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Changes Over Time and Disparities in Schizophrenia Treatment Quality

Busch, Alisa B. MD, MS*‡; Lehman, Anthony F. MD, MSPH; Goldman, Howard MD, PhD; Frank, Richard G. PhD

doi: 10.1097/MLR.0b013e31818475b7
Original Article

Background: Schizophrenia medication and psychosocial treatment options have expanded since the Schizophrenia PORT was conducted. However, there also have been considerable changes in the delivery of mental health care in the public sector, as well as increasing state concerns about Medicaid cost containment.

Objectives: To examine trends and patient characteristics associated with differences in schizophrenia medication and visit treatment quality in a Medicaid population.

Research Design: Observational study of claims data from July 1, 1996 to June 30, 2001.

Subjects: Florida Medicaid enrollees diagnosed with schizophrenia (N = 23,619).

Measures: We examined the likelihood of meeting any 1 and all 4 of the following quality standards: (1) receiving antipsychotic medication, (2) antipsychotic continuity, (3) dosing consistent with PORT recommendations, and (4) mental health visit continuity. Separate models were fit for acute and maintenance phases of treatment.

Results: Approximately 18% of acute and 7% of maintenance phases met all 4 quality standards. Antipsychotic quality improved (largely driven by an increasingly likelihood of receiving any antipsychotic), while visit continuity declined. The greatest disparities were seen for persons with co-occurring substance use disorders and of black race. Quality differences were often phase specific and at times in opposite directions across treatment phases.

Conclusions: The improvement in antipsychotic treatment quality is encouraging. However, visit continuity declined. This study highlights the importance of quality measurement that includes focus on different treatment modalities and phases of care, as well as for potentially vulnerable populations (such as persons with co-occurring substance use disorders and racial/ethnic minorities).

From the *Department of Psychiatry, McLean Hospital, Alcohol and Drug Abuse Treatment Program, Belmont, Massachusetts; †Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland; and ‡Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

Supported by the National Institute of Mental Health (NIMH) through grants R01 MH069721 (to A.B.B. and R.G.F.), K01MH071714 (to A.B.B.), P50 MH073469 (to R.G.F.), and by John D. and Catherine T. MacArthur Foundation, Network on Mental Health Policy Research (to H.G.).

Reprints: Alisa B. Busch, MD, MS, Alcohol and Drug Abuse Treatment Program, McLean Hospital, Assistant Professor of Psychiatry/Instructor in Health Care Policy, Departments of Psychiatry and Health Care Policy, Harvard Medical School, McLean Hospital, Proctor 305, 115 Mill St, Belmont, MA 02478. E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.