Results of a longitudinal analysis of national data to examine relationships between organizational and market characteristics and changes in antipsychotic prescribing in US nursing homes from 1996 through 2006

doi:10.1016/j.amjopharm.2009.05.001

The American Journal of Geriatric Pharmacotherapy

Volume 7, Issue 3, June 2009, Pages 143-150

https://doi.org/10.1016/j.amjopharm.2009.05.001 Get rights and content

Abstract

Objective: The aim of this work was to examine the association between organizational characteristics, market characteristics, and changes in antipsychotic medication use in US nursing homes over time.

Methods: This was a longitudinal study comparing antipsychotic use in US nursing homes from 1996 through 2006 using Medicare and Medicaid data (the Online Survey Certification And Reporting system) and US Department of Health and Human Resources Health Resources and Services Administration data (the Area Resource File). The 3 outcomes of interest were increasing, decreasing, or stable use of antipsychotic medications. The primary independent variables were organizational characteristics (eg, for-profit status, chain membership) and market characteristics (eg, Medicaid reimbursement, levels of competition).

Results: Antipsychotic use increased from 16.4% in 1996 to 25.9% in 2006 (P < 0.05). A multinomial generalized estimating equations model, controlling for facility, staffing, and resident factors, suggested that increased antipsychotic use was associated with for-profit facilities (adjusted odds ratio [AOR], 1.58; 95% CI, 1.51–1.65; P ≤ 0.001). Decreased antipsychotic use was associated with chain membership (AOR, 0.82; 95% CI, 0.79–0.85; P ≤ 0.001), higher levels of competition (AOR, 1.22; 95% CI, 1.16–1.29; P ≤ 0.001), and a higher Medicaid reimbursement rate (AOR, 0.88; 95% CI, 0.85–0.92; P ≤ 0.001).

Conclusions: Antipsychotic use increased in US nursing homes from 1996 through 2006 and was associated with certain organizational characteristics and market characteristics. Future interventions to reduce antipsychotic use in nursing homes will have to focus on these factors.

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We examined the association between nursing home (NH) characteristics and whether NHs had high or low levels of antipsychotic, benzodiazepine, or opioid prescribing to residents with Alzheimer’s disease and related dementias (ADRD). We then measured the likelihood that NHs who were high (low) prescribers of antipsychotics were also high (low) prescribers of benzodiazepines or opioids.
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Using Medicare claims, the Minimum Data Set, and LTCFocus, we measured the share of NH residents with ADRD who filled ≥1 antipsychotic, benzodiazepine, or opioid prescription in 2017. Using linear probability models with state-clustered SEs, we identified which NH characteristics were associated with being in the top (bottom) quartile of the prescribing distribution for each drug class. Finally, we measured whether NHs who were top-quartile (bottom-quartile) antipsychotic prescribers were more likely to be top-quartile (bottom-quartile) benzodiazepine or opioid prescribers.
Across NHs, an average of 29.1% of residents with ADRD received an antipsychotic, 30.2% received a benzodiazepine, and 40.9% received an opioid. Smaller NHs and NHs with a larger share of Medicaid-enrolled residents were more likely to be top-quartile prescribers; NHs with more registered nursing care were more likely to be bottom-quartile prescribers. Antipsychotic prescribing tracked closely with benzodiazepine prescribing, but not opioid prescribing.
The overlap between antipsychotic and benzodiazepine prescribing and our finding that some NH characteristics were consistently associated with prescribing across drug classes may support the idea of an organizational culture of prescribing in NHs, which could inform efforts to improve prescribing quality in NHs. Our results also highlight benzodiazepine and opioid use for ADRD, which were more commonly prescribed than antipsychotics in NHs but have received less regulatory attention.
To What Extent Do Local Nursing Home Prescribing Patterns Relate to Psychotropic Prescribing in Assisted Living?
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This finding may suggest that the increased focus on reducing antipsychotic medication use that has occurred in NHs has spilled over to affiliated AL communities, and changed provider practice in a way that is not accounted for by geography or proximity. The same pattern has been observed in NHs that are members of a chain,32,33 suggesting that chain membership may reflect a higher degree of corporate standardization and oversight that is more salient to how medications are used in long-term care settings than local physician prescribing patterns. In addition, AL settings with a higher share of residents enrolled in Medicaid have higher rates of potentially inappropriate antipsychotic and of antianxiety medication use.
In nursing homes (NHs), psychoactive medication use has received notable attention, but less is known about prescribing in assisted living (AL). This study examined how antipsychotic and antianxiety medication prescribing in AL compares with NHs.
Observational, cross-sectional AL data linked to publicly reported NH measures.
Random sample of 250 AL communities and the full sample of 3371 NHs in 7 states.
We calculated the percentage of residents receiving antipsychotics and antianxiety medications. For each AL community, we calculated the distance to NHs in the state. Linear models estimated the relationship between AL prescribing and that of the closest and farthest 5 NHs, adjusting for AL characteristics and state fixed effects.
The prescribing rate of potentially inappropriate antipsychotics (i.e., excluding for persons with recorded schizophrenia and Tourette syndrome) and of antianxiety medications (excluding for those on hospice) in AL was 15% and 21%, respectively. Unadjusted mean antipsychotic prescribing rates were nominally higher in AL than NHs (14.8% vs 14.6%; P = .056), whereas mean antianxiety prescribing was nominally lower in AL (21.2% vs 22.6%; P = .032). In adjusted analyses, AL rates of antipsychotic use were not associated with NH rates. However, being affiliated with an NH was associated with a lower rate of antipsychotic use [b = −0.03; 95% confidence interval (CI) −0.50 to −0.001; P = .043], whereas antianxiety rates were associated with neighboring NHs’ prescribing rates (b = 0.43; 95% CI 0.16–0.70; P = .002).
This study suggests reducing antipsychotic medication use in NHs may influence AL practices in a way not accounted for by local NH patterns. And, because antianxiety medications have not been the focus of national campaigns, they may be more subject to local prescribing behaviors. It seems advantageous to consider prescribing in AL when efforts are implemented to change NH prescribing, as there seems to be related influence whether by affiliation or region.
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An estimated 50% of nursing home residents have a dementia diagnosis. The purpose of this research was to conduct a needs assessment of directors of nursing (DON) in Iowa nursing homes in relation to caring for patients with Behavioral and Psychological Symptoms of Dementia. DON responses were linked to Online Survey Certification and Reporting/Certification and Survey Provider Enhanced Reporting (OSCAR/CASPER) data to examine how facility characteristics may be associated with use of and confidence in non-drug management strategies. From 431 questionnaires mailed to DONs, 160 (37%) were returned. Regression analysis showed that those who were more confident in managing challenging behavior were more likely to have satisfaction with current training on managing challenging behaviors and had a psychiatrist available to visit the facility. Facilities with a larger proportion of patients with challenging behaviors being treated with non-drug approaches instead of antipsychotics had DONs who were more likely to be confident in non-drug management strategies and have knowledge about the FDA antipsychotic medications risks.
Challenge of changing nursing home prescribing culture
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Furthermore, medication reviews and/or educational interventions alone44–46 did not significantly improve the prevalence of antipsychotic prescribing in a pooled analysis.47 Other studies suggested that differences in organizational culture might also explain the wide variation in the use of antipsychotics in NHs that were unexplained by patient case mix,6,48 organizational (eg, profit status), or market characteristics.49 Although the specific drivers of off-label antipsychotic prescribing remained unclear, facility-level factors such as staffing levels,10,50 nurse beliefs,25 interdisciplinary communication,25,39,51 and availability of resident activities40 appeared to be associated with variations in antipsychotic use.
This article described a framework for improving prescribing in nursing homes (NH) by focusing on the whole facility as a system that has created a “prescribing culture.” We offered this paradigm as an alternative to focused interventions that target prescribers only. We used the example of atypical antipsychotics to illustrate the approach. We also highlighted elements of the NH culture change movement that are germane to medication prescribing, and illustrated which elements of NH culture were shown to be associated with suboptimal quality of care. We concluded by describing current models, including our study funded by the Agency for Healthcare Research and Quality, to identify the best methods of disseminating evidence-based medication use guides in NHs.
A qualitative study exploring visible components of organizational culture: What influences the use of psychotropic medicines in nursing homes?
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Results of a longitudinal analysis of national data to examine relationships between organizational and market characteristics and changes in antipsychotic prescribing in US nursing homes from 1996 through 2006

Abstract

Am J Geriatr Pharmacother

Am J Geriatr Psychiatry

Nursing Home Reform Act

The impact of antipsychotic drug regulations on psychotropic prescribing practices in nursing homes

Am J Psychiatry

Effect of the Omnibus Reconciliation Act 1987 on antipsychotic prescribing in nursing home residents

J Am Geriatr Soc

Changes in antipsychotic drug use in nursing homes during implementation of the OBRA-87 regulations

JAMA

The quality of antipsychotic drug prescribing in nursing homes

Arch Intern Med

The use of atypical antipsychotics in nursing homes

J Clin Psychiatry

A randomized trial of risperidone, placebo, and haloperidol for behavioral symptoms of dementia

Neurology

Comparison of risperidone and placebo for psychosis and behavioral disturbances associated with dementia: A randomized, double-blind trial

J Clin Psychiatry

Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: Systematic review

BMJ

Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease

N Engl J Med

Atypical antipsychotic medications and risk of falls in residents of aged care facilities

J Am Geriatr Soc

Consensus development conference on antipsychotic drugs and obesity and diabetes

Diabetes Care

Exposure to antipsychotics and risk of stroke: Self controlled case series study

BMJ

Venous thromboembolism among elderly patients treated with atypical and conventional antipsychotic agents

Arch Intern Med

Risk of death with atypical antipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials

JAMA

Variation in nursing home antipsychotic prescribing rates

Arch Intern Med