Comparing Nurse Practitioner and Physician Prescribing of Psychotropic Medications for Medicaid-Insured Youths

Abstract

Objective:

To describe psychotropic medication prescribing practices of nurse practitioners (NP) and physicians for Medicaid-insured youths in 2012–2014 in a mid-Atlantic state where NP independent prescribing is authorized.

Method:

From annual computerized administrative claims data in a mid-Atlantic state, we analyzed 1,034,798 dispensed psychotropic medications prescribed by NPs and physicians for 61,526 continuously enrolled Medicaid-insured youths aged 2–17 years. Demographic and clinical characteristics of psychotropic medication users were compared for youths who received psychotropic medication dispensings by NP-only, physician-only, or by both providers using descriptive statistics and generalized estimating equations. We then characterized psychotropic medication prescribing practices by providers within each specialty.

Results:

From 2012 to 2014, the number of psychotropic medication dispensings increased from 346,922 to 349,080. There was a 50.9% increase in the proportion of psychotropic medications prescribed by psychiatric NPs (from 5.9% to 8.8%) and a 28.6% proportional increase by non-psychiatric NPs (from 4.9% to 6.3%). By contrast, the proportion of psychotropic medications prescribed by psychiatrists and by non-psychiatric physicians declined (56.9%–53.0% and 32.3%–31.8%, respectively). Youths diagnosed with depression or anxiety were more commonly treated by NP-only than by physician-only (AOR = 1.33, 95% CI = 1.24–1.43), whereas youths with two or more psychiatric comorbidities were significantly more commonly treated by both NP and physician providers (AOR = 1.44, 95% CI = 1.39–1.50). Psychiatric specialists prescribed the bulk of antidepressants (82.0%) and lithium (92.3%), with much lower prescribing by non-psychiatric specialists (18.0% and 7.7%, respectively). Antipsychotic orders originated from psychiatric specialists 7.4 times more than from their non-psychiatric specialty counterparts, whether physician or NP.

Conclusions:

NPs, relative to physicians, have taken an increasing role in prescribing psychotropic medications for Medicaid-insured youths. The quality of NP prescribing practices deserves further attention.

Introduction

In recent decades, there has been a marked expansion in children's psychotropic medication use within office-based medical practice (Zito et al. 2008; Olfson et al. 2014, 2015). This expansion is being facilitated by increasing mental healthcare to individuals who gained insurance coverage with the passage of the Affordable Care Act (ACA) (Frank et al. 2014). Although child and adolescent psychiatrists play a major role in prescribing medications for children with behavior/mental disorders, there is a shift toward utilizing the services of a variety of primary care physician specialists (e.g., family medicine, pediatrics, or internal medicine) and advanced practice clinicians such as nurse practitioners (NPs) to fill staff shortages.

NPs are one of the fastest growing health professional groups in response to the current need for accessible and cost-effective healthcare (Bodenheimer and Bauer 2016; American Association of Nurse Practitioners [AANP], 2017a). NPs receive graduate-level educational preparation (e.g., Master's level training and doctoral-level NP educational programs) with additional specialty certification. NPs' mandate to independently prescribe psychotropic medications varies by state depending on a state's NP prescriptive authority (AANP 2017b). As of 2016, NPs in 21 states (e.g., Maryland, Wyoming, and Oregon) and the District of Columbia have full prescriptive authority without any legal requirement of physician collaboration. The remaining 29 states (e.g., Florida and Alabama) require some level of physician involvement or collaboration in NP practice (AANP 2017b). Granting a full independent prescriptive authority to NPs may improve mental healthcare access for youths, particularly in the areas where psychiatrists are not readily available.

Currently, a few studies have described prescribing patterns of NPs compared with physicians for a selected psychotropic medication class (e.g., attention-deficit/hyperactivity disorder [ADHD] medications or antidepressants) among various age groups, including children and adolescents (Fisher and Vaughan-Cole 2003; Rettew et al. 2015; Klein et al. 2016). Nevertheless, significant gaps remain due, in part, to difficulties in obtaining recent detailed data that distinguish NP and physician prescribing by clinical specialty. There is also limited information on current psychotropic medication prescribing by NPs compared with physicians within each specialty for children and adolescents, particularly in a state where full independent prescriptive authority is granted to NPs. One study examining ADHD medication prescribing patterns by NPs and physicians using a northwest state's Medicaid-insured youths revealed that NPs prescribed ADHD medications in a similar manner compared with physicians (Klein et al. 2016). Unfortunately, prescribing patterns for other psychotropic medication classes by provider type have not been reported.

The major purpose of this study was to describe the psychotropic medication prescribing practices of NPs versus physicians by specialty (psychiatric versus non-psychiatric specialty) in terms of total prescribing and according to leading psychotropic medication classes for Medicaid-insured youths aged 2–17 years in a mid-Atlantic state where NPs are independently authorized (i.e., without physician oversight) to prescribe medications.

Methods

Data source

This descriptive study used computerized data from Medicaid administrative claim files pertaining to youths enrolled in fee for service and managed care payment systems for the years 2012–2014 from a mid-Atlantic state. These included: (1) enrollment files, (2) physician and outpatient files, and (3) pharmacy claims files. The claims database contained enrollment files at the person level that were linked to prescription drug claims using a pseudo-identification number assigned to each enrollee. Physician and outpatient encounter files were used to identify the clinician-reported diagnoses of youths who were dispensed psychotropic medications during the study period. To identify provider and specialty types, the provider taxonomy information from the public website National Plan and Provider Enumeration Services (NPPES) National Provider Identification (NPI) registry in the Centers for Medicaid and Medicare Services (CMS) was linked to the Medicaid prescription drug claims database through each prescriber's NPI number. This study was approved by the University of Maryland Institutional Review Board.

Study cohort

Initially, we identified 1,051,609 dispensings of psychotropic medications prescribed by physicians and NPs for 62,961 youths 2–17 years old who were continuously enrolled in the Medicaid insurance program each year from 2012 to 2014. From the initial extract, we excluded 604 medication dispensings from providers associated with organization/group NPI numbers because the organization/group NPIs did not contain information on each individual prescriber's provider and specialty type. Further, the medications dispensed for individuals with seizure disorders (ICD-9 CD: 345.xx) who did not have a mental disorder diagnosis (n = 16,207) were excluded to remove cases unrelated to mental health treatment. The total number of observations included in this study was 1,034,798 psychotropic medication dispensings for 61,526 individual youths. We used person as the unit of analysis to describe demographic and clinical characteristics of psychotropic medication users by provider type. To assess prescribing practices by provider type, medication dispensing was used as the unit of analysis. Dispensing-level analysis enabled us to maximize information on prescribing practices with more detailed information on prescriber specialty type (psychiatrists versus psychiatric NPs and non-psychiatric physicians and non-psychiatric NPs).

Provider and specialty types

Provider and specialty type information for psychotropic medication prescribers were identified from the CMS NPI registry associated with each individual prescriber's NPI. At the person-level analysis for demographic and clinical characteristics of psychotropic medication users, prescribers were categorized into three provider types: (1) physician-only, (2) NP-only, and (3) both NP and physician. Using these categories ensured that individuals who received psychotropic medications from multiple provider and specialty types each year were assigned to one unique provider type without overlapping.

To assess the number and percentage of dispensed psychotropic medications from 2012 to 2014, we categorized providers into psychiatric specialty and non-psychiatric specialty. Then, each was divided into two provider types: physician and NP.

Psychotropic medications

Psychotropic medications were identified in the pharmacy claim files from the National Drug Code through the use of a data dictionary. The psychotropic medications were divided into seven drug classes according to the medication therapeutic categories adapted from Zito et al. (2008): ADHD medications, antidepressants, antipsychotics, anxiolytics/hypnotics, anticonvulsant-mood stabilizers, lithium, and alpha-agonists. ADHD medications included stimulants and atomoxetine. Carbamazepine, oxcarbazepine, gabapentin, divalproex/valproate/valproic acid, and lamotrigine were categorized into anticonvulsant-mood stabilizers, excluding anticonvulsant-mood stabilizers in individuals with seizure disorder diagnosis and no psychiatric diagnosis. Alpha-agonists included clonidine and guanfacine.

Psychiatric diagnoses

Clinician-reported psychiatric diagnoses were identified from physician and outpatient files by using the International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM). To organize clinician-reported diagnostic groups from claims, we included psychiatric diagnoses with at least two outpatient physician claims on separate days in each year (West et al. 1994; Burcu et al. 2014). The psychiatric diagnostic groups include schizophrenia; pervasive developmental disorder (PDD) or intellectual disability (ID); bipolar disorder; disruptive behavior disorder; ADHD; depressive disorder; anxiety disorder; adjustment disorder; communication and learning disorder; and any other psychiatric disorders (Zito et al. 2013). We further classified the diagnoses in terms of single, two, and three or more psychiatric comorbidities. Single psychiatric diagnoses were then classified into four categories from previous studies (Zito et al. 2013; Burcu et al. 2014): (1) schizophrenia, PDD/ID, and bipolar disorder, (2) ADHD and disruptive disorder, (3) depression and anxiety, and (4) other psychiatric disorders.

Patient demographic characteristics

Patient socio-demographic and enrollment characteristics used for this study were age group (2–5, 6–11, and 12–17 years), gender, race/ethnicity (white, African-American, and other), region of enrollee's county of residence, and Medicaid eligibility category. Enrollee residence was classified by region into large metropolitan (counties in metropolitan statistical area of at least 250,000 individuals or more), small metropolitan (counties in metropolitan statistical area of less than 250,000 individuals), and non-metropolitan/rural areas (nonmetropolitan counties) adapted from the National Center for Health Statistics urban-rural classification scheme for counties (US Department of Health and Human Services 2014). Medicaid eligibility categories included Temporary Assistance for Needy Families (TANF), State Children's Health Insurance Program (CHIP), Supplemental Security Income (SSI), and foster care. The CHIP program provides Medicaid coverage based on family income equal to or less than 200%–300% of the federal poverty level. TANF coverage is based on family income equal to or less than the federal poverty level. For individuals in more than one Medicaid eligibility group, a hierarchical approach adopted from a previously published algorithm was used in the following order: foster care, SSI, CHIP, and TANF (Zito et al. 2013).

Statistical analysis

SAS version 9.4 and R statistical software were used for data merging and analyses. First, three annual data files from 2012 to 2014 were combined into one database to ensure sufficient observations in each provider type. Then, demographic and clinical characteristics of youths with psychotropic medication dispensings were compared for three provider types (physician-only, NP-only, and both NP and physician). Generalized estimating equation (GEE) models estimated the odds of having (1) NP-only versus physician-only and (2) both NP and physician versus physician-only in each psychiatric diagnosis category after controlling for enrollee age group, gender, race/ethnicity, region of residence, and Medicaid eligibility group. GEE was used in this study to account for individuals identified in a year, and it was repeated in a subsequent year.

To assess trends in psychotropic medication dispensings from 2012 to 2014, we calculated the number and percentage of psychotropic medication dispensings by provider specialty type in each year.

In the combined dataset from 2012 to 2014, the number and the proportion of psychotropic medication dispensings by provider specialty were assessed according to psychotropic medication class. The number of psychotropic medication dispensings per provider was calculated by dividing the number of medication dispensings by the number of providers in each provider specialty type during 2012–2014.

Results

Characteristics of psychotropic medication users by provider type

Compared with the characteristics of youths treated by physician-only, youths treated by NP-only were proportionally more often female, White, Medicaid-eligible by TANF, and residing in small metropolitan or non-metropolitan/rural regions (Table 1). Youths treated by NP-only were proportionally fewer in foster care or in receiving SSI than youths treated by physician-only or those treated by both NP and physician. Overall, the characteristics of youths treated by both NP and physician were similar to the physician-only type. Youths served by physician-only predominated in cities with more than 250,000, whereas youths served by both physician and NP tended to live more commonly in rural areas and small cities.

Table 1.

Demographic Characteristics of Continuously Enrolled Medicaid-Insured Youths ^* Aged 2–17 Years Who Were Dispensed Psychotropic Medications in 2012–2014 According to Provider Type

	Physician-only		NP-only		Both NP and Physician
	N	%	N	%	N	%
Total	89,787	78.87	8118	7.13	15,935	14.00
Age
2–5 years	6470	7.21	601	7.40	1116	7.00
6–11 years	34,838	38.80	2998	36.93	6677	41.90
12–17 years	48,479	53.99	4519	55.67	8142	51.10
Gender
Male	58,078	64.68	4739	58.38	10,246	64.30
Female	31,709	35.32	3379	41.62	5689	35.70
Race/ethnicity
White	37,894	42.20	3949	48.64	8638	54.21
African American	38,758	43.17	3046	37.52	5336	33.49
Other	13,135	14.63	1123	13.83	1961	12.31
Enrollee region of residence
Large	70,836	79.03	5829	71.88	10,418	65.47
Small	14,028	15.65	1760	21.70	4032	25.34
Nonmetro or rural	4773	5.32	520	6.41	1462	9.19
Medicaid eligibility category^a
TANF	47,527	52.94	4891	60.25	8357	52.44
SCHIP	17,354	19.33	1541	18.98	2884	18.10
SSI	15,683	17.47	1124	13.85	2877	18.05
Foster Care	9217	10.27	562	6.92	1817	11.40

Psychotropic medication users continuously enrolled in Medicaid insurance each year from 2012 to 2014 are not mutually exclusive and may have been counted more than one time.

SSI, Supplemental Security Income; TANF, Temporary Assistance for Needy Families; SCHIP, State Children's Health Insurance Program.

Differences in clinician-reported diagnoses among youths according to three provider types (NP-only, physician-only, and both) were evident (Table 2). Youths diagnosed with depression and anxiety were more likely to be treated by NP-only (adjusted OR (AOR) = 1.33, 95% CI = 1.24–1.43) than physician-only. Interestingly, the proportion of youths who received psychotropic medications with no psychiatric diagnosis was much lower in youths treated by both NP and physician (10.69%) than by physician-only (20.67%) and NP-only (21.04%). Youths with three or more psychiatric diagnoses were more likely to be treated by both NP and physician (AOR = 1.46, 95% CI = 1.38–1.53) and less likely to be treated by NP-only (AOR = 0.84, 95% CI = 0.79–0.89) than by physician-only.

Table 2.

Clinical Diagnoses of Continuously Enrolled Medicaid-Insured Youths^* Aged 2–17 Years Who Were Dispensed Psychotropic Medications in 2012–2014 According to Provider Type

	Physician-only (78.87%)		NP-only (7.13%)		Both NP and Physician (14.00%)		NP-only vs. Physician-only		Both vs. Physician-only
	N	%	N	%	N	%	AOR ^a	(95% CI)	AOR ^a	(95% CI)
Single psychiatric diagnosis
ADHD and disruptive disorder	31,702	37.34	2678	35.04	6302	42.77	0.96	(0.91–1.00)	1.17	(1.12–1.21)
Schz, PDD/ID, and bipolar disorder	1087	1.28	71	0.93	160	1.09	0.84	(0.69–1.00)	0.86	(0.73–1.03)
Depression and anxiety	6446	7.59	870	11.38	948	6.43	1.33	(1.24–1.43)	0.86	(0.79–0.92)
Other^b	3372	3.97	444	5.81	378	2.57	1.36	(1.23–1.49)	0.63	(0.56–0.71)
No psychiatric diagnosis	17,544	20.67	1608	21.04	1575	10.69	0.95	(0.90–1.00)	0.51	(0.48–0.53)
Two psychiatric diagnoses	14,235	16.77	1277	16.71	2948	20.01	1.00	(0.95–1.05)	1.22	(1.16–1.27)
Three or more psychiatric diagnoses	10.505	12.37	694	9.08	2424	16.45	0.84	(0.79–0.89)	1.46	(1.38–1.53)

Psychotropic medication users continuously enrolled in Medicaid insurance each year from 2012 to 2014 are not mutually exclusive and may have been counted more than one time.

AOR is odds ratio adjusted for an enrollee's age, gender, race/ethnicity, region of residence, and Medicaid eligibility. In each separate psychiatric diagnosis category, the generalized estimating equations estimated odds of having NP-only or both (NP and physician) versus physician-only.

Other includes adjustment disorder, communication disorder, and other psychiatric disorders.

ADHD, attention-deficit/hyperactivity disorder; Schz, schizophrenia; PDD, pervasive developmental disorder; ID, intellectual disability.

Psychotropic medication trends by provider type and specialty

As shown in Table 3, the proportion of dispensed psychotropic medications prescribed by psychiatrists (from 56.9% to 53.1%) and non-psychiatric physicians (from 32.3% to 31.8%) decreased slightly between 2012 and 2014, whereas during the same period there was a 50.9% increase in psychotropic prescriptions by psychiatric NPs (from 5.9% to 8.8%) and a 28.6% increase by non-psychiatric NPs (from 4.9% to 6.3%).

Table 3.

Time Trend in Dispensed Psychotropic Medications According to Provider Within Each Specialty Group for Continuously Enrolled, Medicaid-Insured Youths (2–17 Years Old) in 2012–2014

	2012		2013		2014
	N	%	N	%	N	%
Psychiatric specialists
Psychiatrists	197,376	56.89	183,999	54.31	185,271	53.07
Psychiatric NPs	20,327	5.86	22,772	6.72	30,855	8.84
Non-psychiatric specialists
Non-psychiatric physicians	112,122	32.32	113,963	33.64	110,829	31.75
Non-psychiatric NPs	17,097	4.93	18,062	5.33	22,125	6.34

NP, nurse practitioner.

Psychotropic medication prescribing practices by provider type

A majority of dispensed medications originated from a relatively small number of psychiatric specialty providers (psychiatrists and psychiatric NPs) (Table 4). A total of 1214 psychiatric specialists prescribed 61.9% of the dispensed psychotropic medications for youths, whereas 6709 non-psychiatric specialists prescribed 38.1% of the medications. The number of psychotropic medications per prescriber was far greater for psychiatric specialists (525.7–543.8) than for non-psychiatric specialists (58.1–62.7) (Table 4).

Table 4.

Number and Proportion of Psychotropic Medications in Total and Within Each Medication Class According to Provider Type Within Each Specialty for Continuously Enrolled, Medicaid-Insured Youths (2–17 Years Old) in 2012–2014

	Psychiatric specialists (n = 1214)				Non-psychiatric specialists (n = 6709)
	Psychiatrists (N = 1078)		Psychiatric NPs (N = 136)		Non-psych physicians (N = 5795)		Non-psych NPs (N = 914)
Number of psychotropic medications per prescriber	525.65		543.78		58.14		62.67

	N	%	N	%	N	%	N	%
Total psychotropic medications	566,646	54.76	73,954	7.15	336,914	32.56	57,284	5.54
Medication class
ADHD medications^a	231,616	43.12	29,554	5.50	236,338	43.99	39,693	7.39
Antipsychotics	83,482	79.03	9628	9.11	10,846	10.27	1681	1.59
Antidepressants	105,775	71.11	16,144	10.85	21,902	14.73	4919	3.31
Anticonvulsant-MS^b	39,034	63.51	5384	8.76	15,437	25.12	1607	2.61
Anxiolytics/hypnotics	8973	44.27	852	4.20	9339	46.07	1106	5.46
Alpha-agonists	89,879	59.00	11,828	7.76	42,469	27.88	8151	5.35
Lithium	8656	86.47	583	5.82	631	6.30	140	1.40

Row percent described the proportion of psychotropic medication, total and in 7 psychotropic medication classes.

ADHD medications comprised stimulants and atomoxetine.

Anticonvulsant-MS refers to anticonvulsant-mood stabilizer.

There was no sizable proportional difference in dispensed psychotropic medications across classes by provider type, except that a higher proportion of antidepressants was prescribed by psychiatric NPs than other medication classes compared with that prescribed by physicians. A notable difference, however, was observed in patterns of psychotropic medications by specialty. Substantial proportions of antipsychotics (88.1%), antidepressants (82.0%), and lithium (92.3%) were prescribed by psychiatric specialists, whereas non-psychiatric specialists were responsible for a greater proportion of ADHD (51.4%) and anxiolytic/hypnotic (51.5%) medication prescribing (Table 4).

Discussion

The study revealed several major differences in psychotropic medication trends by provider type and prescribing practices of NPs and physicians as either psychiatric or non-psychiatric specialists. Specifically: (1) NP—particularly psychiatric NP-prescribed—psychotropic medications increased from 2012 to 2014, whereas physician-prescribed psychotropic medications proportionally decreased; (2) a higher proportion of youths served by NP-only or by both NP and physician lived in small metropolitan or non-metropolitan/rural areas and were likely to be eligible by family income compared with those served by physician-only; (3) NP-only providers more frequently treated youths diagnosed with depression or anxiety compared with youths treated by physician-only, whereas youths served by both NP and physician or physician-only had a greater number of psychiatric comorbidities; and (4) psychiatric specialists were responsible for the greater proportion of antipsychotic, antidepressant, and lithium prescribing than non-psychiatric specialists, whereas non-psychiatric specialists prescribed a higher proportion of ADHD and anxiolytic/hypnotic medications.

Consistent with previous study findings (Graves et al. 2016; Yang et al. 2017), this study highlights the important role of NPs in rural mental healthcare, which has an implication for NP use in expanding mental health services in areas where physician prescribers are not readily available.

Previous studies characterizing the proportion of behavioral health patients treated by NPs showed that these youths were less likely to be severely ill (Fisher and Vaughan-Cole 2003; Greenburg et al. 2006). We observed a similar pattern—youths treated by NP-only had less severe psychiatric diagnoses (e.g., depression or anxiety) without psychiatric comorbidities, whereas physician-only-provided care was greater for individuals diagnosed with serious psychiatric diagnoses, e.g., schizophrenia, PDD, or bipolar disorders.

Interestingly, youths treated by both NP and physician were most likely to have multiple psychiatric comorbidities and were located in small cities and non-metropolitan/rural areas. This finding may reflect a clinical scenario of care collaboration and referral services between NPs and physicians, as it suggests that youths with serious mental illness in medically underserved areas (e.g., rural or non-metropolitan areas), who were initially served by NPs, were referred to physician specialists for specialized mental health treatments.

We found similar patterns of dispensed psychotropic medications by provider type across the drug classes. One of the few differences between overall NP and physician prescribing was that overall, NPs dealt with a greater percentage of antidepressant prescribing than other classes of medications compared with physicians. The greater proportion of antidepressants prescribed by NP providers coincides with a greater proportion of depression and anxiety disorder diagnoses in youths served by NP-only compared with physician-only providers.

A high proportion of antipsychotic dispensings was prescribed by psychiatric NPs, which was far greater than that by non-psychiatric NPs, whose rate was similar to that of non-psychiatric physicians. This implies that the psychiatric NP role may have substituted for that of physicians and highlights an area in need of quality assessment and specialty training (e.g., continuing education).

A distinct pattern emerged on psychotropic medication prescribing by the specialty within each provider type. A greater proportion of ADHD and anxiolytics/hypnotic medications was prescribed by non-psychiatric specialists, whereas psychiatric specialists more often prescribed antipsychotics, antidepressants, mood-stabilizer anticonvulsants, and lithium. Previous studies have consistently reported that non-psychiatrists such as primary care physicians prescribed ADHD medications more frequently than psychiatrists (Chen et al. 2009; Klein et al. 2016), whereas psychiatrists were responsible for more prescribing for other psychotropic medication classes (Chen et al. 2009). Treating youths diagnosed with ADHD has become a common practice in U.S. primary care settings (French 2015). Primary care providers themselves believe that their role in the management of ADHD is appropriate (Power et al. 2015).

Over the past several years, there has been a shift toward primary care-based collaborative mental health services for children and adults. A growing role of primary care physicians in mental health treatments has been well documented in the literature (Woltmann et al. 2012; Olfson et al. 2014; Olfson 2016). Nonetheless, other potential healthcare workforce resources, such as NPs, appear to be understudied despite a growing NP workforce in U.S. healthcare settings (Hanrahan et al. 2010; Bodenheimer and Bauer 2016; AANP 2017a). This may be largely influenced by the difficulty in obtaining high-quality data with a sufficient number of observations of NP psychotropic medication prescribing practice.

Using a recent large healthcare administrative dataset, our study demonstrated that the use of psychotropic medications prescribed by psychiatric NPs for Medicaid-insured youths is growing, whereas the proportion of such medications prescribed by psychiatrists is declining. Given the rising number of psychiatric mental health NP programs across the United States (Hanrahan et al. 2010) and the expansion of the NP prescriptive privilege (Gadbois et al. 2015; AANP 2017b), combined with the increased demands for mental healthcare, this trend is likely to continue. NPs' referral patterns and care coordination with psychiatrists for mental health in children and adolescents should be further evaluated to ensure quality of care delivered to youths with behavioral and mental healthcare needs.

The findings from this study are limited to a single state's Medicaid-enrolled population of youths who largely come from low-income families. The data were from a recent, but relatively short 3-year period (calendar year 2012–2014), thus limiting conclusions about time trends. Second, the ICD-9-CM diagnoses in claims data were collected for billing—not research purposes, so they might not be as valid as research attained diagnoses. Nonetheless, the study provided valuable information on the prescribing patterns of provider types within psychiatric and non-psychiatric specialties for the treatment of Medicaid-insured youths. One caveat on examining providers in child care is the recognition that children may be treated by multiple provider specialists. Approximately 40% of the youths were served either by both NP and physician or by both psychiatric specialist and non-psychiatric specialist. This unique data pattern did not allow us to build statistical models with detailed provider specialty categories because of the difficulty in accounting for possible correlations of dispensed prescriptions for the same individual being treated by multiple providers (Klein et al. 2016). Among youths who were treated by both NP and physician in each year, we were unable to separate out the concurrent prescribing (both NP and physician together) from youths who switched from one provider type to the other. Nonetheless, our study findings are insightful in that we used a recent large healthcare administrative dataset with fairly complete and detailed national prescriber identification information (less than 5% missing), thus reducing the potential for selection bias.

Conclusions

Our study findings highlight an expanded prescribing role for NPs, particularly psychiatric NPs, for publicly insured youths in a state with full independent prescriptive authority for NPs. Building effective care collaboration among clinicians from various provider types and specialties is crucial to accommodate a growing demand for mental health services (Olfson 2016), especially given the critical shortage of pediatric mental health providers (Walker et al. 2015; American Academy of Child and Adolescent Psychiatry 2016). Our study offers detailed analysis for policy makers who may develop workforce collaboration models among psychiatric and non-psychiatric NPs and physicians. Future studies should focus on evaluating the quality of pediatric psychotropic medication prescribing and monitoring practices by NPs based on current national medication practice guidelines. This will ensure that youths with mental healthcare needs receive appropriate and timely healthcare services.

Clinical Significance

This study provides empirical evidence of the psychotropic medication prescribing practices of NPs and physicians between 2012 and 2014, sub-grouped into psychiatric and non-psychiatric specialties for Medicaid-insured youths. The data reflect a state where NPs are authorized to prescribe independent of physician supervision. Regular updating of these practices could help guide future continuing education programs to improve the quality and appropriateness of treatments.

Footnotes

Acknowledgment

This work was supported by the Southern Nursing Research Society Research Grant Award.

Disclosures

No competing financial interests exist.

References

American Academy of Child and Adolescent Psychiatry: Workforce issues.. 2016. Available at: www.aacap.org/aacap/Resources_for_Primary_Care/Workforce_Issues.aspx (Accessed June 8, 2017 ).

American Association of Nurse Practitioners: Press releases and announcement.. 2017a. Available at: www.aanp.org/press-room/press-releases/173-press-room/2017-press-releases/2098-more-than-234-000-licensed-nurse-practitioners-in-the-united-states (Accessed July 23, 2017 )

American Association of Nurse Practitioners: State practice environment.. 2017b. Available at: www.aanp.org/legislation-regulation/state-legislation/state-practice-environment (Accessed July 23, 2017 ).

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