| This study compared the quality of antipsychotic
pharmacotherapy for schizophrenia in the Department of Veterans Affairs
and in a sample of privately insured individuals. Logistic regression
models were used to investigate the effects of health care system
and patient demographic and clinical characteristics on the likelihood
that patients were dosed according to published treatment recommendations.
We found relatively low rates of adherence to treatment recommendations,
which may reflect a lack of awareness of these recommendations among
prescribing physicians, or a belief that the recommendations are inadequate.
Differences between the two systems were mixed, with the VA outperforming
the private with respect to some measures and doing worse on others.
Patient characteristics that significantly affected some of the quality
measures included age, and having a comorbid diagnosis of other psychosis,
dementia/Alzheimer’s disease, major depression, bipolar disorder,
adjustment reaction or dysthymia.
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Background: Comparing quality of care between large health care
systems is important for health systems management. This study used measures
of the quality of pharmacotherapy for patients with schizophrenia and
compared these measures across a sample of patients from the Department
of Veterans Affairs (VA) and the private sector.
Methods: A random sample of all patients diagnosed with schizophrenia
in the VA during fiscal year (FY) 2000 was identified using administrative
data. In the private sector, a sample of patients diagnosed with schizophrenia
in 2000 was identified using MEDSTAT's MarketScan database. For both groups,
use of antipsychotic medications was studied and measures of the quality
of pharmacotherapy were constructed, including whether patients were prescribed
any antipsychotic medication, one of the newer atypical antipsychotics,
and whether dosing adhered to established treatment recommendations. These
measures were compared across the two groups using logistic regression
models, controlling for age, gender, and comorbid diagnoses.
Results: Most patients with a diagnosis of schizophrenia (82% in
the VA and 73% in the private sector) received an antipsychotic medication,
usually one of the newer atypical drugs. Patients in the VA were more
likely to be dosed above treatment recommendations, and less likely to
be dosed below treatment recommendations. Overall, differences in proportion
schizophrenia patients dosed according to recommendations were not statistically
different across the two systems (60% in the VA, 58% in the private sector).
Conclusions: Differences between the two systems were mixed, with
the VA outperforming the private sector with respect to some measures
and doing worse on others.
Implications for Health Care Provision: Although the VA and the
private sector were comparable with respect to the quality measures used
in this study, there is room for improvement in both systems. Treatment
recommendations are based on the best available clinical evidence of effectiveness
and safety. Quality of care might be improved with better adherence to
these recommendations.
Implications for Health Policies: Relatively low rates of adherence
to treatment recommendations may be due to lack of awareness of these
recommendations among prescribing physicians, or a belief that the recommendations
are inadequate. To the extent that low rates of adherence to treatment
recommendations are caused by a lack of awareness among physicians, policies
should be developed to disseminate this information and encourage the
appropriate use of these medications.
Implications for Further Research: Further research is needed to
understand physician prescribing decisions for these medications. To the
extent that physicians feel treatment recommendations for these drugs
are inadequate, further research is needed to refine the recommendations.
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