The impact of OBRA-87 on psychotropic drug prescribing in skilled nursing facilities (original) (raw)
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Journal of the American Medical Directors Association, 2022
Objectives:To summarize current evidence regarding facility and prescriber characteristics associated with potentially harmful medication (PHM) use by residents in nursing homes (NHs), which could inform the development of interventions to reduce this potentially harmful practice.Design:Scoping review.Setting and Participants:Studies conducted in the United States that described facility and prescriber factors associated with PHM use in NHs.Methods:Electronic searches of PubMed/MEDLINE were conducted for articles published in English between April 2011 and November 2021. PHMs were defined based on the Beers List criteria. Studies testing focused interventions targeting PHM prescribing or deprescribing were excluded. Studies were characterized by the strengths and weaknesses of the analytic approach and generalizability.Results:Systematic search yielded 1253 articles. Of these, 29 were assessed in full text and 20 met inclusion criteria. Sixteen examined antipsychotic medication (APM) use, 2 anticholinergic medications, 1 sedative-hypnotics, and 2 overall PHM use. APM use was most commonly associated with facilities with a higher proportion of male patients, younger patients, and patients with severe cognitive impairment, anxiety, depression, and aggressive behavior. The use of APM and anticholinergic medications was associated with low registered nurse staffing ratios and for-profit facility status. No studies evaluated prescriber characteristics.Conclusions and Implications:Included studies primarily examined APM use. The most commonly reported facility characteristics were consistent with previously reported indicators of poor NH quality and NHs with patient case mix more likely to use PHMs.
Psychotropic and psychoactive drugs and hospitalization rates in nursing facility residents
Pharmacy Practice (Internet), 2007
The purpose of this study was to determine if there were any differences in hospitalization rates due to total psychoactive drug "load" between those using and not or formerly using psychotropic and psychoactive medications in a skilled nursing facility; to determine if the diagnosis of dementia and the change in use and load of psychotropic and psychoactive drugs influenced hospitalization rates. Methods: An observational retrospective cohort study was conducted of patient chart, facility disposition changes and consultant pharmacist reports data from a skilled nursing facility of more than 100 beds. Some177 patients resident for 30 or more days over a 19 month period of 2978 patientmonths data were tabulated. A monthly repeatedmeasures assessment method that incorporated all conditions, diseases and medication changes was done on each resident to determine patient demographics, medication usage, and hospitalizations. Results: The rates of hospitalization ranged from 0.04 to 0.07 per patient/month for any psychoactive usage in those with and without dementia as a diagnosis. The rate of hospitalization during the study period for those with no current psychotropic nor regular psychoactive usage was 0.02 and 0.03/pt./month for those respectively with and without the diagnosis of dementia, yet 86% of this sample had used psychotropics or other psychoactive drugs before the period of observation. Conclusion: Preliminary evidence is offered that suggests psychotropics and psychoactive drugs and the total "load" of these drugs may be associated with an increase in the rate and risk of all hospitalizations within a single skilled nursing facility.
International Journal of Geriatric Psychiatry, 2013
Background: Psychotropic drugs are extensively prescribed for the treatment of neuropsychiatric symptoms, despite modest efficacy and severe side effects. Aims: We examined trends in psychotropic drug prescribing in Norwegian nursing homes from 1997 to 2009, in order to gain insight in practice development. Methods: The study is a secondary data analysis of six cross-sectional nursing home studies conducted between 1997 and 2009. Patients aged >65 years were included. We compared the prevalence of psychotropic drugs (antipsychotics, anxiolytics, hypnotics, and antidepressants). Associations between prescription of psychotropics, and patients' age, gender, type of ward, and year of data collection were examined by univariate analysis and logistic regression. Results: Altogether, 7 661 patients (mean age 85.2 years, 72.6% women) were included. Prevalence of all psychotropic drugs combined increased from 57.6% to 70.5%, anxiolytics from 14.9% to 21.9%, hypnotics from 14.5% to 22.9%, and antidepressants from 31.5% to 50.9%. Prevalence of antipsychotics varied between extremes 21.1% and 25.6%. Less prescribing of older drugs was exceeded by an increase in newer drug types. Concomitant prescribing of two or more psychotropic drugs increased from 21% to 33%. Predictors of psychotropic drugs were female gender (except antipsychotics), as well as age <80 years, and residency in special care units (except hypnotics).
International Journal of Geriatric Psychiatry, 2018
Objectives: To assess factors related to antipsychotic (AP) use in skilled nursing facilities for newly admitted residents aged 18 to 49, 50 to 64, 65 to 84, and 85 years or older. Methods: Retrospective, population-level, Minimum Data Set (MDS) 2.0 data from the United States during the year of 2009 were used. Over 1 million residents were included. Fourteen clinically relevant variables were identified through a literature search. Antipsychotic use was defined as APs dispensed daily for the prior 7 days. Logistic regression was used to identify clinically relevant variables, which were then ranked based on magnitude of their association with APs. Results: Bipolar disorder and schizophrenia were consistently related to AP use across age groups. For older age groups, off-label indications such as cognitive impairment, dementia, behavioral symptoms, and physical restraint use were more closely related to AP use, while delusions and hallucinations decreased in strength. Higher proportions of APs were found in all diseases and symptoms in nonelderly adults, with the exception of physical restraint use. Concurrent physical restraint and AP use was highest for older adults aged 65 to 84 at 36%. Conclusions: Correlates of AP use varied by age, with stronger associations between on-label conditions and AP use among younger adults and off-label conditions among older adults. Several less conventional determinants, namely, Parkinson disease, traumatic brain injury, and the use of physical restraints were identified to increase the likelihood of AP use. This study highlights the importance of monitoring for adverse effects for residents of all ages.
International Psychogeriatrics, 2011
ABSTRACTBackground:This study aimed to explore changes in patterns of use of psychotropic medication in Sydney nursing homes over recent years, and to compare current usage rates with those reported from other countries.Methods:Data were obtained from 44 of the 48 nursing homes in a central Sydney health area. Researchers noted details from medication cards concerning residents’ age, gender and all currently prescribed drugs, checking whether medication had been given as prescribed. Frequency of administration of “as required” drugs in the previous four weeks was noted.Results:The pattern of use of psychotropic medication changed considerably between 1993 and 2009. The number of residents taking regularly administered antipsychotics increased by 24% during 1998–2009, though mean dosages decreased. In 2009, fewer residents took hypnotic and/or anxiolytic medications than in the 1990s, and fewer than in countries from which equivalent data have been reported. Antidepressant use increa...
RESPONSE TO REGULATORY STRINGENCY: THE CASE OF ANTIPSYCHOTIC MEDICATION USE IN NURSING HOMES
Health Economics, 2012
This paper studies the impact of regulatory stringency, as measured by the statewide deficiency citation rate over the past year, on the quality of care provided in a national sample of nursing homes from 2000 to 2005. The quality measure used is the proportion of residents who are using antipsychotic medication. Although the changing case-mix of nursing home residents accounts for some of the increase in the use of antipsychotics, we find that reliance on antipsychotics by nursing homes is responsive to state regulatory enforcement. Nursing homes reduce their use of antipsychotics in response to the number and type of deficiencies received by facilities in the state.
Unexplained Variation Across US Nursing Homes in Antipsychotic Prescribing Rates
Archives of Internal Medicine, 2010
Background: Serious safety concerns related to the use of antipsychotics have not decreased the prescribing of these agents to nursing home (NH) residents. We assessed the extent to which resident clinical characteristics and institutional prescribing practice were associated with antipsychotic prescribing.
BMC geriatrics, 2017
The use of antipsychotic medications (APMs) in nursing home residents in the U.S. is an increasingly prominent issue and has been associated with increased risk of hospitalization, cardiovascular events, hip fractures, and mortality, among other adverse health events. The Food and Drug Administration has placed a black box warning on these drugs, specifying that they are not meant for residents with dementia, and has asked providers to review their treatment plans. The purpose of this systematic PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses)-based review was to summarize original research studies on facility level characteristics contributing to the use of antipsychotics in nursing homes across the United States, in order to investigate the variation of use. We searched Ovid Medline, Embase, Cochrane Library, Web of Science, CINAHL, PsycInfo, and Sociological Abstracts. Articles were selected according to the following criteria: (1) Population of interes...
Impact of programs to reduce antipsychotic and anticholinergic use in nursing homes
Alzheimer's & Dementia: Translational Research & Clinical Interventions, 2017
Introduction: Antipsychotics are used for managing behavioral and psychological symptoms of dementia (BPSD) but have risks. Anticholinergics can worsen outcomes in dementia. The Improving Antipsychotic Appropriateness in Dementia Patients educational program (IA-ADAPT) and Centers for Medicare and Medicaid Services Partnership to Improve Dementia Care (CMS Partnership) promote improved care for BPSD. The purpose of this study was to evaluate the impact of these programs on medication use and BPSD among nursing home residents. Methods: This quasi-experimental longitudinal study used Medicare and assessment data for Iowa nursing home residents from April 2011 to December 2012. Residents were required to be eligible for six continuous months for inclusion. Antipsychotic use and anticholinergic use were evaluated on a monthly basis, and changes in BPSD were tracked using assessment data. Results are presented as odds ratios (ORs) per month after exposure to the IA-ADAPT or the start of the CMS Partnership. Results: Of 426 eligible Iowa nursing homes, 114 were exposed to the IA-ADAPT in 2012. Nursing home exposure to the IA-ADAPT was associated with reduced antipsychotic use (OR [95% CI] 5 0.92 [0.89-0.95]) and anticholinergic use (OR [95% CI] 5 0.95 [0.92-0.98]), reduced use of excessive antipsychotic doses per CMS guidance (OR [95% CI] 5 0.80 [0.75-0.86]), increased odds of a potentially appropriate indication among antipsychotic users (OR [95% CI] 5 1.04 [1.00-1.09]), and decreased documentation of verbal aggression (OR [95% CI] 5 0.96 [0.94-0.99]). Facilities with two or more IA-ADAPT exposures had greater reductions in antipsychotic and anticholinergic use than those with only one. The CMS Partnership was associated with reduced antipsychotic use (OR [95% CI] 5 0.96 [0.94-0.98]) and decreased documentation of any measured BPSD (OR [95% CI] 5 0.98 [0.97-0.99]) as well as delirium specifically (OR [95% CI] 5 0.98 [0.96-0.99]). Discussion: This study suggests that the IA-ADAPT and the CMS Partnership improved medication use with no adverse impact on BPSD.
Provision of Psychopharmacological Services in Nursing Homes
The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 2009
We examined the psychopharmacological services provided within 3 months of nursing home (NH) admission to a whole population of newly admitted Florida NH residents 65 years and older (N = 947) for a 1-year period via secondary analyses of selected variables from Medicaid and the Online Survey and Certifi cation and Reporting System. Within 3 months of admission, 12% received nonpsychopharmacological mental health care. However, 71% of new residents received at least one psychoactive medication, and more than 15% were taking four or more psychoactive medications. Most of those being treated with psychoactive medication had not received psychopharmacological treatment 6 months prior to admission (64%) and had not received a psychiatric diagnosis 6 months preceding admission (71%). Blacks were less likely to receive medications than non-Hispanic Whites. Results expand on past research by identifying an increase in the amount of psychoactive medications prescribed to NH residents, a lack of prior psychiatric treatment and diagnoses for those currently receiving psychoactive medications, only limited provision of nonpsychopharmacological mental health care, and racial or ethnic differences in the use of medications by NHs.