Inappropriate Antipsychotic Use Research Articles

Staffing and Antipsychotic Medication Use in Nursing Homes and Neighborhood Deprivation

Inappropriate use of antipsychotic medications in nursing homes is a growing public health concern. Residents exposed to higher levels of socioeconomic deprivation in the area around a nursing home may be currently exposed, or have a long history of exposure, to more noise pollution, higher crime rates, and have less opportunities to safely go outside the facility, which may contribute to psychological stress and increased risk of receiving antipsychotic medications inappropriately. However, it is unclear whether neighborhood deprivation is associated with use of inappropriate antipsychotic medications and whether this outcome is different by facility staffing levels. To evaluate whether reported inappropriate antipsychotic medication use differs in severely and less severely deprived neighborhoods, and whether these differences are modified by higher levels of total nurse staffing. This was a cross-sectional analysis of a national sample of nursing homes that linked across 3 national large-scale data sets for the year 2019. Analyses were conducted between April and June 2023. Neighborhood deprivation status (severe vs less severe) and total staffing hours (registered nurse, licensed practical nurse, certified nursing assistant). This study estimated the association between neighborhood deprivation and the percentage of long-stay residents who received an antipsychotic medication inappropriately in the nursing home at least once in the past week and how this varied by nursing home staffing through generalized estimating equations. Analyses were conducted on the facility level and adjusted for state fixed effects. This study included 10 966 nursing homes (1867 [17.0%] in severely deprived neighborhoods and 9099 [83.0%] in less deprived neighborhoods). Unadjusted inappropriate antipsychotic medication use was greater in nursing homes located in severely deprived neighborhoods (mean [SD], 15.9% [10.7%] of residents) than in those in less deprived neighborhoods (mean [SD], 14.2% [8.8%] of residents). In adjusted models, inappropriate antipsychotic medication use was higher in severely deprived neighborhoods vs less deprived neighborhoods (19.2% vs 17.1%; adjusted mean difference, 2.0 [95% CI, 0.35 to 3.71] percentage points) in nursing homes that fell below critical levels of staffing (less than 3 hours of nurse staffing per resident-day). These findings suggest that levels of staffing modify disparities seen in inappropriate antipsychotic medication use among nursing homes located in severely deprived neighborhoods compared with nursing homes in less deprived neighborhoods. These findings may have important implications for improving staffing in more severely deprived neighborhoods.

Antipsychotic Prescribing in Older Adults after In-Hospital Initiation.

In older adults, the use of antipsychotics to treat delirium or the behavioural and psychological symptoms of dementia is potentially inappropriate and may be associated with adverse effects. Antipsychotics newly initiated in hospital may be inadvertently continued after discharge. In the Saskatchewan Health Authority (SHA) - Regina area, the frequency and duration of antipsychotic continuation for older adults after initiation during a hospital stay is unknown. To describe potentially inappropriate antipsychotic use in older adults after discharge from hospital, specifically rates of postdischarge antipsychotic therapy after initiation in hospital and continuation up to 180 days after discharge; prescribing regimens used; risk factors associated with continuation; pharmacist involvement; and plans for antipsychotic discontinuation, tapering, and/or follow-up. This retrospective chart review included inpatients 65 years of age or older who were discharged from medicine units at SHA - Regina area hospitals between September 30, 2021, and June 28, 2022. Outpatient dispensing histories were also gathered. Of the 189 patients included in the analysis, 60 (31.7%) had continuation of antipsychotic therapy at discharge. Of these, 48 (80.0%), 33 (55.0%), and 24 (40.0%) had continuation of antipsychotic therapy at 30, 90, and 180 days after discharge, respectively. Of the patients with continuing antipsychotic therapy, 53 (88.3%) were 75 years of age or older, and 9 (15.0%) had documentation of an outpatient antipsychotic follow-up plan. Postdischarge continuation of antipsychotics was similar to that reported in the literature. Patients continued on antipsychotics after discharge were at a greater than 50% risk of continuation at 90 days and were unlikely to have a follow-up plan. Future quality improvement efforts should include standardized prioritization of medication reviews, documentation of indications, and regular reassessment of therapy.

Comparing quality of care outcomes between assisted living and nursing homes before and during the COVID-19 pandemic.

While assisted living (AL) and nursing home (NHs) residents in share vulnerabilities, AL provides fewer staffing resources and services. Research has largely neglected AL, especially during the COVID-19 pandemic. Our study compared trends of practice-sensitive, risk-adjusted quality indicators between AL and NHs, and changes in these trends after the start of the pandemic. This repeated cross-sectional study used population-based resident data in Alberta, Canada. Using Resident Assessment Instrument data (01/2017-12/2021), we created quarterly cohorts, using each resident's latest assessment in each quarter. We applied validated inclusion/exclusion criteria and risk-adjustments to create nine quality indicators and their 95% confidence intervals (CIs): potentially inappropriate antipsychotic use, pain, depressive symptoms, total dependency in late-loss activities of daily living, physical restraint use, pressure ulcers, delirium, weight loss, urinary tract infections. Run charts compared quality indicators between AL and NHs over time and segmented regressions assessed whether these trends changed after the start of the pandemic. Quarterly samples included 2015-2710 AL residents and 12,881-13,807 NH residents. Antipsychotic use (21%-26%), pain (20%-24%), and depressive symptoms (17%-25%) were most common in AL. In NHs, they were physical dependency (33%-36%), depressive symptoms (26%-32%), and antipsychotic use (17%-22%). Antipsychotic use and pain were consistently higher in AL. Depressive symptoms, physical dependency, physical restraint use, delirium, weight loss were consistently lower in AL. The most notable segmented regression findings were an increase in antipsychotic use during the pandemic in both settings (AL: change in slope = 0.6% [95% CI: 0.1%-1.0%], p = 0.0140; NHs: change in slope = 0.4% [95% CI: 0.3%-0.5%], p < 0.0001), and an increase in physical dependency in AL only (change in slope = 0.5% [95% CI: 0.1%-0.8%], p = 0.0222). QIs differed significantly between AL and NHs before and during the pandemic. Any changes implemented to address deficiencies in either setting need to account for these differences and require monitoring to assess their impact.

Variation and Correlation of Potential Unintended Consequences of Antipsychotic Reduction in Ontario Nursing Homes Over Time.

Potentially inappropriate antipsychotic use has declined in nursing homes over the past decade; however, increases in the documentation of relevant clinical indications (eg, delusions) and the use of other psychotropic medications have raised concerns about diagnosis upcoding and medication substitution. Few studies have examined how these trends over time vary across and within nursing homes, information that may help to support antipsychotic reduction efforts. To jointly model facility-level time trends in potentially inappropriate antipsychotic use, antidepressant use, and the indications used to define appropriate antipsychotic use. We conducted a repeated cross-sectional study of all nursing homes in Ontario, Canada between April 1, 2010 and December 31, 2019 using linked health administrative data (N=649). Each nursing home's quarterly prevalence of potentially inappropriate antipsychotic use, antidepressant use, and relevant indications were measured as outcome variables. With time as the independent variable, multivariate random effects models jointly estimated time trends for each outcome across nursing homes and the correlations between time trends within nursing homes. We observed notable variations in the time trends for each outcome across nursing homes, especially for the relevant indications. Within facilities, we found no correlation between time trends for potentially inappropriate antipsychotic and antidepressant use ( r =-0.0160), but a strong negative correlation between time trends for potentially inappropriate antipsychotic use and relevant indications ( r =-0.5036). Nursing homes with greater reductions in potentially inappropriate antipsychotics tended to show greater increases in the indications used to define appropriate antipsychotic use-possibly leading to unmonitored use of antipsychotics.

Long-Term Care Resident Health and Quality of Care During the COVID-19 Pandemic: A Synthesis Analysis of Canadian Institute for Health Information Data Tables.

Long-term care (LTC) homes ("nursing homes") were challenged during the first year of the COVID-19 pandemic in Canada. The objective of this study was to measure the impact of the COVID-19 pandemic on resident admission and discharge rates, resident health attributes, treatments, and quality of care. Synthesis analysis of "Quick Stats" standardized data table reports published yearly by the Canadian Institute for Health Information. These reports are a pan-Canadian scorecard of LTC services rendered, resident health characteristics, and quality indicator performance. LTC home residents in Alberta, British Columbia, Manitoba, and Ontario, Canada that were assessed with the interRAI Minimum Data Set 2.0 comprehensive health assessment in fiscal years 2018/2019, 2019/2020 (pre-pandemic period), and 2020/2021 (pandemic period). Risk ratio statistics were calculated to compare admission and discharge rates, validated interRAI clinical summary scale scores, medication, therapy and treatment provision, and seventeen risk-adjusted quality indicator rates from the pandemic period relative to prior fiscal years. Risk of dying in the LTC home was greater in all provinces (risk ratio [RR] range 1.06-1.18) during the pandemic. Quality of care worsened substantially on 6 of 17 quality indicators in British Columbia and Ontario, and 2 quality indicators in Manitoba and Alberta. The only quality indicator where performance worsened during the pandemic in all provinces was the percentage of residents that received antipsychotic medications without a diagnosis of psychosis (RR range 1.01-1.09). The COVID-19 pandemic has unveiled numerous areas to strengthen LTC and ensure that resident's physical, social, and psychological needs are addressed during public health emergencies. Except an increase in potentially inappropriate antipsychotic use, this provincial-level analysis indicates that most aspects of resident care were maintained during the first year of the COVID-19 pandemic.

CHANGING TALK (CHAT) ONLINE COMMUNICATION EDUCATION FOR ADULT DAY CARE STAFF: EVALUATION AND FUTURE DIRECTIONS

Abstract Communication education has been effective in reducing elderspeak use for nursing home staff and subsequently reduces resistiveness to care and inappropriate antipsychotic medication use in residents living with dementia. Communication is fundamental for dementia care and educating staff in other long-term service and support settings such as Adult Day Care (ADC) is needed. Tailoring education to the specific setting is indicated to optimize acceptability and effectiveness. ADC staff (N=22) from 3 ADC centers participated in the Changing Talk: Online Training (CHATO). Results for the 19 staff who completed the education program were analyzed. A focus group was conducted with a subset of participants to evaluate feasibility, applicability, and directions for tailoring for ADC settings. Knowledge gain was demonstrated by score increases 15.0 percentage points (p&amp;lt;.001) from pre- to post-education on the Changing Talk Scale (CHATS). Confidence in Dementia Care (CODE) scores significantly increased after CHATO (p=.05), indicating an increase in confidence in caring for clients with dementia. The mean Modified Diffusion of Innovation scale score was 2.2 (1=intend to use skills in practice to 5=don’t intend to use), indicating intent to use with clients. Program evaluation ratings were positive indicating satisfaction. Focus group participants reported that the CHATO was valuable and recommended ADC specific scenarios. The results support the value of CHATO for ADC staff as well as specific directions to better tailor the education to increase applicability in this LTSS setting.

122: APPROPRIATE USE OF QUETIAPINE IN ICU AND GENERAL MEDICINE PATIENTS

Introduction: In recent years, atypical antipsychotics, like, quetiapine, have gained traction for its off-label indications and sedative properties. The goal of this study is to describe the typical indication for quetiapine in the ICU and general medicine services to evaluate if quetiapine is being used according to evidence-based practice and guidelines. Methods: A retrospective analysis of an electronic medical record report was performed. Admitted patients who received a dose of quetiapine were included. General demographics collected include age, gender, and hospital length of stay. Additional data collected include quetiapine indication, CAM-ICU score at quetiapine initiation, duration of therapy, psych consult, home regimen, discharged on quetiapine, discharged from the ICU to the floor with a new quetiapine indication. Results: Over two months, 115 patients were identified and included. The cohort was ~63 years old, mostly male (60%), with an average hospital length of stay of 19 days. Delirium/agitation was the most frequent off-label indication (70%) with (30%) patients receiving quetiapine for a psychiatric or insomnia indication. At the initiation of quetiapine (38%) of patients were CAM positive. On average quetiapine was not initiated until six days into the hospital admission with (27%) of patients resuming a home regimen. During the admission (15%) of patients had a psychiatric consult placed. The cohort had (25%) of patients discharged from the ICU to the floor with quetiapine continued, and (44%) of patients discharged home with quetiapine that was a continuation of home therapy or a new start. The mortality rate for the entire population evaluated was 22%, additional comorbidities were not evaluated at the time of analysis. For delirium/agitation the common dosages were a combination of 25mg/25mg/50mg. For psychiatric indications the average dose was 100-300mg at bedtime. Conclusions: Psychoactive medications are frequently continued during transitions of care without a clear indication, especially in ICU patients discharging. To aid in discontinuation of potentially inappropriate use of atypical antipsychotics more effort should be made to prescribe according to true indication with a plan to discontinue when appropriate.

Deficiency Citations on Inappropriate Psychotropics Use Related to Care for Behavioral Symptoms of Dementia.

The Centers for Medicare and Medicaid (CMS) initiated the National Partnership to Improve Dementia Care in Nursing Homes in 2012, which helped decrease antipsychotics use. However, inappropriate use of antipsychotics and other psychotropic medications to control behavioral symptoms associated with dementia persists. Nursing homes (NHs) can be flagged for inappropriate psychotropics use as a deficiency of care citation (F-758 tag). The purpose of this study was to comprehensively explore inappropriate psychotropic medication use deficiency, F-758 citations, in caring for NH residents with dementia. A mixed-methods study was performed. During the first quarter of 2018 (January-March), 3526 NHs were surveyed, of which 642 received F-758 tags. Of the 642, the sample was confined to the 444 NHs that received the citation for the care of residents with dementia. Information on deficiencies was obtained from 2018 Certification and Survey Provider Enhanced Reporting data. Inspection reports for deficiencies were obtained from Centers for Medicare and Medicaid Nursing Home Compare and ProPublica. Quantitative analysis was used to examine the frequency of involved psychotropic medications, scope/severity of F-758 deficiency citations, and reasons for the citations. Reasons for F-758 citations by psychotropic medication categories and scope/severity of the citations were also examined using χ² tests. Qualitative data analysis was conducted using content analysis with an inductive coding approach to summarize the inspection reports. Antipsychotics were the most involved drug category for F-758 tag citations. The 3 most common reasons for F-758 citations included failure to identify and/or monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs), and maintain 14-day limitations on Pro Re Nata (PRN) psychotropic orders (121 NHs). Compared with those with no involvement of antipsychotic drugs, facilities with antipsychotics-related F-758 tags had higher rates of failure to identify/monitor behavioral symptoms (P&lt;.001), attempt gradual drug reduction (P &lt; .001), and provide adequate indications for psychotropics use (P &lt; .001). NHs with F-758 tags related to inappropriate antianxiety medication use had a higher prevalence of failure to maintain 14-day limitation on PRN orders (P &lt; .001) and provide nonpharmacologic interventions (P &lt; .001). This study suggests areas for improvement that could potentially reduce inappropriate psychotropics use. Supporting quality of dementia care workforce and improving cooperation within healthcare staff and professionals are recommended to ensure proper nonpharmacologic and pharmacologic interventions.

Association Between Long-Term Care Facility Staffing Levels and Antipsychotic Use in US Long-Term Care Facilities.

Inappropriate use of antipsychotics is an indicator of quality of care in long-term care (LTC) facilities. There is evidence to suggest that staffing levels in LTC may be associated with the rates of inappropriate antipsychotic use. This study sought to examine the association between staffing and antipsychotic prescribing in LTC facilities. Cross-sectional study investigated the association between reported staffing levels and the frequency of inappropriate antipsychotic prescribing at US LTC facilities between 2016 and2018. Data from the Nursing Home Compare and LTCFocus datasets were linked, which contain information from the Minimum Data Set database on facility characteristics and staffing measures from the Payroll-Based Journal system. A final sample set of 10,436 facilities was used. Descriptive statistics were calculated for all variables of interest. An unadjusted linear correlation analysis and linear regression were performed. Potential confounders were investigated by comparison across low-vs high-staffing facilities where adjusted for in regression analyses. The mean staff level for the facilities was identified as 3.69 (SD= 0.67) staffing hours per patient per day, and the mean antipsychotic use rate across all facilities was 15.24% (SD= 8.62%). There was a 0.75% decrease in inappropriate antipsychotic prescribing per unit increase in overall staff-to-patient ratio. When looking at staffing types, a 3.09% decrease in inappropriate antipsychotic prescribing was observed per unit increase in licensed staff hours. More specifically, we saw a 2.25% decrease per unit increase in RN staffing hours, a 1.83% decrease per unit increase in LPN staffing hours, and nursing aide staffing hours were not associated with antipsychotic use. These findings provide support for policy-based interventions to decrease antipsychotic use in LTC facilities by improving staffing skill mix and staffing levels. The results may also inform nursing staff education and training on antipsychotic prescribing practices.

Deficiency of Care Reports on Inappropriate Psychotropic Medication Use Related to Care for Behavioral Symptoms of Dementia

The Centers for Medicare and Medicaid (CMS) initiated the National Partnership to Improve Dementia Care in Nursing Homes in 2012, which led to a steady decline in antipsychotics use. However, inappropriate use of antipsychotics and other psychotropic drugs remains in nursing home (NH) residents with behavioral symptoms of dementia despite limited efficacy and the risk of adverse effects. NHs can receive a deficiency of care citation (F-758 tag) for inappropriate psychotropic medication use. The purpose of this study was to examine the nature of inappropriate psychotropic drug use deficiency citations in caring for NH residents with dementia.

Potential Unintended Consequences of Antipsychotic Reduction in Ontario Nursing Homes.

Antipsychotic reduction in nursing homes has been a focus of research and policy attention for several decades; however, there is evidence that these initiatives may have had unintended consequences, such as medication substitution and changes in diagnosis coding. Our objectives were to describe temporal changes in the use of antipsychotics, potential substitution medications, and diagnoses and symptoms used to establish the appropriateness of antipsychotic prescribing. Repeated cross-sectional study design. Individuals, 66 to 105years of age, living in nursing homes in Ontario, Canada between April 1, 2010 and December 31,2019. Linked health administrative and clinical data were used to estimate the quarterly prevalence of dispensed antipsychotics, antidepressants, anticonvulsants, and benzodiazepines, as well as diagnoses and symptoms (eg, schizophrenia and delusions) applied to establish the appropriateness of antipsychotic use. Generalized linear models with generalized estimating equations, binomial distribution, and identity link function estimated the absolute changes over time among the population overall, by dementia diagnosis, and by severity of aggressive behaviors and cognitive impairment. Among over 70,000 nursing home residents each quarter, we observed general declines in antipsychotic (-0.70% per year [95% confidence limit (CL)-0.74%,-0.66%]) and benzodiazepine use (-1.17% per year [95% CL -1.20%,-1.14%]), and increases in antidepressant (0.89% per year [95% CL 0.84%, 0.94%]) and anticonvulsant use (1.06% per year [95% CL 1.03%, 1.09%]). Although initially stable, the coding of delusions increased from 3.5% to 10.2% (1.18% per year [95% CL 1.12%, 1.24%]) between 2014 and 2019, whereas schizophrenia remained stable. Increases in antidepressant use and recorded delusions were more pronounced among residents with dementia and aggressive behaviors. Medication substitution and changes in diagnosis/symptom coding may be potential unintended consequences of initiatives to reduce inappropriate antipsychotic use. How this corresponds to resident-level prescribing and clinical outcomes warrants further investigation.

18.1 Diagnoses and Treatment After Juvenile Justice Mental Health Service Evaluation

The aim of this poster is to compare diagnoses and medications prescribed in secure juvenile detention before and after evaluation by a trauma-informed mental health service. Participants included all consecutive admissions to New York City secure juvenile detention facilities between September 17, 2015 and October 30, 2016 (N = 1638). A total of 322 participants were referred to a facility-based mental health service for diagnostic evaluation and medication treatment as indicated. Prior historical diagnoses and medication usage were abstracted from history gathered during the evaluation and any other available records. Following evaluation, there were significantly higher rates of diagnoses for disruptive behavioral (73.3% vs 17.1%; p < 0.001), substance-related (52.8% vs 4.7%; p < 0.001), trauma-related (46.3% vs 3.1%; p < 0.001), and depressive (14.3% vs 8.1%; p = 0.008) disorders. There were significantly lower rates for bipolar disorders and non–DSM-5 diagnoses. Prescription rates after evaluation were significantly less for antipsychotics (8.7% vs 35.1%; p < 0.001), psychostimulants (24.5% vs 38.2%; p < 0.001), and mood stabilizers (2.2% vs 9.6%; p < 0.001), and significantly more for sleep aids (14.9% vs 6.2%; p < 0.001). These data are among the first to compare diagnoses and treatment following detention-based treatment with those received prior to admission to juvenile detention. The results highlight the high and inappropriate use of antipsychotics and mood stabilizers. They also show higher rates of trauma-related, depressive, and disruptive behavioral diagnoses following evaluation that support the need for trauma-informed and nonpharmacological treatment in detention. The higher rates of substance-related diagnoses following evaluation underscores the need for substance use treatment programs within juvenile detention.

Impacts of 2012 update to the AGS beers criteria on potentially inappropriate antipsychotic medication use among older adults

BackgroundThe 2012 update of the American Geriatric Society's (AGS) Beers Criteria addended a list of antipsychotics. This study examined whether this update was associated with potentially inappropriate antipsychotic medication (PIAM) use among the elderly. MethodsThis study included multi-year (2006–2018) data from the Medical Expenditure Panel Survey (MEPS). Using a difference-in-differences model, the PIAM use patterns were examined among older adults (aged 65 and older) between pre and post 2012 using near-elderly (aged 50–64) as a control group. The study sample includes individuals aged 50 and older who had filled psychotropic medications during 2006–2018 (N = 20,422). MeasuresThe newly added antipsychotics in the 2012 Beers Criteria was used to identify PIAM. Outcomes include: 1) A binary indicator of whether the individual filled PIAM at least once during a given year; and 2) The total number of PIAM prescriptions filled by each individual during the same period of time. ResultsAfter adjustment for confounding, the likelihood of using PIAMs declined significantly more in the elderly than in the near-elderly group (AOR=0.77, p-value=0.038). In pre and post comparisons, no significant reduction was found in the total number of PIAM prescription fills. ConclusionsThe update of AGS Beers Criteria was associated with the reduction in the prevalence of PIAM use among older adults. However, no reduction in the total number of PIAM prescription fills was found once the elderly initiated a PIAM treatment. This suggests a need for clinical and policy efforts to control overall PIAM consumption particularly among the elderly PIAM users.

Cost-effectiveness of a Province-wide Quality Improvement Initiative for Reducing Potentially Inappropriate Use of Antipsychotics in Long-Term Care in British Columbia, Canada.

BackgroundPotentially inappropriate use of antipsychotics (PIUA) raises serious concerns about safety, quality, and cost of care for residents in long-term care (LTC).ObjectiveThis study aimed to estimate the cost-effectiveness of the Call for Less Antipsychotics in Long-Term Care (Clear) initiative compared with the status quo (pre-Clear, baseline).MethodsA model-based cost-utility analysis, from a public-payer perspective in British Columbia, was conducted using secondary data of residents in LTC homes from 2013 to 2019. Residents’ health resource utilization and quality-adjusted life-year (QALY) measures were extracted from multiple administrative databases. Six Markov states were modelled for post-antipsychotic progression representing PIUA, appropriate use of antipsychotic, complete withdrawal, and death. The primary outcome was the incremental cost per QALY gained.ResultsA cohort of 35,669 residents was included in the primary analysis. The Clear initiative, over 10 years, was estimated to have an incremental cost-effectiveness ratio (ICER) of CA$26,055 (2020 Canadian dollars) per QALY gained at an incremental cost of CA$5211 per resident and a QALY gain of 0.20. In the subgroup analyses, our findings were even more favourable for Clear wave 2 (ICER of CA$24,447 per QALY gained) and Clear wave 3 (ICER of CA$25,933 per QALY gained). At a willingness-to-pay of CA$50,000 per QALY gained, the probabilities of Clear waves 2 and 3 were 82% cost-effective.ConclusionThis study demonstrated incremental costs and yielded favourable ICERs for Clear compared with the baseline. More research is needed to understand the level of support for individual care homes to sustain the Clear initiative in the long run.Supplementary InformationThe online version contains supplementary material available at 10.1007/s41669-021-00267-6.

Effect of a multimethod quality improvement intervention on antipsychotic medication use among residents of long-term care

BackgroundAntipsychotic medications are used to address neuropsychiatric symptoms associated with dementia. Evidence suggests that among older adults with dementia, their harms outweigh their benefits. A quality improvement initiative was conducted...

Local Nursing Home Prescribing Patterns and Psychoactive Prescribing in Assisted Living

Because prescribing practices in long-term care settings may reflect regional influences, we examined how potentially inappropriate antipsychotic and antianxiety medication prescribing in assisted living (AL) compared to prescribing in nursing homes (NHs) based on their proximity, using generalized linear models adjusting for facility characteristics and state fixed effects. Data were derived from a seven state sample of AL communities and data for the same seven states drawn from publicly available data reported on the Nursing Home Compare website. In adjusted analyses, AL rates of antipsychotic use were not associated with the rates in the nearest or farthest NHs. However, AL communities that were affiliated with a NH had lower rates of potentially inappropriate antipsychotic use (b=−0.27[95%CI=−0.50,−0.04]). In a separate model, antianxiety medication prescribing rates in AL were significantly associated with neighboring NHs’ rates of prescribing (b=2.65[95%CI=1.00,4.29]). Findings suggest efforts to change prescribing in NHs may influence prescribing in AL.

Unreported Antipsychotic Use Increasing in Nursing Homes: The Impact of Quality-Measure Exclusions on the Percentage of Long-Stay Residents Who Got an Antipsychotic Medication Quality-Measure

ObjectiveExcluded from reporting to CMS's Percentage of long-stay residents who got an antipsychotic medication quality-measure are antipsychotics prescribed to nursing home patients with schizophrenia, Tourette's, or Huntington's. Over the 4 years following its 2012 debut, the quality-measure calculated a 27% reduction in inappropriate antipsychotic use but also an 18.3% increase in exclusion claims. This study evaluated the impact of these exclusions on the measure's findings. MethodsClaims data for the years 2011–2016 retrospectively identified the prevalence of schizophrenia, Tourette's, and Huntington's in quarterly cohorts of Virginia long-stay residents prescribed antipsychotics. Annualized diagnoses in 2011 were compared with subsequent years using simple logistic regression. ResultsIn 2016, 29% of the antipsychotics prescribed in Virginia nursing homes were to residents with diagnoses of schizophrenia, Tourette's, and Huntington's, a significant 32% increase from 2011. ConclusionAlmost 30% of the antipsychotics employed in Virginia nursing homes are excluded from CMS's long-stay antipsychotic quality-measure.

AGING, DISABILITY, AND END‐OF‐LIFE

Research ObjectivePreliminary research demonstrated an increase in the reporting of schizophrenia diagnoses among nursing home (NH) residents subsequent to the Centers for Medicare &amp; Medicaid Services (CMS) National Partnership to Improve Dementia Care. Some researchers posit that as much as 20% of the reduction in inappropriate antipsychotic use could be explained by the changes in schizophrenia reporting. Given known health disparities and higher antipsychotic use for black NH residents, we examined how race and dementia influence the rate of schizophrenia diagnoses among NH residents. To date, no study uses a formal test, concurrently adjusting for relevant covariates, to examine trends in schizophrenia reporting following the National Partnership.Study DesignUsing a quasi‐experimental study design, we examined long‐stay NH residents’ quarterly and/or yearly Minimum Data Set (MDS) 3.0 assessments between 2011 and 2015. The main outcome variable was the presence of a schizophrenia diagnosis. Using a difference‐in‐difference analysis adjusting for independent variables, we examined the relationship before and after the partnership. Our independent variables were added to our unadjusted model in a stepwise fashion: 1) age, sex, and race; 2) diabetes and heart conditions indicating poor heart health; and finally, 3) activities of daily living and changes in health, end‐stage disease, and symptoms and signs scale scores.Population StudiedLong‐stay US NH residents.Principal FindingsThere were over 4 million MDS assessments annually. Schizophrenia reporting increased by 9.1% in the dementia group as compared to 9.9% in the nondementia group (P &lt; 0.0001). Black residents had a significantly higher likelihood of schizophrenia reporting (4%, P &lt; 0.0001). After controlling for covariates, there was a 16.7% increase in schizophrenia reporting for blacks with dementia and 14.6% increase for non‐blacks with dementia (P &lt; .0001). There was no racial disparity identified among the nondementia group after controlling for covariates.ConclusionsBlack NH residents were more likely to have schizophrenia documented on their MDS assessments, and following the partnership to rein in antipsychotic medication use, schizophrenia reporting rates increased faster for blacks with dementia than their non‐black peers and their peers without dementia. Further work is needed to determine whether schizophrenia diagnoses are appropriately employed in NH practice, particularly for black Americans.Implications for Policy or PracticeResearchers and policy makers should consider race and socioeconomic status when examining the impact of new policies and practices. The 2012 National Partnership may have had unintended consequences that negatively impacted black NH residents with dementia. Additionally, controlling for relevant covariates is important for properly interpreting changes in diagnoses and potentially for measuring the changes in inappropriate antipsychotics.Primary Funding SourceThe study was funded by the Agency for Healthcare Research and Quality.

A Canadian Cohort Study to Evaluate the Outcomes Associated with a Multicenter Initiative to Reduce Antipsychotic Use in Long-Term Care Homes

ObjectivesTo evaluate the impact of a multicenter intervention to reduce potentially inappropriate antipsychotic use in Canadian nursing homes at the individual and facility levels. DesignLongitudinal, population-based cohort study to evaluate the Canadian Foundation for Healthcare Improvement's Spreading Healthcare Innovations Initiative to reduce potentially inappropriate antipsychotic use in 6 provinces/territories. Setting and ParticipantsAdults in nursing homes in 6 provinces/territories in Canada between 2014 and 2016. The sample involved 4927 residents in 45 intervention homes and 122,570 residents in 1193 control homes in the first quarter of the study. MeasuresAssessment data based on the Resident Assessment Instrument 2.0 were used in both settings to track antipsychotic use and to obtain risk-adjusters for a quality indicator on potentially inappropriate use. InterventionQuality improvement teams in participating organizations were provided with education, training, and support to implement localized strategies intended to reduce antipsychotic medication use in residents without diagnosis of psychosis. ResultsAt the resident level, we found that the odds of remaining on potentially inappropriate antipsychotics were 0.75 in intervention compared with control homes after adjusting for age, sex, aggressive behavior, and cognition. These findings were evident within the pooled Canadian data as well as within provinces. At the facility level, the intervention homes had greater improvements in risk-adjusted quality indicator performance than the control homes, and this was true for the worst, median, and best-performing homes at baseline. There was no major change in the quality indicator for worsening of behavior symptoms. Conclusions/ImplicationsThe Canadian Foundation for Healthcare Improvement intervention was associated with a reduction in potentially inappropriate antipsychotic use at both the individual and facility levels of analysis. This improvement in performance was independent of secular trends toward reduced antipsychotic use in participating provinces. This suggests that substantial improvements in medication use may be achieved through targeted, collaborative quality improvement initiatives in long-term care.

Inappropriate Antipsychotic Use: The Impact of Nursing Home Socioeconomic and Racial Composition.

Previous research suggests black nursing home (NH) residents are more likely to receive inappropriate antipsychotics. Our aim was to examine how NH characteristics, particularly the racial and socioeconomic composition of residents, are associated with the inappropriate use of antipsychotics. This study used a longitudinal approach to examine national data from Long-Term Care: Facts on Care in the US (LTCFocUS.org) between 2000 and 2015. We used a multivariate linear regression model with year and state fixed effects to estimate the prevalence of inappropriate antipsychotic use at the NH level. Free-standing NHs in the United States. The sample consisted of 12 964 NHs. The outcome variable was inappropriate antipsychotic use at the facility level. The primary indicator variables were whether a facility had high proportions of black residents and the percentage of residents with Medicaid as their primary payer. NHs with high and low proportions of blacks had similar rates of antipsychotic use in the unadjusted analyses. NHs with high proportions of black residents had significantly lower rates of inappropriate antipsychotic use (β = -2; P < .001) in the adjusted analyses. Facilities with high proportions of Medicaid-reliant residents had higher proportions of inappropriate use (β = .04; P < .001). Findings from this study indicate a decline in the use of antipsychotics. Although findings from this study indicated facilities with higher proportions of blacks had lower inappropriate antipsychotic use, facility-level socioeconomic disparities continued to persist among NHs. Policy interventions that focus on reimbursement need to be considered to promote reductions in antipsychotic use, specifically among Medicaid-reliant NHs. J Am Geriatr Soc 68:630-636, 2020.