Appropriateness of Psychopharmaco-logical Medication.

Abstract

To the Editor: We read with great interest the recent article by Wei et al.1 that examined the appropriateness of psychopharmacological medication use in the nursing home population. Documenting the appropriateness of drug use in nursing homes is critical to ensure that residents do not receive medications with known risks and little benefit. Previous studies and a government report document a much higher prevalence of inappropriate use,2-6 so we were surprised to read that the authors found that more than 90% of antipsychotic use in nursing homes was defined as appropriate. Appropriateness of indication and dose were defined in this study, as well as a previous study from the same team,7 using the Centers for Medicare and Medicaid Services (CMS) Unnecessary Medications Guidance indexed in appendix PP,8 although the old and new versions of the CMS Unnecessary Medications Guidance both clearly state that “diagnoses alone do not warrant the use of antipsychotic medications.”8, 9 As described in F329, the survey tag under which guidelines for unnecessary medication is provided, CMS additional criteria define appropriate use beyond indication, dose, and duration. For example, documentation of failed attempts at nonpharmacological interventions or gradual dose reductions is required (Table 1). It is unclear from the methods whether any of these additional criteria were used in defining “appropriate antipsychotic medication use.” Furthermore, we are concerned that the use of a 6-month window to determine appropriateness of use for acute conditions contributed to misclassification of appropriate antipsychotic use. According to F329, the treatment period for acute conditions is limited to 7 days unless documentation provided by a clinician justifies further use and nonpharmacological interventions are ineffective. Although recent national efforts have led to promising reductions in inappropriate antipsychotic use, CMS reminds us that further reductions of antipsychotic medications by 25% by the end of 2015 and 30% by the end of 2016 are still warranted in long-stay nursing home residents.10 Conflict of Interest: Drs. Lapane and Tjia are funded by National Institute on Aging Grant AG046839–01 evaluating inappropriate use of antipsychotics in hospitals. Dr. Lapane is principal investigator. She also has served as a consultant to Janssen on use of antipsychotics in patients with schizophrenia. Author Contributions: All authors participated in drafting and review of the letter. Sponsor's Role: None.