Effectiveness of confidential reports to physicians on their prescribing of antipsychotic medications in nursing homes (original) (raw)
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American Journal of Public Health, 1987
We conducted a statewide, controlled trial of the efficacy of an educational visit in reducing antipsychotic drug prescribing for nursing home patients. Frequent antipsychotic drug prescribers were visited by a trained physician counselor who stressed known drug risks for elderly patients and suggested techniques for reducing antipsychotic drug use. Although well-received, the visit did not reduce antipsychotic drug prescribing. This negative finding suggests that future interventions address factors within the nursing home which encourage antipsychotic drug use.
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.
Journal of the American Medical Directors Association
dementia antipsychotics qualitative nursing home behavioral and psychological symptoms of dementia (BPSD) a b s t r a c t Objectives: Caution is advised when prescribing antipsychotics to people with dementia. This study explored the determinants of appropriate, evidence-based antipsychotic prescribing behaviors for nursing home residents with dementia, with a view to informing future quality improvement efforts and behavior change interventions. Design: Semistructured qualitative interviews based on the Theoretical Domains Framework (TDF). Setting and Participants: A purposive sample of 27 participants from 4 nursing homes, involved in the care of nursing home residents with dementia (8 nurses, 5 general practitioners, 5 healthcare assistants, 3 family members, 2 pharmacists, 2 consultant geriatricians, and 2 consultant psychiatrists of old age) in a Southern region of Ireland. Measures: Using framework analysis, the predominant TDF domains and determinants influencing these behaviors were identified, and explanatory themes developed. Results: Nine predominant TDF domains were identified as influencing appropriate antipsychotic prescribing behaviors. Participants' effort to achieve "a fine balance" between the risks and benefits of antipsychotics was identified as the cross-cutting theme that underpinned many of the behavioral determinants. On one hand, neither healthcare workers nor family members wanted to see residents oversedated and without a quality of life. Conversely, the reality of needing to protect staff, family members, and residents from potentially dangerous behavioral symptoms, in a resource-poor environment, was emphasized. The implementation of best-practice guidelines was illustrated through 3 explanatory themes ("human suffering"; "the interface between resident and nursing home"; and "power and knowledge: complex stakeholder dynamics"), which conceptualize how different nursing homes strike this "fine balance." Conclusions: Implementing evidence-based antipsychotic prescribing practices for nursing home residents with dementia remains a significant challenge. Greater policy and institutional support is required to help stakeholders strike that "fine balance" and ultimately make better prescribing decisions. This study has generated a deeper understanding of this complex issue and will inform the development of an evidence-based intervention.
2014
Background: Antipsychotic medications are commonly used to manage the behavioral and psychological symptoms of dementia. Several large studies have demonstrated an association between treatment with antipsychotics and increased morbidity and mortality in people with dementia. Aims: To assess the effectiveness of interventions used to reduce inappropriate prescribing of antipsychotics to the elderly with dementia in residential care. Method: Systematic searches were conducted in 12 electronic databases. Reference lists of all included studies and forward citation searching using Web of Science were also conducted. All quantitative studies with a comparative research design and studies in which recognized methods of qualitative data collection were used were included. Articles were screened for inclusion independently by 2 reviewers. Data extraction and quality appraisal were performed by 1 reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary. Results: Twenty-two quantitative studies (reported in 23 articles) were included evaluating the effectiveness of educational programs (n ¼ 11), in-reach services (n ¼ 2), medication review (n ¼ 4), and multicomponent interventions (n ¼ 5). No qualitative studies meeting our inclusion criteria were identified. Eleven studies were randomized or controlled in design; the remainder were uncontrolled before and after studies. Beneficial effects were seen in 9 of the 11 studies with the most robust study design with reductions in antipsychotic prescribing levels of between 12% and 20%. Little empirical information was provided on the sustainability of interventions. Conclusion: Interventions to reduce inappropriate prescribing of antipsychotic medications to people with dementia resident in care homes may be effective in the short term, but longer more robust studies are needed. For prescribing levels to be reduced in the long term, the culture and nature of care settings and the availability and feasibility of nondrug alternatives needs to be addressed.
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.
Assessing approaches and barriers to reduce antipsychotic drug use in Florida nursing homes
Aging & Mental Health, 2014
Objectives: Antipsychotic medications have been federally regulated since 1987, yet research suggests they continue to be used inappropriately to alleviate behavioral symptoms associated with dementia. In 2012, the Centers of Medicare and Medicaid launched a new initiative to reduce antipsychotic medication in nursing homes by 15% nationally. The aim of this study was to examine qualitative data to explore strategies that have been implemented, to assess which strategies are evidence-based, and to make recommendations to improve upon practices to reduce antipsychotic medication use. Method: A convenience sample of 276 nursing home professional staff members were surveyed about these topics using open-ended questions. Results: Theme-based content analysis yielded three main themes. The themes related to changes in practice included the following: (1) increased review of resident behavior and antipsychotic medication regimens; (2) reduction in antipsychotic medications or dosage; and (3) increased use of nonpharmacological interventions. The main themes relevant to needed assistance included the following: (1) education; (2) clinical support; and (3) increased financial resources and reimbursement. Discussion: Overall findings indicate that the majority of facilities are actively responding to the initiative, but challenges remain in education, finding mental health support, and in reimbursement.
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...
American Journal of Geriatric Psychiatry, 2008
Controlled studies or randomized controlled studies were included for review. The authors identified 26 studies evaluating the impact of medication reviews and/or educational interventions on psychotropic drug use in long-term care facilities. Eleven studies met the inclusion criteria for this review and the data from six of these studies were included in a meta-analysis. The pooled odds ratio (OR) from five studies on hypnotic prescribing showed a decrease in use postintervention (OR ϭ 0.57, 95% confidence intervals [CI] ϭ 0.41-0.79). The pooled OR from five studies on prevalence of antipsychotic prescribing postintervention was not significant (OR ϭ 0.81, 95% CI ϭ 0.63-1.04). Medication reviews and/or educational interventions are effective at reducing psychotropic drug prescribing. However, research on the benefits of these interventions in reducing psychotropic drug use on total health care costs and resident health outcomes is lacking. (Am J Geriatr Psychiatry 2008; 16:621-632)
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.
Journal of the American Medical Directors Association, 2019
Antipsychotic deprescribing dementia long-term care behavioral and psychological symptoms of dementia patient-centered care a b s t r a c t Objectives: Antipsychotic medications are often used for the first-line management of behavioral and psychological symptoms of dementia (BPSD) contrary to guideline recommendations. The Optimizing Practices, Use, Care and ServiceseAntipsychotics (OPUS-AP) strategy aims to improve the well-being of long-term care (LTC) residents with major neurocognitive disorder (MNCD) by implementing a residentcentered approach, nonpharmacologic interventions, and antipsychotic deprescribing in inappropriate indications. Design: Prospective, closed cohort supplemented by a developmental evaluation. Setting and Participants: Residents of designated wards in 24 LTC centers in Québec, Canada. Methods: Provincial guidelines were disseminated, followed by the implementation of an integrated knowledge translation and mobilization strategy, including training, coaching, clinical tools, evaluation of clinical practices, and a change management strategy. Antipsychotic, benzodiazepine, and antidepressant prescriptions; BPSD; and falls were evaluated every 3 months, for 9 months, from January to October This work was funded by the Ministry of Health and Social Services of the province of Québec, and the Canadian Foundation for Healthcare Improvement (CFHI). Funding to complete the analysis of the results was provided by the Centre for Aging and Brain Health Innovation (CABHI). The authors declare no conflict of interest.