1. The Antipsychotic Atlas Project - Overview Kennedy, J (PI); S Murphy; S McPherson & M Layton (co-Is) Start date: 9/13End date: 8/15 This research project is intended to benefit Washington residents with dementia, schizophrenia, bipolar disorder or diabetes and is funded by a $340,288 grant awarded from the Washington State Attorney General’s Office. The grant originated as part of a “cy pres,” or “next best use” of settlement monies, stemming from a 2012 settlement agreement between the Washington State Attorney General’s Office and Janssen Pharmaceuticals, Inc., concerning the marketing of Risperdal, Risperdal Consta, Risperdal M-Tab and Invega.

2. The Antipsychotic Atlas Project – Background The top five atypical antipsychotics account for over $8 billion in annual U.S. sales, paid mostly by the federal Medicare and Medicaid programs. These antipsychotic medications are approved by the Federal Drug Administration (FDA) for treatment of schizophrenia and bipolar disorder, but are also prescribed to millions of Americans with other psychiatric conditions. Information on the current scope of off-label prescribing and other clinically important antipsychotic use patterns is quite limited.

3. The Antipsychotic Atlas Project – Study Objectives The objective of this two year study is to provide a detailed portrait of antipsychotic utilization in Washington at the regional support network (RSN) and county level. We will use newly released Medicare D claims data to document patient level disparities in use, including off label use and nonadherence. We will then assess relative rates of metabolic syndrome, stroke, and thromboembolism among WA antipsychotic users.

4. Descriptive analysis of antipsychotic users Denominator file All 2010 WA Part D Beneficiaries (includes Medicare Advantage) N = 477,310 Denominator file All 2010 WA Part D Beneficiaries (includes Medicare Advantage) N = 477,310 Numerator file 1+ antipsychotic prescriptions N = 29,973 Numerator file 1+ antipsychotic prescriptions N = 29,973 6.3% of WA Part D recipients filled an antipsychotic prescription in 2010

5. Antipsychotic prescription use by WA county

6. Anti-Psychotic Use by County CountyNPercent CountyNPercent Pierce4,0078.3% Clallam4484.8% Columbia408.2% Asotin1204.7% Kitsap1,0918.1% Pacific1254.5% Whitman1788.0% Grant3154.5% Thurston1,1987.8% Jefferson1694.4% King8,2156.9% Mason2234.3% Spokane2,6646.8% Kittitas1154.3% Whatcom1,0496.4% Skamania284.0% Walla 2966.1% Island2383.9% Snohomish2,7076.1% Okanogan1643.8% Cowlitz6195.7% San Juan653.6% Grays Harbor4265.6% Klickitat843.6% Chelan2905.5% Stevens1493.6% Benton5655.5% Ferry263.5% Clark1,8795.4% Adams313.4% Skagit5485.2% Garfield113.3% Lewis4395.2% Pend Oreille433.1% Yakima9475.0% Wahkiakum163.0% Douglas2304.8% Lincoln392.9% Franklin1724.8%

7. Antipsychotics Used in 2010 and 2011 CategoryNpercent Typical antipsychotics76,79011.6% Haloperidol35,01945.6% Perphenazine11,85115.4% Fluphenazine9,28812.1% Thiothixene5,8167.6% Chlorpromazine5,3296.9% Loxapine3,3194.3% Thioridazine3,3094.3% Trifluoperazine2,8483.7% Atypical antipsychotics587,88588.4% Quetiapine229,00039.0% Risperidone172,01829.3% Aripiprazole77,16513.1% Clozapine49,4568.4% Ziprasidone46,0297.8% Paliperidone11,2421.9% Olanzapine2,9750.5%

8. WA Antipsychotic User Attributes CategoryNpercent Gender Women17,3556.3% Men12,6176.3% Race and ethnicity White25,4656.2% Black1,58612.8% Asian1,0574.2% Hispanic1,0626.5% Native American 4628.8% Age 21-6417,65919.1% 65 or older12,3133.2% Dual eligibility Dual eligible21,95915.7% Medicare only8,3882.5%

9. The Antipsychotic Atlas Project – What’s Next? Patterns of prescription drug events or PDEs (N=2.4 million) 1.Antipsychotic medication discontinuation a)Without replacement (nonadherence) b)With replacement (switching) 2.Excessive or subtherapeutic dosing 3.Simultaneous use of psychiatric medications (polypharmacy)

10. The Antipsychotic Atlas Project – What’s Next? Analysis of inpatient and outpatient services (fee for service beneficiaries; N=1.3 million claims) 1.Off-label prescribing rates (by drug, county and recipient attributes) 2.Adverse clinical outcomes (metabolic syndrome, stroke, thromboembolism)