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Clinical Practice Guidelines
 
The Provider Advisory Committee (PAC) of CBHNP adopts Clinical Best Practice Guidelines to serve as benchmarks for future quality improvement initiatives. The PAC includes representation from our Provider groups as well as county representation. The committee has focused on the most common diagnoses seen in our HealthChoices population. The committee has adopted six clinical practice guidelines, and measures have been developed for two. Six Clinical Practice Guidelines have been evaluated and recommended as relevant for the CBHNP Provider Network:
  • Major Depressive Disorder
    Adopted the American Psychiatric Association Practice Guideline for the Treatment of patients with Major Depressive Disorder 3rd Ed. (October, 2010). Available on-line from APA at this link
    • Update December 2011: No changes noted, re-adopted as currently referenced. No subsequent guideline watch has been published.
  • Attention-Deficit Hyperactivity Disorder
    Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention Deficit Hyperactivity Disorder in children and adolescents. Adopted the American Academy of Pediatrics Clinical Practice Guideline: ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention Deficit Hyperactivity Disorder in children and adolescents (November 2011; Pediatrics 128(5):1007-1022,2011). Available online at this link
    • Update December 2011: This Clinical Practice Guideline was adopted during the December 2011 meeting. Of note is that this CPG represents an update and combination of the two previously adopted CPGs for ADHD: Diagnosis and Evaluation of the Child with Attention-Deficit/Hyperactivity Disorder (May 2000) and Treatment of the School-Aged Child with Attention-Deficit/Hyperactivity Disorder (October 2001).
  • Substance Use Disorders
    Adopted the American Psychiatric Association Practice Guideline For The Treatment Of Patients With Substance Use Disorders, (2nd Edition, August 2006). Available online from APA at this link
    • Update December 2011: No changes noted, re-adopted as currently referenced, including the April 2007 Guideline Watch at
      this link
    • The reference includes the following statement: This guideline is more than 5 years old and has not yet been updated to ensure that it reflects current knowledge and practice. In accordance with national standards, including those of the Agency for Healthcare Research and Quality ™ National Guideline Clearinghouse, this guideline can no longer be assumed to be current. The April 2007 Guideline Watch associated with this guideline provides additional information that has become available since publication of the guideline, but it is not a formal update of the guideline.
  • Bipolar Disorder
    Adopted the American Psychiatric Association Practice Guideline for the Treatment of Patients with Bipolar Disorder (2nd Edition, April 2002). Available online from APA at this link
    • No changes noted, re-adopted as currently referenced, including the November 2005 Guideline Watch: this link
    • The reference includes the following statement: This guideline is more than 5 years old and has not yet been updated to ensure that it reflects current knowledge and practice. In accordance with national standards, including those of the Agency for Healthcare Research and Quality ™ National Guideline Clearinghouse, this guideline can no longer be assumed to be current. A third edition of this guideline is in development. The November 2005 Guideline Watch associated with this guideline provides additional information that has become available since publication of the guideline, but it is not a formal update of the guideline.
  • Schizophrenia
    Adopted the American Psychiatric Association Practice Guideline for the Treatment of Patients with Schizophrenia, Second Edition, (Second Edition, February 2004). Available online from APA at this link
    • No changes noted, re-adopted as currently referenced.
    • The reference includes the following statement: This guideline is more than 5 years old and has not yet been updated to ensure that it reflects current knowledge and practice. In accordance with national standards, including those of the Agency for Healthcare Research and Quality National Guideline Clearinghouse, this guideline can no longer be assumed to be current. The November 2009 Guideline Watch associated with this guideline provides additional information that has become available since publication of the guideline, but it is not a formal update of the guideline.
  • Psychiatric Evaluation of Adults
    Adopted the American Psychiatric Association Practice Guideline for the Psychiatric Evaluation of Adults (2nd Edition, June 2006). Available online from APA at this link
    • Update December 2011: No changes noted, re-adopt as currently referenced. No subsequent guideline watch has been published.

While all Clinical Practice Guidelines were re-adopted by the PAC, since the last review the two ADHD guidelines previously adopted by the committee were updated and combined into one comprehensive guideline. There have been no new Guideline Watches added to any of the adopted practice guideline even though some are over 5 years old. There is no longer information presented on the APA website regarding the timing for planned revisions to those Practice Guidelines 5 years old or older. The committee will continue to monitor the website and information clearinghouses for information regarding updated guidelines.

Clinical Practice Guideline Measures
It was decided that all guidelines that are evaluated by PAC and considered helpful will be made available as a reference to providers to guide practice. For the purposes of provider performance measurement on Clinical Practice Guidelines, the following Guidelines were identified as sources to help guide the Guideline Measures reviewed by the committee:
  • Bipolar Disorders. The American Psychiatric Association Practice Guideline for the Treatment of Patients with Bipolar Disorder (2nd Edition, April 2002).
  • ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention Deficit Hyperactivity Disorder in children and adolescents. The American Academy of Pediatrics Clinical Practice Guideline: ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention Deficit Hyperactivity Disorder in children and adolescents (November 2011; Pediatrics 128(5):1007-1022,2011).

CBHNP continued to focus on the Guideline measures by obtaining pharmacy data from HealthChoices Physical Health MCO’s. Some data elements obtained and reported from pharmacy measures continued to skew the results and additional adjustments were identified, however the adjustments did not have the expected impact on that report outcome. The committee will continue to discuss and request adjustments to the data elements in order to obtain the most accurate and representative results.

Measure 1: Percentage of members with a Bipolar Disorder diagnosis who are prescribed at least one of the first-line medication options (as recommended by the guideline),

Identify all Members with Bipolar Disorder diagnoses (296.4x; 296.5x; 296.6x; 296.7; 296.80; 296.89) who had at least one claim for a medication management visit (90862) in an identified 1-year period of time.

For the same annual period, request pharmacy data from Gateway for each identified Member for the following medications: Lithium, valproate, divalproex, lamotrigine, carbamazepine, oxcarbazepine, olanzapine, risperidone, clozapine, ziprasidione, quetapine, aripiprazole, asenapine, paliperidone, fluoxetine/olanzapine combination (Symbyax),

Determine the percentage of Bipolar Disorder patients who are prescribed at least one of the first-line medication options recommended by the guideline.

Measure 2: Percentage of Members with a Bipolar Disorder diagnosis who are also diagnosed and/or who have been treated for substance abuse or dependence as recommended by the guideline.

Bipolar disorder with a co-morbid substance use disorder is a very common presentation, with bipolar disorder patients of both sexes showing much higher rates of substance use than the general population. As a benchmark, the Epidemiologic Catchment Area (ECA) study found rates of alcohol abuse or dependence in 46% of patients with bipolar disorder compared to 13% for the general population. Comparable drug abuse and dependence figures are 41% and 6%, respectively.

Identify all Members with Bipolar Disorder diagnoses (296.4x; 296.5x; 296.6x; 296.7; 296.80; 296.89) who had at least one claim for any service in an identified 1-year period of time.

Identify secondary diagnoses of the following Substance-Related Disorders (303.90; 305.00; 304.40; 305.70; 304.30; 305.20; 304.20; 305.60; 304.50; 305.30; 304.60; 305.90; 304.00; 305.50; 304.60; 305.90; 304.10; 305.40; 304.80; 304.90; 305.90) and/or Substance Abuse treatment authorization within the same annual time period within the same annual time period.

Measure 3: Percentage of members with an ADHD diagnosis who are prescribed at least one of first-line medication options (recommended by the guideline).

Identify all Members with ADHD diagnoses (314.01; 314.00; 314.9) who had at least one claim for a medication management visit (90862) in an identified 1-year period of time. Identify the PH-MCO for each identified Member.

For the same annual period, request pharmacy data from the PH-MCO for each identified Member for the following medications: methylphenidate; amphetamine; or other FDA-approved non-stimulants including :
  • Adderall
  • Adderall XR
  • Concerta
  • Daytrana
  • Desoxyn
  • Dexedrine
  • Dextrostat
  • Focalin
  • Focalin XR
  • Metadate CD
  • Methylin
  • Ritalin
  • Ritalin SR
  • Ritalin LA
  • Strattera
  • Vyvance
  • Catapres
  • Intuniv
Determine the percentage of ADHD patients who are prescribed at least one of first-line medication options recommended by the guideline.

Measure 4: Percentage of members with ADHD diagnosis who have had at least two psychiatry visits in the annual period.

Identify all Members with ADHD diagnoses (314.01; 314.00; 314.9) who had at least one claim for a psychiatric evaluation (90801) or medication management visit (90862) in an identified 1-year period of time. Eliminating those from the analysis who have co-occurring

Total the number of 90801 and 90862 visits that occur in the annual time period. (Eliminating or controlling for treatment initiated in the last 3 months of the year), calculate the percentage of members with ADHD diagnosis who have had at least two psychiatry visits in the annual period. Calculate the average number of psychiatry visits for members with ADHD diagnoses in the annual time period.

Except for measure 2, there are no established targets for these measures. The current data, for the valid findings, serve as the Baseline for any future report comparisons. New, more current measures will be established and initiated in 2012.