Home Quality Research Articles

Priorities for End-of-Life Care Reporting in Nursing Homes: Results From a Mixed-Methods Study

The aim of the “Trajectories” project is to compile measures of nursing home (NH) quality to better characterize the final year of life for residents. In the first phase, we worked with various stakeholder groups to identify their priorities to focus the selection of possible outcomes relevant to end-of-life needs. Policy- and decision-makers from 5 Canadian health regions participated in an on-line, modified Delphi process to reach consensus on 3-4 measures of each burdensome symptoms and potentially inappropriate care practices. NH residents and families or care aides participated in an interview process using the Action Project Method. To date, all participants identified pain, mental health care, polypharmacy, and dyspnea as priorities. Policy- and decision-makers additionally identified infections and acute care transfers as priorities, while residents and families additionally identified mobility, cognition, and pressure ulcer care as priorities. There was general consistency across groups in terms of priorities but additional measures seemed to reflect either a system-wide or more personal perspective, depending on the source. Data collection with frontline staff and managers is on-going. Moving forward, we will use this list of prioritized outcomes to quantitatively assess the trajectories of these outcomes and associated factors, and to create a profile that allows for monitoring of end-of-life care in NHs.

Bridging the Gap in Quality Among High Medicaid Nursing Homes: The Role of Management and Community Factors

Nursing home quality has been a matter of long-standing policy interest at the federal and state level, as it concerns the health and well-being of one of our most vulnerable populations. Mor et al. (2004) described the nursing home industry as a ‘two-tiered’ system, with the lower-tier nursing homes operating in a resource-constrained environment given their high proportion of Medicaid residents (85% or higher). Medicaid is the largest payer of nursing homes but its reimbursement rates typically lag Medicare as well as private pay. Lower tier facilities are characterized by lower professional staffing and occupancy rates, and worse quality. Such facilities have a higher proportion of minority residents and are generally located in communities with significant proportions of poor and minority residents, exacerbating the existing disparities in nursing home care. However, there are performance variations among high Medicaid nursing homes, with some facilities performing significantly better than others on both quality and financial performance. What may explain the superior performance of certain nursing homes that are operating in a similarly resource-constrained environment? Factors, such as management resources and environmental resource availability, may be the critically important differentiators. The purpose of this symposium is to examine the organizational/management and community factors that may be associated with high-performance among a similar group of resource-constrained nursing homes. Using survey, secondary, and qualitative data analysis, this symposium will explore the role that culture change, leadership style, human resource management practices, knowledge management, and community factors can have on nursing home performance.

The Impact of Leadership Styles on Quality and Financial Performance in High Medicaid Nursing Homes

This study examines the association between leadership styles on resident quality and financial performance in under resourced nursing homes (70% or higher Medicaid census). The Bonoma/Slevin leadership model was used to classify managers into four categories, autocrat, consultative autocrat, consensus manager, and shareholder manager. Survey data from 391 nursing home directors (response rate of 37%) from 2017- 2018, were merged with secondary data from LTCFocus, Area Health Resource File, Medicare Cost Reports, and Nursing Home Compare. Two models were ran to examine the effect of leadership styles on the dependent variable(s) nursing home STAR data (quality) and operating margin (financial performance). The independent variables were composite scores for leadership styles, with autocrat as the reference group. Control variables included organizational (ownership, chain affiliation, size, occupancy, payer mix, staffing, and race/ethnicity), and county factors (Medicare Advantage penetration, per capita income, poverty, education, unemployment, and competition). Multivariate regression was used to model the relationship between leadership styles and nursing home quality and financial performance. The consultative autocrat was associated with lower quality (p < 0.05), while the consensus manager was associated with lower profit margin (p < 0.05), as compared to autocratic leadership. The consultative autocrat, who solicits information from the staff yet still makes all significant decisions, is associated in lower quality; however, a consensus manager, who delegates their authority to the group, is associated with lower financial performance. Under-resourced nursing homes who face dual pressures need to recognize trade-offs of different decision making styles for quality and financial performance.

Age Matters: Building Blocks Needed to Inform Nurse Staffing Hours Requirements in Residential Care for Older Adults

This study addresses the need for more complete information about the impact of nurse staffing hours (NSH) on nursing home quality of care. We used national data to examine the relationship between three types (Registered Nurse, Licensed Practical Nurse, and Nurse Aide) of hours, and long-stay quality of care measures over time, taking into account the possible confounding influence of regional differences. Data analyzed were from U.S. Nursing Home Compare datasets which reflect quarterly reports, July 1, 2018 - June 30, 2019 (14,768 facilities). The hours for each staff type in each facility were compared with the facility’s four-quarter quality average scores for each of the 12 measures. Results showed only one strong and statistically significant relationship (Beta= .548; p< .001) between Nurse Aide hours and the quality measure used in data sets to exemplify facilities that serve “lower-risk” residents. Analyzes using multiple R (.517) indicate that the linear combination of the three NSH types strongly and significantly (p< .001) predicted the four-quarter average scores and explained 27% of the variance in the scores. Holding the other two NSH types constant, the scores for that measure increased by 63 for each additional increase in the Nurse Aide nurse staffing hours per resident per day. There was no multicollinearity among the three types of staffing hours. This research adds information to the foundation needed for future research about process indicators to assess their efficacy as measures of actual quality of care, and will be submitted as a Technical Note to journals.

Culture Change Initiatives in High Medicaid Nursing Homes: Does Time of Adoption Make a Difference?

Racial/ethnic disparities have been well documented in long-term care literature. As the population ages and becomes more diverse over time, it is essential to identify mechanisms that may eliminate or mitigate racial/ethnic disparities. Culture change is a movement to transition nursing homes to more home-like environments. The literature on culture change initiatives and quality has been mixed, with little to no literature on the use of culture change initiatives in high Medicaid nursing homes and quality. The purpose of this study was to examine how the involvement of culture change initiatives among high Medicaid facilities was associated with nursing home quality. The study relied on both survey and secondary nursing home data for the years 2017-2018. The sample included high Medicaid (85% or higher) nursing homes. The outcome of interest was the overall nursing home star rating obtained from the Nursing Home Compare Five-Star Quality Rating System. The primary independent variable of interest was the years of involvement in culture change initiatives among nursing homes, which was obtained from the nursing home administrator survey. The final model consisted of an ordinal logistic regression with state-level fixed effects. High-Medicaid nursing homes with six or more years in culture change initiatives had higher odds of having a higher star rating, while facilities with one year or less had significantly lower odds of having a higher star rating. Culture change initiatives may require some time to effectively implement, but these initiatives are potential mechanisms to improve quality in high Medicaid nursing homes.

Culture Change and Quality Star Ratings in High Medicaid Nursing Homes: Does Time of Adoption Make a Difference?

Racial/ethnic disparities have been well documented in long-term care literature. Culture change is a movement to transition nursing homes to more home-like environments to improve the quality of care for all residents. The purpose of this study was to examine how the involvement of culture change initiatives among high Medicaid facilities was associated with nursing home quality. The study relied on both survey and secondary nursing home data for the years 2017-2018. The sample included high Medicaid facilities. The final model consisted of an ordinal logistic regression. High-Medicaid nursing homes with six or more years in culture change initiatives had higher odds of having a higher star rating, while facilities with one year or less had significantly lower odds of having a higher star rating. Culture change initiatives may require some time to effectively implement, but these initiatives are potential mechanisms to improve quality in high Medicaid nursing homes.

Posthospital Nursing Home Utilization and Quality Indicators Among Medicare Beneficiaries in Puerto Rico: Comparison With the United States

ObjectivesThe purpose of the study is to contribute to the literature regarding post-acute nursing home utilization and quality indicators among Medicare beneficiaries in Puerto Rico compared with the US mainland. DesignMedicare data from 2015 to 2017 was used to identify new discharges to skilled nursing facilities (SNFs) using the Minimum Data Set and the Medicare Provider Analysis and Review. Setting and ParticipantsPost-acute care patients admitted to SNFs in Puerto Rico and the United States. MethodsOur final cohort included 4,732,222 beneficiaries from Puerto Rico and the United States enrolled in Medicare fee-for-service or Medicare Advantage programs admitted to an SNF (N = 15,197) following an acute hospital stay. We compared demographic, clinical, and facility-level characteristics among patients in Puerto Rico and the United States. We also described 2 quality indicators among these groups: (1) 30-day rehospitalization rates and (2) successful discharge from the facility to the community. ResultsMedicare patients in Puerto Rico were physically and cognitively healthier than patients in the United States. Puerto Ricans were also more likely to be admitted to lower quality nursing homes than US patients (2.5 vs 3.4). Finally, Puerto Ricans had higher rates of successful discharge to the community [17.6, 95% confidence interval (CI) 13.0-22.3], but higher 30-day rehospitalization rates compared with US patients (11.2, 95% CI 6.2-16.3). These differences were consistent even when comparing these quality outcomes among Puerto Ricans to US Hispanics only. Conclusions and ImplicationsSNFs in the United States and Puerto Rico are now receiving financial penalties for high readmission rates. Currently, Medicare does not measure readmission rates for Medicare Advantage patients—even though some states, including Puerto Rico, have a high proportion of Medicare Advantage beneficiaries. As Medicare Advantage enrollment continues to increase, our results highlight the importance of measuring performance among Medicare Advantage patients and assessing disparities in quality of post-acute care among patients in Puerto Rico and the United States.

Assessing Nursing Homes Quality Indicators' Between-Provider Variability and Reliability: A Cross-Sectional Study Using ICCs and Rankability.

Nursing home quality indicators are often used to publicly report the quality of nursing home care. In Switzerland, six national nursing home quality indicators covering four clinical domains (polypharmacy, pain, use of physical restraints and weight loss) were recently developed. To allow for meaningful comparisons, these indicators must reliably show differences in quality of care levels between nursing homes. This study’s objectives were to assess nursing home quality indicators’ between-provider variability and reliability using intraclass correlations and rankability. This approach has not yet been used in long-term care contexts but presents methodological advantages. This cross-sectional multicenter study uses data of 11,412 residents from a convenience sample of 152 Swiss nursing homes. After calculating intraclass correlation 1 (ICC1) and rankability, we describe between-provider variability for each quality indicator using empirical Bayes estimate-based caterpillar plots. To assess reliability, we used intraclass correlation 2 (ICC2). Overall, ICC1 values were high, ranging from 0.068 (95% confidence interval (CI) 0.047–0.086) for polypharmacy to 0.396 (95% CI 0.297–0.474) for physical restraints, with quality indicator caterpillar plots showing sufficient between-provider variability. However, testing for rankability produced mixed results, with low figures for two indicators (0.144 for polypharmacy; 0.471 for self-reported pain) and moderate to high figures for the four others (from 0.692 for observed pain to 0.976 for physical restraints). High ICC2 figures, ranging from 0.896 (95% CI 0.852–0.917) (self-reported pain) to 0.990 (95% CI 0.985–0.993) (physical restraints), indicated good reliability for all six quality indicators. Intraclass correlations and rankability can be used to assess nursing home quality indicators’ between-provider variability and reliability. The six selected quality indicators reliably distinguish care differences between nursing homes and can be recommended for use, although the variability of two—polypharmacy and self-reported pain—is substantially chance-driven, limiting their utility.

Factors Affecting Nursing Home Quality of Life in Residents With Dementia.

Factors Affecting Nursing Home Quality of Life in Residents With Dementia.

Families' and Residents' Perspectives of the Quality of Nursing Home Care: Implications for Composite Quality Measures

ObjectivesTo assess (1) the relationship of consumers' assessment of overall nursing home quality to their assessment of specific dimensions of quality; and (2) the implications of this relationship for composite quality measures in Nursing Home Compare. DesignA survey conducted in 2017 elicited respondents' assessments of the quality of overall care and 13 specific dimensions of care. Settings and ParticipantsThe sample consisted of 4449 respondents who either resided in a nursing home or had a family member who resided in a nursing home during the 6 months before the survey. MethodsWe estimated regression models to infer the relationship between consumers' assessments of overall quality and 13 specific dimensions of quality. The regression coefficients, indicating the implicit importance/weight assigned by respondents to each dimension as a component of the consumers' assessment of overall quality, were used to create a prototype composite quality measure. ResultsFor long-stay residents, 8 of the 13 quality dimensions were significantly associated with their overall ratings of quality. Five dimensions achieved significance for short-stay residents. The magnitude of importance weights varied substantially across dimensions of care. Conclusions and ImplicationsOur findings suggest that Nursing Home Compare could be improved by augmenting the technical information in the 5-Star composite measure with consumers' assessments of the additional, nontechnical dimensions of quality.

The relationship of nursing home price and quality of life

BackgroundKnowledge about the relationship between the residents’ Quality of Life (QOL) and the nursing home price is currently lacking. Therefore, this study investigates the relationship between 11 dimensions of QOL and nursing homes price in Flemish nursing homes.MethodsThe data used in this cross-sectional study were collected by the Flemish government from years 2014 to 2017 and originates from 659 Flemish nursing homes. From 2014 to 2016, data on the QOL of 21,756 residents was assessed with the InterRAI instrument. This instrument contains 11 QOL dimensions. Multiple linear regression analyses were conducted to examine the research question.ResultsThe multiple linear regressions indicated that a 10 euro increase in the daily nursing home price is associated with a significant decrease (P < 0.001) of 0.1 in 5 dimensions of QOL (access to services, comfort and environment, food and meals, respect, and safety and security). Hence, our results indicate that the association between price and QOL is very small. When conducting a subgroup analysis based on ownership type, the earlier found results remained only statistically significant for private nursing homes.ConclusionOur findings show that nursing home price is of limited importance with respect to resident QOL. Contrary to popular belief, our study demonstrates a limited negative effect of price on QOL. Further research that includes other indicators of QOL is needed to allow policymakers and nursing home managers to improve nursing home residents’ QOL.

Five-Star Ratings and Managerial Turnover: Evidence from the Nursing Home Industry

AbstractThe government-sponsored Five-Star Quality Rating System (FSQRS) aggregates multiple measures of nursing home quality into a standardized overall rating. Previous research has found that the FSQRS affected consumer demand and correspondingly motivated a strategic shift toward competing for higher ratings, most notably among nursing homes in more competitive markets. The primary objective of this article is to provide evidence on whether it produced a complementary change in the weight placed on quality ratings in senior management retention decisions. Using the Florida nursing home administrator files from 2007 to 2013, our analysis reveals that the FSQRS motivated a substantial and significant increase in the sensitivity of administrator turnover to star ratings, particularly in more competitive nursing home markets (JEL I18, L15, J63, G24, G34).

Assuring Quality in Nursing Homes: The Black Box of Administrative and Clinical Leadership-A Scoping Review.

Licensed nursing home administrators (NHA) and directors of nursing (DON) are responsible for nursing home quality and assuring optimal performance and job satisfaction/retention of their nursing home workforce. NHA/DON-focused studies have generated important foundational knowledge over the last three decades; yet, targeted research is needed to understand and apply the complexities of the black box of this top management team. This scoping review identifies, reviews, synthesizes, and maps the topical areas of research in NHA/DON positions in U.S. nursing homes. We conducted searches of 5 databases, yielding 3,479 records; screening/review yielded 88 unique records. We used thematic analysis to code the primary foci of the studies and the variables associated with the concepts of interest. Most papers (n = 40) focused on role characteristics, 23 examined approaches to management and leadership, 24 focused on perceptions about the role, and the remaining 12 examined role structure. The role-related themes linked to outcomes (n = 42), processes (n = 27), and structures (n = 30). We highlight important gaps for future research and offer a call to action for research, policy, practice, and education collaborations to accelerate the rate of research and translate the findings into best practices for NHA/DON to lead and manage the nursing home workforce and build capacity to ensure person-centered, high-quality care. Based on foundational descriptive studies, it is time to use what is known to design and implement interventions that enhance the capacity of NHA/DON to improve the structures, processes, and outcomes of nursing homes.

Perception on service quality in old age homes: A qualitative study in Karachi, Pakistan.

The growing number of older people due to demographic transition is paving the way for nongovernmental organizations and the private sector for mushrooming of old age homes (OAHs). These homes function either free or fee for services and the services provided at these OAHs determines the quality of life of older people. The aim of the study was to explore the stakeholders' perception on the quality of services offered to people living in OAHs. A descriptive qualitative study design was used to explore stakeholders' perception of elderly living experiences in old age homes. Three OAH were selected through purposive sampling for the study. Data collected from February-March 2015 through the structured interview guide. Participants' for FGDs were recruited through universal sampling, while purposive sampling was used for KIIs selection. Researcher ensured all ethical considerations for the entire study period. Two major themes were drawn including the reasons and experiences of older people living in OAH, secondly the need for caregivers' academic competencies. Majority of KIIs and FGDs reported common responses under the two themes. Also the elderly experiences varied from living comfortably to being depressed. KIIs and caregivers' FGD participants' strongly urged the need for caregivers' training and institutional accreditation. The results of the study on the older people's experiences and challenges of living in OAHs, strongly propose community support system and credentialing of the caregivers for age appropriate care. Moreover the capacity building of academia for offering specialized training in gerontology and geriatrics is also highlighted.

Association of Patient-Centered Medical Home designation and quality indicators within HRSA-funded community health center delivery sites

BackgroundPatient-Centered Medical Home (PCMH) adoption is an important strategy to help improve primary care quality within Health Resources and Service Administration (HRSA) community health centers (CHC), but evidence of its effect thus far remains mixed. A limitation of previous evaluations has been the inability to account for the proportion of CHC delivery sites that are designated medical homes.MethodsRetrospective cross-sectional study using HRSA Uniform Data System (UDS) and certification files from the National Committee for Quality Assurance (NCQA) and the Joint Commission (JC). Datasets were linked through geocoding and an approximate string-matching algorithm. Predicted probability scores were regressed onto 11 clinical performance measures using 10% increments in site-level designation using beta logistic regression.ResultsThe geocoding and approximate string-matching algorithm identified 2615 of the 6851 (41.8%) delivery sites included in the analyses as having been designated through the NCQA and/or JC. In total, 74.7% (n = 777) of the 1039 CHCs that met the inclusion criteria for the analysis managed at least one NCQA- and/or JC-designated site. A proportional increase in site-level designation showed a positive association with adherence scores for the majority of all indicators, but primarily among CHCs that designated at least 50% of its delivery sites. Once this threshold was achieved, there was a stepwise percentage point increase in adherence scores, ranging from 1.9 to 11.8% improvement, depending on the measure.ConclusionGeocoding and approximate string-matching techniques offer a more reliable and nuanced approach for monitoring the association between site-level PCMH designation and clinical performance within HRSA’s CHC delivery sites. Our findings suggest that transformation does in fact matter, but that it may not appear until half of the delivery sites become designated. There also appears to be a continued stepwise increase in adherence scores once this threshold is achieved.

Home Team (Dis)Advantage Patterns in the National Hockey League: Changes Through Increased Emphasis on Individual Performance With the 3-on-3 Overtime Rule.

Past research examining National Hockey League (professional ice hockey; NHL) data from the 4-on-4 overtime era (seasons between 2005-06 and 2013-14) revealed an inconsistent home team (dis)advantage pattern such that home teams that were superior to their visiting counterparts had slightly greater odds of winning during regulation play compared to overtime (demonstrating home crowd advantages for team performance during regulation); in contrast, home teams experienced lower odds of winning in the shootout period than in overtime regardless of team quality (thereby demonstrating risks for individual choking from home crowd pressures). In this study, we explored the NHL home (dis)advantage pattern during four more recent seasons (2015-16 through 2018-19) in which the league instituted 3-on-3 play during overtime (perhaps increasing individual pressure for athletes competing in the 3-on-3 overtime period). We used archival data from the regular season (N=5,002 games) to compare home teams' odds of winning in regulation (with 5-on-5 skaters per team) to overtime (with 3-on-3) and in the shootout, adjusting for the quality of home and visiting teams. We conducted fixed-effects and multi-level logistic regression modeling. Evenly matched home teams were 1.66 times more likely to win than inferior home teams when games concluded in regulation versus overtime. Superior home teams were 4.24 times more likely to win than inferior home teams when games concluded in regulation rather than overtime. Thus, it is apparently more difficult for superior and evenly matched home teams to win in overtime than during regulation, suggesting that such home teams may be susceptible to choking in overtime. In contrast to the earlier 4-on-4 overtime era, home teams did not have lower odds of winning in the shootout compared to overtime. These results may have implications for NHL coaches' and players' tactical decision-making.

Nursing home residents’ ADL status, institution-dwelling and association with outdoor activity: a cross-sectional study

IntroductionThe Norwegian regulations for nursing homes consider access to meaningful activities to be an indicator for the quality of nursing homes. Activities of daily living (ADL) provide important basic self-care skills for nursing home residents. Due to the physical changes caused by ageing and comorbidities, nursing home residents may experience functional decline over time, which may affect their ability to perform meaningful ADL, such as outdoor activity, which is considered a valuable and meaningful activity in Norwegian culture. This study aimed to investigate the association between ADL status, institution-dwelling and outdoor activity among nursing home residents.MethodsThis cross-sectional study included 784 residents aged >67 years living in 21 nursing homes in 15 Norwegian municipalities between November 2016 and May 2018. The Barthel Index was used to assess the nursing home residents’ ADL status. Other variables collected were age, gender, body weight and height, visits per month, institution, ward, and participation in weekly outdoor activities. Descriptive statistics were used to provide an overview of the residents’ characteristics. A Poisson regression model was used to test the association between the outdoor activity level as the dependent variable and ADL score, institution, and other control variables as independent variables.ResultsMore than half (57%) of the nursing home residents in this sample did not go outdoors. More than 50% of the residents had an ADL score <10, which indicates low performance status. Further, we found that residents’ ADL status, institution, ward, and number of visits had an impact on how often the residents went outdoors.DiscussionThe nursing home residents in this study rarely went outdoors, which is interesting because Norwegians appreciate this activity. Differences in the number of visits might explain why some residents went outdoors more often than other residents did. Our findings also highlight that the institutions impact the outdoor activity. How the institutions are organized and how important this activity is considered to be in the institutions determine how often the activity is performed.ConclusionThe low frequency of the outdoor activities might be explained by a low ADL score. More than 50% of the residents had an ADL score <10, which indicates low performance status. Despite regulations for nursing home quality in Norway, this result suggests that organizational differences matter, which is an important implication for further research, health policy and practice.

Evaluation of 1-Year in-Home Monitoring Technology by Home-Dwelling Older Adults, Family Caregivers, and Nurses.

Introduction: Population aging is increasing the needs and costs of healthcare. Both frailty and the chronic diseases affecting older people reduce their ability to live independently. However, most older people prefer to age in their own homes. New development of in-home monitoring can play a role in staying independent, active, and healthy for older people. This 12-month observational study aimed to evaluate a new in-home monitoring system among home-dwelling older adults (OA), their family caregivers (FC), and nurses for the support of home care.Methods: The in-home monitoring system evaluated in this study continuously monitored OA's daily activities (e.g., mobility, sleep habits, fridge visits, door events) by ambient sensor system (DomoCare®) and health-related events by wearable sensors (Activity tracker, ECG). In the case of deviations in daily activities, alerts were transmitted to nurses via email. Using specific questionnaires, the opinions of 13 OA, 13 FC, and 20 nurses were collected at the end of 12-months follow-up focusing on user experience and the impact of in-home monitoring on home care services.Results: The majority of OA, FC, and nurses considered that in-home sensors can help with staying at home, improving home care and quality of life, preventing domestic accidents, and reducing family stress. The opinion tended to be more frequently favorable toward ambient sensors (76%; 95% CI: 61–87%) than toward wearable sensors (Activity tracker: 65%; 95% CI: 50–79%); ECG: 60%; 95% CI: 45–75%). On average, OA (74%; 95% CI: 46–95%) and FC (70%; 95% CI: 39–91%) tended to be more enthusiastic than nurses (60%; 95% CI: 36–81%). Some barriers reported by nurses were a fear of weakening of the relationship with OA and lack of time.Discussion/Conclusion: Overall, the opinions of OA, FC, and nurses were positively related to in-home sensors, with nurses being less enthusiastic about their use in clinical practice.

Inside the Black Box of Improving on Nursing Home Quality Measures.

Nursing Home Compare (NHC) reports quality measures (QMs) for nursing homes (NHs) as part of its 5-star rating system. Most of the QMs are based on facility self-reported data, prompting questions about their validity. To better understand how NHs interact with the QMs, we used qualitative methods, including semistructured interviews with NH personnel (n = 110), NH provider association representatives (n = 23), and observations of organizational processes in 12 NHs in three states. We found that most NHs are working to improve the quality of care they provide, not merely their QM scores. However, our interviews and observations revealed limitations with the QMs, suggesting that the QMs-on their own-may not accurately reflect the quality of care NHs provide. Our findings suggest several changes to improve NHC, including adding information related to resident and family experience, providing greater risk adjustment, and providing incentives for NHs that serve socially and medically complex residents.

Decrease of Anticholinergic Drug Use in Nursing Home Residents in the United States, 2009 to 2017.

To investigate the time course of anticholinergic drug use in nursing home residents and assess if any temporal change in anticholinergic use varied by nursing home quality rating. Retrospective repeated cross-sectional analysis of Medicare enrollment, Parts A, B, and D, claims data linked to the Minimum Data Set from 2009 to 2017. Medicare-certified nursing homes. Long-term residents 65 years or older with nursing home stay of at least 100 consecutive days within a given calendar year. Estimates of anticholinergic drug prescription rates between 2009 and 2017 were based on a binary variable indicating whether a resident received a drug with high anticholinergic activity, as defined by the Anticholinergic Cognitive Burden scale, for at least 1 day during the initial 100 consecutive days of nursing home stay in a given calendar year. We used mixed effects logistic regression models to determine adjusted rates of anticholinergic use each year and test the interaction between nursing home quality rating and year, while adjusting for patient and nursing home characteristics. The cohort included 786,858 100-day nursing home stays (299,354 unique residents) in 6,703 nursing homes for the years 2009 to 2017. Prescription rates were stable at approximately 34% to 35% between 2009 and 2011, then gradually decreased to 24.3% in 2017 (P < .0001), with the decline being more pronounced in nursing homes having high quality ratings (P < .0001). Rates for anticholinergic drugs in nursing homes with 4 to 5 star quality rating (33.7% in 2011 to 23.3% in 2017) showed a steeper decline over time relative to nursing homes with 1 to 2 star quality rating (34.2% in 2011 to 25.2% in 2017) (P < .0001). The use of drugs with high anticholinergic activity has declined from 2009 to 2017, with a greater decline in higher-quality nursing homes.