filled, sex of the child, date the prescription was written, date filled, the 11-digit national drug code (NDC) for the medication prescribed, supply prescribed, and the prescribing provider's National Provider taxonomy. Encounter claims data from 2010 through 2012 with a provider diagnosis of ADHD included the same unique child identifier, the encounter provider taxonomy, the date of the encounter, and the service diagnoses.

Unit of analysis

A 30-day supply represents the minimum amount for which a typical prescriber would initiate or refill a prescription and is defined as 28–31 days for inclusion in the final analysis file. This unit of analysis was consistent with the supply amount written in majority of prescriptions in the data files.

Provider type

Provider type (NP, physician) and specialty (family, pediatrics, and psychiatry) for the prescribing practitioner were identified by the National Provider taxonomy codes. Providers were classified as specialists or generalists using the following taxonomy codes: Physicians Generalist (207Q00000X, 207QA0000X, 208D00000X, 207RA0000X, 208000000X, 2080A0000X, 2083P0901X); Physician Specialist (2080P0006X, 2080P0008X, 2084P0804X, 2084P0005X, 2084P0800X, 2084N0402X, 2084F02002X, 2084N0400X, 2084P0802X); NP Generalists (363L00000X, 363LP0200X, 363LF0000X, 363LP2300X); NP Specialists (163WP0808X, 163WP0809X, 163WP0807X, 64S00000X, 364SP0807X, 364SP0810X, 363LP0808X). As Clinical Nurse Specialists (CNS) with psychiatric specialty are eligible for licensure as an NP in Oregon, CNS prescribers were included in the total NP numbers, however the number of CNS was small (n = 2).

Medications prescribed

Drugs were differentiated into controlled and noncontrolled substances by active ingredient. Controlled substances included methylphenidate, amphetamine-dextroamphetamine mixed salts, lisdexamfetamine, dexmethylphenidate, and dextroamphetamine. Noncontrolled substances included guanfacine, clonidine, and atomoxetine. Classification of a prescription NDC as an ADHD medication was based on the Healthcare Effectiveness Data and Information Set (HEDIS) 2013 measure for follow-up care for children prescribed ADHD medication. NDCs with an ADHD indication were aggregated based on active ingredient resulting in the eight medication categories. Using the active ingredient eliminated possible variance due to dosage form, strength, release mechanism, and package size.

Statistical analysis

Descriptive statistics, including mean, standard deviation (SD), frequency, and percentage, were used to characterize children included in the study. Provider prescribing rates were analyzed at the 30-day supply prescription level (n = 82,754). We summarized prescribing rates using 30-day supply prescriptions by the age of the child at the time the prescription was written: 3–5; 6–11; and 12–18 years. A secondary analysis at the child level using prescription drug event (PDE) was done to evaluate the effect of aggregating prescriptions by multiple providers to a unique child. Additional variables included child sex and medication type prescribed (controlled vs. noncontrolled) for the eight ADHD medications of interest.

Results

Sample

We excluded records for the following reasons: lack of ADHD diagnosis (n = 3892), prescriptions for non-ADHD medications (n = 93,309), or prescriptions not written by a physician or NP (n = 15,905). The resulting data file included 84,258 prescription record claims for the eight active ingredients of interest written in Oregon in 2012 by NPs and physicians to children meeting study criteria.

The drugs included in this analysis were limited to the following: methylphenidate, amphetamine-dextroamphetamine mixed salts, lisdexamfetamine, dexmethylphenidate, dextroamphetamine, guanfacine, clonidine, and atomoxetine. There were 10,753 unique children who were treated by either a NP prescriber or a physician in 2012. The average age of the children at the time of the first prescription written was 10.8 (SD = 3.4) years. The majority of children treated were males (n = 7877; 73%).

Prescribing by provider type

A total of 1785 prescribers wrote 82,754 30-day supply prescriptions. Of the 381 NPs prescribers, the majority were generalists (n = 303, 79.5%). Similarly, 86% (n = 1242) of the physician prescribers were generalists and 14% (n = 162) were specialists.

Breakdowns of prescribing patterns by age group and sex were similar among the four provider groups (Table 1). Slightly over half of the 30-day supply prescriptions written by each of the four provider groups were to children aged 6–11 (ranging from 54.0% for physician specialists to 59.1% for physician generalists). Less than 5% of the 30-day supply prescriptions written by each of the four provider groups were written to children aged 3–5 years of age. Almost three fourths of 30-day supply prescriptions written by each of the four provider groups were to males (ranging from 70.9% for NP generalists to 76.8% for physician specialists). Child-level analysis comparing prescribing rates based on PDEs showed very similar trends to the 30-day supply prescriptions analysis (Supplementary Table S1; Supplementary Data are available online at www.liebertpub.com/cap).

Table 1.

Demographic Characteristics of Children (Aged 3–18) with an Attention-Deficit/Hyperactivity Disorder Diagnosis by Prescribing Provider Type and Specialty (n = 82,754 30-Day Supply Prescriptions)

	Generalists prescribers				Specialists prescribers
	Physicians (1242 providers)		NPs (303 providers)		Physicians (162 providers)		NPs (78 providers)
30-day supply prescriptions	49,213		6175		18,133		9233
Mean (SD) age	10.55 (3.29)		11.10 (3.36)		11.11 (3.36)		11.01 (3.46)
30-day supply prescriptions	n	%	n	%	n	%	n	%
Age 3–5	2092	4.3	180	2.9	601	3.3	374	4.1
Age 6–11	29,077	59.1	3440	55.7	9797	54.0	5044	54.6
Age 12–18	18,044	36.6	2555	41.4	7735	42.7	3815	41.3
30-day supply prescriptions	n	%	n	%	n	%	n	%
Male	36,682	74.5	4380	70.9	13,927	76.8	6883	74.6
Female	12,531	25.5	1795	29.1	4205	23.2	2350	25.4

NP, nurse practitioner; SD, standard deviation.

A subanalysis was done of 3-year olds within the data set. There were few prescriptions for 3-year olds (n = 89) written for 8 females and 21 males. All of these prescriptions were written by physicians, with the majority being written by pediatricians, who are classified as physician generalists (n = 75.8%).

Controlled medication prescribing

The difference in prescribing patterns for controlled medications between specialists and generalists was consistent across age groups (Fig. 1). The highest percentage of controlled drugs was prescribed for children aged 12–18 by all prescriber types and specialties. Generalists wrote the highest percentage of 30-day supply prescriptions for controlled medications overall.

FIG. 1.

Controlled medications as a percent of all 30-day supply prescriptions by prescribing provider type and specialty (n = 82,754 30-day supply scripts).

Of the total number of 30-day supply prescriptions written by each provider group, NP generalists and physician generalists wrote the highest percentage of 30-day supply prescriptions for controlled medications compared to NP and physician specialists. Shown in Table 2, of the prescriptions written by nurse generalists and physician generalists, 61.5% and 71.17% (respectively) were for controlled medications compared to 51.5% by NP specialists and 48.8% by physician specialists.

Table 2.

Controlled Versus Noncontrolled Medications of Children (Ages 3–18) with an Attention-Deficit/Hyperactivity Disorder Diagnosis by Prescribing Provider Type and Specialty (n = 82,754 30-Day Supply Prescriptions)

	Generalists prescribers				Specialists prescribers
	Physicians (1242 providers)		NPs (303 providers)		Physicians (162 providers)		NPs (78 providers)
30-day supply prescriptions	49,213		6175		18,132		9233
30-day supply prescriptions	n	%	n	%	n	%	n	%
Controlled Medications	35,273	71.7	3799	61.5	8848	48.8	4758	51.5
Noncontrolled medications	13,940	28.3	2376	38.5	9284	51.2	4475	48.5
30-day supply prescriptions	n	%	n	%	n	%	n	%
Controlled medications
Methylphenidate	21,139	43.0	2274	36.8	5297	29.2	2639	28.6
Lisdexamfetamine	1978	4.0	159	2.6	786	4.3	515	5.6
Dextroamphetamine	11,018	22.4	1270	20.6	2496	13.8	1515	16.4
Dexmethylphenidate	1138	2.3	96	1.5	269	1.5	89	0.9
Noncontrolled medications
Guanfacine	5812	11.8	995	16.1	4785	26.4	2324	25.2
Clonidine	4419	9.0	605	9.8	2301	12.7	1237	13.4
Atomoxetine	3709	7.5	775	12.6	2198	12.1	914	9.9

NP, nurse practitioner.

The largest comparative difference in the percentage of 30-day prescriptions written by drug type was for methylphenidate (a controlled medication) where 36.8% of prescriptions were written by NP specialists and 43.0% of prescriptions by physician specialists, compared to 28.6% and 29.2% for NP and physician generalists (respectively). Dextroamphetamine also varied by prescriber specialty with 20.6% of prescriptions written by NP specialists and 22.4% of prescriptions written by physician specialists, compared to 16.4% and 13.8% for NP and physician generalists.

Noncontrolled medication prescribing

Of the total number of 30-day supply prescriptions written by each provider group, NP specialists and physician specialists wrote the highest percentage of 30-day supply prescriptions for noncontrolled medications compared to NP and physician generalists. NP specialists (48.5%) and physician specialists (51.2%) wrote noncontrolled medications at a higher percentage, versus 38.5% by nurse generalists and 28.3% physician generalists. NP and physician specialists more frequently prescribed noncontrolled guanfacine (25.2% and 26.4%) than NP and physician generalists (16.1% and 11.8%). Clonidine was prescribed with similar frequency by generalists (9.8%, 9.0%) and specialists (13.4%, 12.7%) regardless of licensure type. Atomoxetine was also prescribed with similar frequency by both NP generalists and specialists (12.6% vs. 9.9%) and physician generalists (7.5%) than specialists (12.1%). These similarities in prescribing patterns for controlled and noncontrolled medications between generalists and specialists were also confirmed using the child-level analysis approach comparing prescribing rates based on PDEs (Supplementary Table S2).

Discussion

This study illustrates overall congruence in prescribing between prescriber types, but some differences among specialists regarding controlled substance prescribing for ADHD when compared by age of child. Generalist physicians, generalist NPs, and specialist NPs prescribed controlled drugs in increasing rates by child age group. Physician specialists prescribed controlled substances equally across age groups.

Studies that focus on physician prescribing identify that the majority of medications prescribed for children with ADHD are not prescribed by specialists (Zito et al. 1999). Our study also finds that generalists prescribe more ADHD medications for children than specialists overall. Very young children (ages 3–5) were the exception.

Nonmedical use of stimulants in adolescents has been estimated at less than 5% compared to more prevalent misuse of pain relievers at 15%–18% (Young et al. 2012). Our results do not show a decrease in controlled substance prescribing patterns as children reach adolescence. If prescribers were concerned about controlled substance misuse in adolescence, our expectation would be to observe a decreasing trend in prescribing controlled substances by age. These findings may also represent increasing diagnosis by child age or other differences in entry into the healthcare system, which were not controlled for by this study design.

Prescriber differences based on drug were largely due to prescribing practices of three drugs: methylphenidate, dextroamphetamine, and guanfacine. This may represent more familiarity by generalists with methylphenidate and dextroamphetamine medications, as well as the strength of evidence supporting them in national guidelines aimed at generalist prescribers rather than specialist prescribers (Subcommittee on ADHD, 2011). Specialists in this study less frequently prescribed controlled substances, whether NP or physician. Specialist prescribers much more frequently prescribed guanfacine, a noncontrolled substance (NPs at 25.2% and physicians at 26.4% of 30-day prescriptions), than generalist prescribers. This likely represents the use of this as a second-line medication for more refractory cases referred to or managed by a specialist.

Relationship of findings to current practice

Methylphenidate-containing drugs are the most common prescribed controlled substance in this study across all age ranges, while some national studies have found it more common for adolescents (Chai et al. 2012). While methylphenidate containing drugs are less costly for treatment of ADHD than other available drugs, Oregon's formulary process does not mandate them as first-line therapy.

Prescribing patterns for medications are influenced by many factors, including state law and license and certification requirements. Medications dispensed for mental health diagnoses are currently exempt from state formulary restriction under Oregon state law, although providers are still educated and encouraged to follow evidence-based guidelines. Prior authorization criteria in Oregon do restrict prescribing of CNS stimulants exceeding maximum doses to a psychiatrist (DURM 2014).

Provider prescribing patterns for children with Medicaid mirror larger studies that include children with private and public insurance in aggregate (Chai et al. 2012). Children in Oregon on Medicaid accessed physician generalists more frequently than specialists for prescribing treatment of ADHD. Pediatricians in this study were identified as generalists and performed the vast majority of prescribing for children less than 4 years of age. In 2014, the OHA evaluated dose-specific parameters by age, dose, and indication for ADHD claims submitted under fee-for-service retrospectively for claims submitted between August and November of 2012 (DURM 2014). Standard pharmacotherapy was defined in this report as meeting all recommendations from the American Academy of Pediatrics and state recommendations for age, dose, indication, and presence of other medication therapies. They found that, while nonstandard pharmacotherapy was common (44%), it generally represented nonstandard indication or age rather than polypharmacy. Nonstandard dosing was primarily found in the noncontrolled substance category. While dosing was not evaluated in this study, noncontrolled substances were more frequently prescribed by specialists than generalists of both types, especially guanfacine.

Access to mental healthcare is constrained by factors including limitations in supply and scope of prescribers. Of mental health providers nationally, the majority are nonprescribers, such as clinical social workers and psychologists (Heisler and Bagalman 2015). A recent large national study of physician prescribers supports the finding that generalists prescribe most ADHD medications for children in the US (Anderson et al. 2015), however, the study of Oregon prescribing practices also specifically includes NP prescribers in its analysis. NP generalists did prescribe a higher percentage of controlled substances for adolescents than physician specialists, but their prescribing trends were consistent with those of physician generalists. Specialists may be more comfortable overall with use of off-label, partial-label, and nontraditional stimulants than generalists. Further study specific to prescribing of noncontrolled drugs for treatment of ADHD focused on age- and dose-specific data may reveal more regarding prescriber preferences. Noncontrolled substances may also represent treatment failure and subsequent referral to a specialist for treatment.

Policy and clinical implications

It is likely that prescribing for ADHD by nonspecialists will continue in Oregon since the prevalent group of prescribers are generalists. These generalists are family practitioners, physicians, or NPs, who may lack formalized training in prescribing psychotropic medications (Fraser and Oyama 2013). With continued growth in the incidence of diagnosing ADHD, constraints on existing prescribers will increase due to low supply. All, but four of Oregon's 36 counties are designated mental healthcare professional shortage areas (OHA 2014), and mental health prescribers represent a small supply of the whole workforce (Heisler and Bagalman 2015). It is not realistic to limit prescribing to mental health specialists because of known provider gaps in supply and distribution. While behavioral interventions and nonpharmacologic options should be funded, supported, and utilized for Medicaid covered children, it is also important to support safe prescribing when prescribing becomes necessary or indicated.

Scope of practice

Despite a high incidence of prescribing for children with ADHD by nonspecialists in primary care, few are formally prepared to do so. National professional organizations are beginning to recognize the need for generalists to support their scope by continuing education or credentialing and certification, rather than restricting care to specific specialties. In acknowledging the role of NPs and clinical nurse specialists in providing mental healthcare to children, the Pediatric Nursing Certification Board (PNCB) developed a certification exam for the Pediatric Primary Care Mental Health Specialist (PMHS) in 2011. This exam is open to primary care pediatric and family NPsm as well as child/adolescent clinical nurse specialists and family psychiatric NPs who need additional credentials to demonstrate competency in diagnosis, management, or comanagement of children with ADHD and other mental health disorders. As of 2014, there are 307 advanced practice registered nurses with this credential.

It is not known whether NP generalists in this study completed additional educational preparation to prescribe for ADHD. The prescribing patterns of NP generalists and physician generalists versus specialists were similar when comparing at the prescription or child level of analysis. NP generalists provided care to a similar age group of patients as physicians, with the exception of very young children (age three in this study). Further examination of comfort in prescribing for children and use of referral sources to support scope of practice, as well as continuing education needs for generalists would be beneficial for patient care regardless of licensure type.

Scope of practice varies from state to state for NP s. Prior national studies of practice patterns identify that primary care NPs are more likely to treat Medicaid patients and practice in community-based settings than primary care physicians (Buerhaus et al. 2015). Although scope is expanding, NPs in many states are restricted in their practice related to prescribing controlled substances (AANP 2015). Such restrictions often target the ability to prescribe for ADHD specifically or limit such prescribing to psychiatric specialists (personal communication, Tay Kopanos, AANP). Expansion of scope of practice in Oregon for NPs specifically impacted ability to prescribe controlled substances from 2000 to 2008. Studies such as this enhance research findings documenting that NPs prescribe in a manner similar to physicians when given the authority to prescribe controlled substances and, therefore, have implications for states with known shortages of mental health prescribers.

Limitations

A possible limitation of the study may be the use of a Medicaid database, as it does not reflect all children treated for ADHD. Diagnosis of ADHD in children aged 4–17 is more prevalent for those with public health insurance (11.7%) compared to private insurance (8.6%) or uninsured (5.7%) (Pastor et al. 2015). Variations in coverage, prescriptive authority, and healthcare access vary significantly from state to state, which further limits generalizability for the Medicaid population as a whole.

Inferential comparisons of prescribing rates could not be performed because some children were seen by multiple provider types (nurse prescribers, physicians) and specialty types (family, pediatrics, psychiatry). Therefore, generalized linear mixed models were not utilized because data were not exclusively nested within hierarchies. Statistical models that do not handle multilevel data (such as generalized linear regression or logistic regression) were not appropriate for this study. Limitations in methodology as noted resulted in the predominance of prescribing analysis using descriptive statistics only. Cautious interpretation of descriptive statistics should reflect the potential for a unique child to be seen by multiple prescribers and receive multiple medications.

Other limitations to analysis of the full 2012 dataset included unclear taxonomy information that may have excluded providers who would otherwise be included in the cohort. National Provider Identifier (NPI) taxonomies are self-assigned and therefore may not capture all licensure types or overlap/dual licenses. NPI category confirmation with licensing data could not occur due to the confidentiality requirements in the data use agreement prohibiting linkage of patients with a named prescriber or personally identifiable confirmatory data such as a Drug Enforcement Administration (DEA) number. This agreement therefore limited the ability to analyze and present prescriber level characteristics.

Inherent limitations in prescribing databases include discontinuation of therapy shortly after fill, loss of, or changes in insurance coverage, therapy changes, and gaps that occur between prescribing and fill date. The use of two forms of analysis (30-day prescriptions and PDE) as well as specific criteria for continuous coverage inclusion attempted to mitigate the impact of these limitations. This criterion does limit study generalizability to a less consistently insured population. It is also important to note that the age of the child at prescribing may be discrepant from the age at fill, which accounted for the data request generation in a 730-day time frame. This study also did not examine specific doses of medications that may capture additional incidents of off-label prescribing.

Conclusions

These findings offer important insight into prescribing patterns for vulnerable children. The unique long-term prescribing authority for controlled substances by NPs in Oregon provides the ability to confirm similar prescribing patterns for ADHD. While these findings are reassuring, support for generalist physicians and NPs will continue to need to be provided, as they are the primary prescribers for ADHD in this population.

Future Research

Further analysis of off-label or partial-label prescribing with dose-specific parameters is recommended to confirm prescriber guideline adherence and help guide educational and certification options, as well as support consultation networks that are being enacted in state policy. While drug type analysis in this study helped confirm prescribing patterns, dose analysis is required to better understand prescriber variances.

Methylphenidate is the only consensus guideline pharmacologic option for ages 4–5. Nonpharmacologic options are preferred for initial treatment (Subcommittee on ADHD 2011). Prescribing medications that are appropriate for the diagnosis, but not for the age range treated may be called “partial approval” prescribing (Kearns and Hawley 2014). While off-label prescribing is permitted by Oregon law and not prohibited by Oregon Medicaid formulary, it is not common among Medicaid prescribers (DURM 2014). While this study did not examine specific doses of medications, drug classifications by active ingredient into controlled and noncontrolled suggest that young children aged 3–5 are receiving controlled substances most frequently by physician generalists, followed by NP generalists. Further sensitivity analysis regarding doses and types of medications by age will reveal more regarding prevalence of both off-label and partial-label prescribing, as the latter is likely to be more common in practice.

State variance in formulary, funding, and coverage for Medicaid and mental health conditions support multistate studies to confirm prescribing practice. While challenging to implement, the development of more all-payer, all-claims databases and sharing among institutions will ultimately help improve knowledge of prescribing practices.

Children in Oregon on Medicaid with a diagnosis of ADHD received treatment within a reasonably narrow span of medications identified in this analysis. While access to mental health specialists is constrained in Oregon, very young children all received treatment from a physician. In this study, children under age 4 (n = 29) primarily received their prescriptions from a pediatrician. The recent policy decision from the Oregon legislature to fund the Opal-K program, which provides consultation with psychiatric providers for primary care clinicians, may further impact prescribing patterns and help support generalist physicians and NPs as they see children in the community (www.ohsu.edu/xd/education/schools/school-of-medicine/departments/clinical-departments/psychiatry/divisions-and-clinics/child-and-adolescent-psychiatry/opal-k/index.cfm). Studies that track the impact of this support to generalist practice in mental health services will help facilitate these programs' ongoing sustainability.

Clinical Significance

This study examines and compares prescribing patterns for ADHD among and between NP and physician prescribers, and generalist versus specialist prescribers, using Oregon Medicaid payer data from 2012 (n = 10,753 children). Few studies have examined the impact of licensure and specialty on prescribing practices, particularly in states where legal authority to prescribe is similar among the prescribers in question.

Footnotes

Acknowledgment

The authors would like to acknowledge Dr. Lois James, Research Assistant Professor at Washington State University for her assistance with the initial analysis for this study.

Disclosures

No competing financial interests exist.

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