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As a result of participating in the Medicaid Medical Directors' Learning Network—an ÂÜÀòÊÓƵKnowledge Transfer project—the Alabama Medicaid Agency used findings from AHRQ's Effective Health Care Program to initiate a physician education program. The Comparative Effectiveness Review, Efficacy and Comparative Effectiveness of Off-Label Use of Atypical Antipsychotics, was influential in the development of the program, which supports evidence-based, guideline-supported prescribing of atypical antipsychotic medication in children.

Robert Moon, MD, Medical Director for the Alabama Medicaid Agency, says, "The ÂÜÀòÊÓƵComparative Effectiveness Review had an immediate impact. It was a valuable reference document that helped me initiate conversations with the clinical community in my State about the use of atypical antipsychotics. The review raised important safety concerns about these medications and was useful to Alabama Medicaid in the development of our physician education initiatives."

Moon notes that there are no U.S. Food and Drug Administration (FDA)-approved indications for the use of atypical antipsychotics in children younger than 5 years of age, though there is significant "off-label" prescribing of these drugs for children in Alabama. Moon used the atypical antipsychotic review to raise awareness that this issue was being analyzed nationally in an effort to support an Alabama-specific analysis of off-label use.

Atypical antipsychotic medications are second-generation drugs designed to cause fewer neurological complications than conventional antipsychotics. Some atypical antipsychotics approved to treat schizophrenia and bipolar disorders are being prescribed off-label for young children with behavior problems such as attention-deficit disorder and aggression.

Alabama Medicaid claims data identified more than 400 children aged 0 to 4 years who had received atypical antipsychotic medications during 2007. Approximately half of these children did not have an FDA-approved diagnosis; the other half would have had an FDA-approved diagnosis had they been older. Prescribers for these children included general and child psychiatrists, general internal medicine physicians, neurologists, and pediatricians.

Alabama Medicaid's Pharmacy and Therapeutics Committee convened a multi-agency task force to evaluate these findings and make recommendations. Members of the task force included child psychiatrists, other physicians, representatives of the Department of Mental Health, a private insurance representative, and pharmacists. A two-phase education program was then developed for providers.

In the first phase, begun in May 2009, educational letters were sent to providers whose prescribing practices differed from practices generally accepted as evidence-based for antipsychotic medications prescribed to children aged 18 and younger.

In the second phase, board-certified child psychiatrists made educational phone calls to identified prescribers to discuss the use of these medications in children younger than 5 years of age. The calls did not deny coverage, but explored evidence-based and/or guideline-supported prescribing.