Antipsychotic utilization, healthcare resource use and costs, and quality of care among fee-for-service Medicare beneficiaries with schizophrenia in the United States

Figures & data

Figure 1. Sample attrition.

Table 1. Characteristics of National Sample of Fee-for-Service Medicare Beneficiaries with Schizophrenia in 2019.

	Overall		LIS		Non-LIS
	N	%	N	%	N	%
N	314,888	100%	285,134	100%	29,754	100%
Age, mean (SD)	56.5 (15.0)		55.7 (14.9)		65.6 (13.4)
18–24	2,283	0.7	2,240	0.8	43	0.1
25–34	24,912	7.9	24,267	8.5	645	2.2
35–44	47,104	15.0	45,153	15.8	1,951	6.6
45–54	58,482	18.6	54,878	19.2	3,604	12.1
55–64	82,946	26.3	76,052	26.7	6,894	23.2
65–74	64,012	20.3	53,938	18.9	10,074	33.9
75–84	26,063	8.3	21,218	7.4	4,845	16.3
≥85	9,086	2.9	7,388	2.6	1,698	5.7
Sex
Female	129,778	41.2	114,622	40.2	15,156	50.9
Male	185,110	58.8	170,512	59.8	14,598	49.1
Race
White	206,118	65.5	182,439	64.0	23,679	79.6
Black	75,279	23.9	71,235	25.0	4,044	13.6
Hispanic	14,414	4.6	13,960	4.9	454	1.5
Other	19,077	6.1	17,500	6.1	1,577	5.3
Part D low-income subsidy (LIS) status
LIS	285,134	90.6	285,134	100.0	0	0.0
Full LIS	282,340	89.7	282,340	99.0	0	0.0
Dual eligibles	271,419	86.2	271,419	95.2	0	0.0
Partial LIS	2,794	0.9	2,794	1.0	0	0.0
Non-LIS	29,754	9.4	0	0.0	29,754	100.0
Original reason for Medicare eligibility
Age	40,421	12.8	31,824	11.2	8,597	28.9
Both disability and ESRD	537	0.2	499	0.2	38	0.1
Disability	273,473	86.8	252,379	88.5	21,094	70.9
ESRD	457	0.1	432	0.2	25	0.1
Census region
Midwest	77,906	24.7	69,833	24.5	8,073	27.1
Northeast	70,395	22.4	63,386	22.2	7,009	23.6
South	106,741	33.9	96,211	33.7	10,530	35.4
West	59,846	19.0	55,704	19.5	4,142	13.9
Metropolitan status
Rural	58,242	18.5	53,215	18.7	5,027	16.9
Urban	256,646	81.5	231,919	81.3	24,727	83.1
Type of schizophrenia disorder
Paranoid schizophrenia	91,386	29.0	83,349	29.2	8,037	27.0
Disorganized type schizophrenia	8,481	2.7	7,929	2.8	552	1.9
Catatonic type schizophrenia	2,649	0.8	2,259	0.8	390	1.3
Undifferentiated schizophrenia	18,724	5.9	17,303	6.1	1,421	4.8
Residual schizophrenia	7,083	2.2	6,421	2.3	662	2.2
Schizophreniform disorder	4,216	1.3	3,797	1.3	419	1.4
Other specific types	24,306	7.7	22,428	7.9	1,878	6.3
Schizophrenia, unspecified	180,526	57.3	165,974	58.2	14,552	48.9
Schizotypal disorder	1,997	0.6	1,702	0.6	295	1.0
Number of Elixhauser comorbidities
≤2	35,228	11.2	32,066	11.2	3,162	10.6
3–4	41,433	13.2	37,659	13.2	3,774	12.7
5+	238,227	75.7	215,409	75.5	22,818	76.7
Selected physical comorbidities^a
Hypertension	185,337	58.9	166,365	58.3	18,972	63.8
Congestive heart failure	32,470	10.3	29,056	10.2	3,414	11.5
Valvular disease	19,868	6.3	16,925	5.9	2,943	9.9
Peripheral vascular disease	61,032	19.4	55,490	19.5	5,542	18.6
Diabetes without chronic complications	103,931	33.0	94,786	33.2	9,145	30.7
Diabetes with chronic complications	71,185	22.6	64,822	22.7	6,363	21.4
Obesity	90,564	28.8	82,407	28.9	8,157	27.4
Hypothyroidism	72,108	22.9	64,292	22.5	7,816	26.3
Chronic pulmonary disease	88,257	28.0	80,767	28.3	7,490	25.2
Paralysis	14,957	4.7	13,954	4.9	1,003	3.4
Other neurological disorders	101,602	32.3	91,863	32.2	9,739	32.7
Renal failure	35,011	11.1	30,966	10.9	4,045	13.6
Liver disease	23,367	7.4	21,366	7.5	2,001	6.7
Deficiency anemias	81,984	26.0	74,419	26.1	7,565	25.4
HIV and AIDS	2,953	0.9	2,783	1.0	170	0.6
Selected mental comorbidities^b				0.0		0.0
Depressive disorders	110,847	35.2	99,385	34.9	11,462	38.5
Anxiety disorders	109,917	34.9	98,501	34.5	11,416	38.4
Substance-related and addictive disorders	91,847	29.2	85,991	30.2	5,856	19.7
Sleep-wake disorders	63,662	20.2	56,838	19.9	6,824	22.9
Trauma- and stressor-related disorders	26,158	8.3	23,664	8.3	2,494	8.4

Note: Selected sample characteristics by state are presented in Supplementary Table 5.

^aBased on Elixhauser comorbidities.

^bBased on DSM-V Mental comorbidities.

Figure 2. Antipsychotic utilization in the national sample of fee-for-service Medicare beneficiaries with schizophrenia in 2019, overall and by Part D low income subsidy status. Abbreviations. LIS, Low-income subsidy; AP, antipsychotic medication; OAP, oral antipsychotic medication; LAI, long-acting injectable.

Table 2. Annual healthcare resource utilization in the national sample of fee-for-service Medicare beneficiaries with schizophrenia in 2019, overall and by Part D low income subsidy status.

	Overall		LIS		Non-LIS
Outcome	Percent/Mean	SD	Percent/Mean	SD	Percent/Mean	SD
Number of beneficiaries with schizophrenia in 2019	314,888		285,134		29,754
All-cause: Any inpatient admission, %	27.6%		27.4%		29.7%
All-cause: Number of inpatient admissions among those with an admission, mean (SD)	2.0	1.7	2.0	1.7	1.9	1.6
All-cause: Total inpatient length of stay among those with an admission, mean (SD)	27.4	76.4	27.4	76.0	26.9	79.7
All-cause: Any ER visit, %	47.2%		47.4%		44.6%
All-cause: Number of ER visits among those with an ER visit, mean (SD)	4.3	6.0	4.3	6.1	4.0	5.1
All-cause: Any E&M visit, %	87.3%		86.7%		92.9%
All-cause: Number of E&M visits among those with an E&M visit, mean (SD)	9.6	7.9	9.5	7.8	10.6	8.2
Mental health-related: Any inpatient admission, %	26.9%		26.7%		28.5%
Mental health-related: Number of inpatient admissions among those with an admission, mean (SD)	1.9	1.6	1.9	1.6	1.9	1.4
Mental health-related: Total inpatient length of stay among those with an admission, mean (SD)	27.4	77.0	27.4	76.5	26.9	80.9
Mental health-related: Any ER visit, %	38.4%		38.7%		35.6%
Mental health-related: Number of ER visits among those with an ER visit, mean (SD)	3.1	4.3	3.1	4.3	2.7	3.4
Mental health-related: Any E&M visit, %	77.9%		77.2%		84.5%
Mental health-related: Number of E&M visits among those with an E&M visit, mean (SD)	5.8	4.6	5.8	4.6	5.7	4.4
Schizophrenia-related: Any inpatient admission, %	23.0%		23.1%		22.0%
Schizophrenia-related: Number of inpatient admissions among those with an admission, mean (SD)	1.7	1.4	1.8	1.4	1.6	1.1
Schizophrenia-related: Total inpatient length of stay among those with an admission, mean (SD)	27.8	81.4	27.9	80.6	27.0	89.5
Schizophrenia-related: Any ER visit, %	28.0%		28.4%		24.0%
Schizophrenia-related: Number of ER visits among those with an ER visit, mean (SD)	2.4	3.1	2.5	3.1	2.1	2.7
Schizophrenia-related: Any E&M visit, %	71.1%		70.7%		74.7%
Schizophrenia-related: Number of E&M visits among those with an E&M visit, mean (SD)	5.1	4.1	5.1	4.2	4.9	3.9

Abbreviations. LIS, Low-income subsidy; ER visits, emergency room visits; E&M visits, evaluation and management visits.

Table 3. Annual healthcare costs in the national sample of fee-for-service Medicare beneficiaries with schizophrenia in 2019, overall and by Part D low income subsidy status.

	Overall		LIS		Non-LIS
Outcome	Mean	SD	Mean	SD	Mean	SD
Number of beneficiaries with schizophrenia in 2019	314,888		285,134		29,754
All-cause: Total costs	$23,662	$31,923	$24,092	$31,940	$19,537	$31,466
All-cause: Medical costs	$13,335	$25,838	$13,201	$25,639	$14,627	$27,636
All-cause: Pharmacy costs	$10,326	$18,241	$10,892	$18,585	$4,909	$13,380
Mental health-related: Total costs	$15,000	$22,706	$15,363	$22,756	$11,529	$21,923
Mental health-related: Medical costs	$9,338	$20,795	$9,303	$20,736	$9,671	$21,352
Mental health-related: Pharmacy costs	$5,662	$10,146	$6,059	$10,449	$1,858	$5,206
Schizophrenia-related: Total costs	$12,109	$19,805	$12,566	$20,023	$7,738	$16,964
Schizophrenia-related: Medical costs	$6,921	$17,287	$6,997	$17,399	$6,187	$16,151
Schizophrenia-related: Pharmacy costs	$5,189	$9,952	$5,568	$10,261	$1,552	$4,955

Abbreviation. LIS, Low-income subsidy.

Table 4. Quality measures in the national sample of fee-for-service Medicare beneficiaries with schizophrenia in 2019, overall and by Part D low income subsidy status.

Outcome	Overall	LIS	Non-LIS
Number of beneficiaries using antipsychotics in 2019	284,888	259,775	25,113
Antipsychotic adherence: PDC ≥ 0.80	80.9%	81.3%	76.5%
Number of beneficiaries with hospitalization in 2019	86,922	78,091	8,831
Inpatient readmission within 7 days of discharge	18.4%	18.1%	21.2%
Inpatient readmission within 30 days of discharge	27.3%	27.1%	29.0%
Any E&M physician visit within 30 days of discharge	55.6%	55.0%	60.9%
Antipsychotic dispensed within 30 days of discharge	67.1%	68.3%	57.1%

Abbreviations. LIS, Low-income subsidy; PDC, proportion of days covered; E&M visits, evaluation and management visits.

Table 5. State and county-level variations in selected measures of antipsychotic utilization, healthcare resource utilization, costs, and quality of care in a national sample of fee-for-service Medicare beneficiaries with schizophrenia, 2019.

	State level						County level
	Mean	Median	25th percentile	75th percentile	Interquartile range	Co-efficient of variation	Mean	Median	25th percentile	75th percentile	Interquartile range	Co-efficient of variation
Antipsychotic utilization
Any AP	90.6%	90.8%	89.7%	91.7%	2.0%	0.02	90.8%	91.4%	88.1%	94.3%	6.2%	0.06
Any SGA AP	82.6%	82.1%	80.5%	84.8%	4.3%	0.04	82.6%	83.3%	78.3%	87.8%	9.5%	0.09
Any LAI	21.0%	20.8%	17.7%	23.5%	5.8%	0.21	20.2%	19.4%	14.3%	25.3%	11.0%	0.44
Any SGA LAI	14.9%	14.4%	11.7%	17.2%	5.5%	0.28	14.2%	13.5%	9.1%	18.5%	9.4%	0.53
OAP only	69.6%	70.2%	67.1%	72.2%	5.1%	0.07	70.7%	71.2%	64.6%	76.9%	12.3%	0.14
Any SGA OAP only	64.6%	65.3%	61.5%	68.0%	6.5%	0.07	65.4%	65.6%	59.0%	71.8%	12.8%	0.16
Health resource utilization
All-cause: Any inpatient admission	26.9%	26.0%	24.7%	29.0%	4.3%	0.11	26.4%	25.9%	21.1%	31.3%	10.2%	0.34
All-cause: Number of inpatient admissions  among those with an admission	1.9	1.9	1.8	2.0	0.2	0.08	1.9	1.8	1.5	2.1	0.6	0.31
All-cause: Total inpatient length of stay among  those with an inpatient admission	26.8	21.8	19	32.5	13.5	0.44	22.4	17.2	12.2	24.6	12.4	1.07
All-cause: Any ER visits	47.4%	47.0%	45.5%	49.1%	3.6%	0.06	47.1%	47.0%	41.4%	52.7%	11.3%	0.21
All-cause: Number of ER visits among  those with an ER visit	4.2	4.2	4.0	4.5	0.5	0.11	3.9	3.7	3.1	4.5	1.4	0.33
All-cause: Any E&M visit	89.6%	90.1%	86.5%	93.3%	6.8%	0.05	88.9%	90.9%	84.8%	94.7%	9.9%	0.10
Mental health-related: Any inpatient admission	26.3%	25.5%	24.3%	28.2%	3.9%	0.11	25.7%	25.0%	20.3%	30.4%	10.1%	0.34
Mental health-related: Number of inpatient  admissions among those with an admission	1.9	1.8	1.8	2.0	0.2	0.07	1.8	1.8	1.5	2.0	0.5	0.30
Mental health-related: Total inpatient length  of stay among those with an admission	26.8	21.5	18.6	32.8	14.2	0.45	22.4	17	11.9	24.2	12.3	1.09
Mental health-related: Any ER visits	38.3%	38.2%	37.0%	39.7%	2.7%	0.07	36.8%	37.3%	31.3%	42.5%	11.2%	0.27
Mental health-related: Number of ER  visits among those with an ER visit	3.2	3.1	2.9	3.4	0.5	0.14	2.8	2.7	2.2	3.3	1.1	0.37
Mental health-related: Any E&M visit	81.7%	82.9%	76.7%	87.1%	10.4%	0.08	80.1%	82.4%	73.9%	88.9%	15.0%	0.16
Schizophrenia-related: Any inpatient admission	22.8%	22.3%	21.4%	23.9%	2.5%	0.10	21.5%	21.4%	16.7%	25.8%	9.1%	0.37
Schizophrenia-related: Number of inpatient  admissions among those with an admission	1.7	1.7	1.6	1.8	0.1	0.06	1.6	1.6	1.3	1.8	0.5	0.31
Schizophrenia-related: Total inpatient length  of stay among those with an admission	26.7	20.8	18	33.5	15.5	0.48	22	15.8	10.8	23.4	12.6	1.24
Schizophrenia-related: Any ER visits	28.0%	27.5%	25.5%	30.6%	5.1%	0.11	25.3%	25.4%	19.7%	30.9%	11.2%	0.36
Schizophrenia-related: Number of ER visits  among those with an ER visit	2.5	2.3	2.2	2.7	0.5	0.16	2.2	2.1	1.7	2.5	0.9	0.38
Schizophrenia-related: Any E&M visit	75.6%	76.3%	69.3%	82.3%	13.0%	0.10	73.6%	75.9%	66.2%	83.3%	17.1%	0.19
Healthcare Costs
All-cause: Total costs	$23,048	$22,905	$21,918	$24,345	$2,427	0.08	$22,292	$21,887	$18,894	$25,081	$6,187	0.24
Mental health-related: Total costs	$14,860	$14,731	$13,800	$15,942	$2,142	0.09	$13,892	$13,714	$11,435	$16,041	$4,606	0.28
Schizophrenia-related: Total costs	$12,235	$12,184	$11,056	$13,361	$2,305	0.12	$11,141	$10,870	$8,824	$13,121	$4,297	0.32
Quality measures
Antipsychotic adherence: PDC ≥ 0.8	81.0%	81.8%	77.3%	84.6%	7.3%	0.05	80.8%	81.8%	75.5%	86.7%	11.2%	0.11
Inpatient readmission within 7 days of discharge	17.9%	17.9%	16.0%	19.6%	3.6%	0.14	17.7%	17.6%	12.5%	22.7%	10.2%	0.46
Inpatient readmission within 30 days of discharge	26.4%	26.4%	24.5%	28.3%	3.8%	0.11	26.4%	26.4%	20.0%	32.5%	12.5%	0.37
Any E&M physician visit within 30 days of discharge	59.8%	59.8%	53.9%	66.2%	12.3%	0.12	58.6%	58.7%	50.0%	66.7%	16.7%	0.23
Antipsychotic dispensed within 30 days of discharge	69.0%	69.2%	65.6%	72.4%	6.8%	0.08	68.7%	69.6%	61.8%	76.5%	14.7%	0.17

Abbreviations. AP, Antipsychotic medication; OAP, oral antipsychotic medication; LAI, long-acting injectable; ER visits, emergency room visits; E&M visits, evaluation and management visits; PDC, proportion of days covered.

Data availability statement

The data that support the findings of this study are not publicly available due to privacy restrictions.