Medicaid Mental Illness Quality

Disparities in Schizophrenia Care

Do African Americans and Latinos receive the same quality care as Caucasians?  This is the question asked by Horvitz-Lennon et al. (2014).

Quality of Care

Before one can answer this question, one first has to define what “quality care” means.  The authors use the following definition for pharmacological indicators:

  • Any use of antipsychotic drugs,
  • Conditional on antipsychotic use, any use of long-acting injectable antipsychotics,
  • Two indicators of antipsychotic drug adherence (full adherence, defined as ≥80 percent medication possession ratio (MPR), and low adherence, defined as ≤50 percent MPR)
  • Two indicators of clozapine use (any clozapine use, and adequate duration and dose of clozapine treatment among users, defined as ≥90 days of clozapine use with a daily dose of ≥300 mg as of the 29th day of the trial),
  • Nonclozapine antipsychotic polypharmacy (simultaneous use of ≥2 nonclozapine antipsychotics for >90 days).

In addition to pharmaceutical treatment, the psychosocial indicators were as follows:

  • Any receipt of psychosocial services (at least once),
  • Routine receipt of psychotherapy (at least once every quarter).

The authors used the following appropriateness indicators:

  • Two indicators of continuity of care (follow-up care within 7 and 30 days of discharge from the first observed inpatient admission for schizophrenia),
  • Receipt of routine psychiatric services (any outpatient psychiatric service at least once every quarter),
  • Heavy use of Emergency Department (ED) services (≥4 ED visits with a primary diagnosis of schizophrenia),
  • Heavy use of inpatient services for schizophrenia (≥30 inpatient days or ≥3 inpatient admissions with a primary diagnosis of schizophrenia).

The authors also created a composite measure defined as follows:

The composite measure excluded three indicators initially considered for inclusion. These were adequate duration of clozapine treatment (90 or more days of clozapine use); above-range dose among maintenance users of first-generation antipsychotic (FGA) drugs (PORT-discordant dosing during a 3-month or longer period following the end of acute-phase treatment); and use intensity among users of psychosocial services (number of visits). We excluded the clozapine indicator because a more informative measure of clozapine treatment adequacy was included in the composite measure. We excluded the other two indicators because of small numbers.


The authors used claims data from Medicaid Analytic eXtract (MAX) from four states: California, Florida, New York and North Carolina between 2002 and 2009 assembled as data. The specific MAX files used were Personal Summary, the source for eligibility and ICD-9 diagnoses; Inpatient; Pharmacy; and Other Services, the source for data on use of outpatient services.


Across the four states and over the entire study period, 66–70 percent of person-episodes had full antipsychotic drug adherence, and 55–71 percent received routine psychiatric care. Low antipsychotic drug adherence was not insubstantial (14–19 percent); clozapine use was low (5–7 percent)…and heavy inpatient use was not rare, observed in 3–10 percent of the person-episodes

Significant racial disparities were also found.

[R]egardless of state and with few exceptions, quality of care was worst for blacks. Latinos’ quality of care tended to be better than blacks’ but lower than that of whites. An exception was FL, where Latinos outperformed whites in most psychosocial and appropriateness indicators.


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