Background
Methods
Study selection
Data extraction
Quality assessment
Data analysis
Expert | Profession |
---|---|
Jeannie Lee | Geriatric pharmacist |
Howard Eng | Pharmacist/health services researcher |
Jane Mohler | Gerontologist/epidemiologist |
Scott Bolhack | Geriatrician/nursing home medical director |
Mindy Fain | Geriatrician |
Debbie Dyjak | RN educator in nursing home |
Lee Olitsky | Nursing home administrator |
Beverly Heasley | Nursing home administrator |
University of Arizona, University of Washington, University of Pennsylvania, University of South Carolina, Oregon Health and Science University, and University of Illinois at Chicago | Healthy Brain Research Network Collaborating Centers |
Results
Study selection
Author | Study Title | Journal | Study Design | Total Pt. # | Total NH # | Sample Rep. |
---|---|---|---|---|---|---|
Bonner AF, Field TS, Lemay CA, et al., 2015 | Rationales that providers and family members cited for the use of antipsychotic medications in nursing home residents with dementia | Journal of the American Geriatrics Society | Qualitative, descriptive | 204 | 26 | 5 CMS regions: (III, IV, VIII, IX) |
Bowblis JR, Crystal S, Intrator O, et al., 2012 | Response to regulatory stringency: the case of antipsychotic medication use in nursing homes | Health Economics | Retrospective cohort | NA | 14,743 | 48 states |
Briesacher BA, Limcangco MR, Simoni-Wastila L, et al., 2005 | The quality of antipsychotic drug prescribing in nursing homes | Archives of Internal Medicine | Retrospective cohort | 1,096 | NA | national |
Briesacher BA, Tjia J, Field T, et al., 2013 | Antipsychotic use among nursing home residents | JAMA | Retrospective cohort | 1,402,039 & 561,681* | 5,038 | 48 states |
Castle NG, Hanlon JT, Handler SM, 2009 | 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 | American Journal of Geriatric Pharmacotherapy | Retrospective cohort | NA | 15,155 & 17,213** | national |
Chen Y, Briesacher BA, Field TS, et al., 2010 | Unexplained variation across US nursing homes in antipsychotic prescribing rates | Archives of Internal Medicine | Retrospective cross sectional | 16,586 | 1,257 | national |
Hughes CM, Lapane KL, Mor V, 2000 | Influence of facility characteristics on use of antipsychotic medications in nursing homes | Medical Care | Cross sectional | NA | 14,631 | national |
Huybrechts KF, Rothman KJ, Brookhart MA, et al., 2012 | Variation in antipsychotic treatment choice across US nursing homes | Journal of Clinical Psychopharmacology | Retrospective cohort | 65,618 | 5,751 | 45 states |
Kamble P, Chen H, Sherer J, Aparasu RR, 2008 | Antipsychotic drug use among elderly nursing home residents in the United States | American Journal of Geriatric Pharmacotherapy | Cross sectional | 11,227 | 1,174 | national |
Kamble P, Chen H, Sherer J, Aparasu R, 2009 | Use of antipsychotics among elderly nursing home residents with dementia in the US: an analysis of National Survey Data | Drugs & Aging | Cross sectional | 6,103 | 1,174 | national |
Kamble P, Sherer J, Chen H, Aparasu R, 2010 | Off-label use of second-generation antipsychotic agents among elderly nursing home resident. | Psychiatric Services | Retrospective cross sectional | 2,605 | 1,174 | national |
Konetzka RT, Brauner DJ, Shega J, et al., 2014 | The effects of public reporting on physical restraints and antipsychotic use in nursing home residents with severe cognitive impairment | Journal of the American Geriatrics Society | Retrospective cohort | 809, 645 | 4,258 | 6 states: CA,FL, IL,NY, OH,TX |
Lester P, Kohen I, Stefanacci RG, Feuerman M, 2011 | Antipsychotic drug use since the FDA black box warning: survey of nursing home policies | Journal of the American Medical Directors Association | Cross sectional (survey) | NA | 250 | national |
Lucas JA, Chakravarty S, Bowblis JR, et al., 2014 | Antipsychotic medication use in nursing homes: a proposed measure of quality | International Journal of Geriatric Psychiatry | Cross sectional | 155,095 | NA | 7 states: CA, FL, GA, IL, NJ, OH, TX |
Miller SC, Papandonatos G, Fennell M, Mor V, 2006 | Facility and county effects on racial differences in nursing home quality indicators | Social Science & Medicine | Cross sectional | 63,932 | 408 | NY |
Pimentel CB, Donovan JL, Field TS, et al., 2015 | Use of atypical antipsychotics in nursing homes and pharmaceutical marketing | Journal of the American Geriatrics Society | Nested mixed-methods, cross-sectional study of NHs in a cluster randomized trial | 93 | 41 | CT |
Stevenson DG, Decker SL, Dwyer LL, et al., 2010 | Antipsychotic and benzodiazepine use among nursing home residents: findings from the 2004 National Nursing Home Survey | American Journal of Geriatric Psychiatry | Cross Sectional | 12,090 | 1,174 | national |
Svarstad BL, Mount JK, Bigelow W, 2001 | Variations in the treatment culture of nursing homes and responses to regulations to reduce drug use | Psychiatric Services | Longitudinal cohort | 1,181 | 16 | WI |
Tjia J, Field T, Lemay C, et al., 2014 | Antipsychotic use in nursing homes varies by psychiatric consultant | Medical Care | Nested cross sectional study of NHs in a cluster randomized trial | NA | 60 | national |
Study design and quality assessment
Subjects and representative sample
Facility characteristics associated with APM use
Factors increasing use | Probable Etiologies | References | ||
---|---|---|---|---|
Expert panel inferences | Article Explanations | |||
Physical Facility Characteristics | ||||
Physical Location | Located in metropolitan area | - Possible greater share of for-profit facilities - Different organizational culture in urban locations - More crowded NH may result in less medication screens -Less staff per resident | -No explanation given | Stevenson, 2010 |
Not located in the West or Midwest OR Located in the central South or Northeast | - Different state laws and regulation regarding NHs -Regional variation in training/org. cultures/hiring patterns/staffing levels and mix may all affect quality of care -Difference in provider practice pattern | - Approaches may differ regionally - Facilities in the East used a psychiatrist more often than those in the West - Note: Briesacher, 2005 et al. found lower APM rates in southern U.S. | Briesacher, 2005, Briesacher, 2013, Chen, 2010, Hughes, 2000 & Stevenson, 2010 | |
Facility Size | Smaller facility size | -Economies of scale. As a result, larger facilities may be able to have more specialization and devote greater resources to quality care/improvement | -Larger facilities may be able to provide more comprehensive services due to economies of scale and may be more able to implement change processes | Chen, 2010, Hughes, 2000 & Kamble, 2009 |
Business Type | For-profit status | - Maximize profit and minimize cost - APMs may substitute for staff, education or training - For profits minimize expenditure which leads to low quality of staffing - Non-teaching environment can be slower to adopt clinical guidelines | -APMs may be used to maximize profits and minimize the need for hands-on care -APMs may be used in for-profit facilities as chemical restraints | Castle, 2009, Hughes, 2000, Lester, 2011, Miller, 2006 & Lucas, 2014 |
Presence of Acuity Services | Alzheimer’s disease special care unit or other special care units | -The proportion of patients with Alzheimer’s disease or dementia may be larger than in other NHs -Dementia- related behavioral symptoms may occur more often | - A result of the impact of case-mix that is not completely captured in the aggregate diagnostic and behavioral variables included as controls | Hughes, 2000 |
Staffing Characteristics | ||||
Staff Ratios | Lower RN Staffing | - Lower staff to patient ratios means less time spent with patients resulting in increased APM use | - Greater use of APMs has been consistently associated with lower staff to patient ratios | Hughes, 2000, Lucas, 2014, Miller, 2006, & Svarstad, 2001 |
Lower nurse aid staffing | - Nurse aides spend more time with the patients, which results in less need for pharmacological treatment | - Nurse aides may have more patient time, resulting in less APM use | Hughes, 2000 | |
Higher LPN staffing | - Less time spent with the patients -Different level of training could play a role | - LPNs do not spend as much time with the patient | Lucas, 2014 | |
BH Expertise | Increasing number of mental health professionals and physicians | - Physicians typically spend very little time with nursing home patients - NHs with more mental health professionals may accept more patients with BH issues | - Consultant psychiatry is often identified with higher APM use - Lucas et al. found however that the presence of mental health staff did not affect APM use | Bonner, 2015, Hughes, 2000 & Lucas, 2014 |
Facilities served by the highest-ranked psychiatric consultant group | - High ranked psychiatric consultant groups make take on NHs with more BH problem patients, resulting in higher APM use | - Characteristics of psychiatric consultant groups can influence prescribing | Tija, 2014 | |
Less SS support | Minimal involvement of social services | - Social services may caution against the use of antipsychotic medications or involve the family | - Social services influence decision making regarding antipsychotic medication use. | Bonner, 2015 |
Occupancy characteristics | ||||
Resident Mix | Greater Facility share of Medicaid residents | -Lower funding results in less quality of care and increased use of APMs | - Medicaid provides less funding than private insurance resulting in fewer overall funds, possibly resulting in higher APM use -Lower Medicaid reimbursement is associated with increased APM use | Castle, 2009, Hughes, 2000, Lucas, 2014 & Stevenson, 2010 |
Lower Medicare census | No explanation | No explanation given | Stevenson, 2010 | |
Increased racial diversity | -Less funds are associated with lower quality of care in NHs | - Less funds, less resources, aligning with the idea of two tiers of USA NH care | Bonner, 2015 & Miller, 2006 | |
Occupancy rate | Low occupancy rate | - Maybe NHs with high APM use become less favorable for the elder population and their families | - Less funds are available and APMs may be used as a cheaper alternative for staff | Hughes, 2000 |
Market Characteristics | ||||
Competition | Minimal or no presence of competition | - Competition may force NHs to improve quality of care to maintain occupancy | - The presence of competition has shown to increase the quality of care in NHs | Castle, 2009 |
Chain membership | Independent Ownership (not part of a chain) | - May have less resources, standardization, and accountability, which may lower quality of care | - Chain membership may result in a higher degree of corporate standardization and oversight | Castle, 2009 |
Quality Characteristics | ||||
Reporting deficiencies | NH subject to reporting of physical restraints | - Facilities used chemical restraints instead of physical restraints in place of addressing root causes of the overuse | - The result of subjecting NHs to report physical restraint use was an increase of antipsychotic use as a substitution | Konetzka, 2014 |
Deficiency citations | Facilities with a higher number of deficiency citations | - Facilities ranked in the highest quartile for deficiencies most likely provide lower quality of care, which could result in the use of APMs as chemical restraints | -Multitasking incentive problem. The efforts to improve quality are spread to multiple areas of concern | Lucas, 2014 & Bowblis, 2012 |