Current antipsychotics quality measure is too hard on long-term care providers, researchers argue

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An updated quality measure would paint a fairer picture of nursing homes' antipsychotic prescribing practices, say researchers at Miami University in Ohio and Rutgers, the State University of New Jersey.

Off-label antipsychotic prescribing to control behavioral symptoms of dementia has been associated with potential “serious harmful effects,” the investigators acknowledged. However, they described their concerns with the current quality measure on the Nursing Home Compare website, which is meant to show consumers the extent of off-label antipsychotic prescribing in a given facility.

In 2012, the Centers for Medicare & Medicaid Services introduced the quality measure, which assesses how many long-stay residents are on antipsychotic medications and do not have a diagnosis of schizophrenia, Tourette's syndrome or Huntington's disease. However, the Food and Drug Administration has said antipsychotics also may be appropriately used for bipolar disorder or similar syndromes, as well as for “severe agitation and aggression that causes serious risk to self or others,” the researchers wrote in a report on their findings in the International Journal of Geriatric Psychiatry.

The team broadened the current criteria to include the FDA guidance. They applied this alternative quality measure to a sample of Medicaid residents from nursing homes in seven populous states by using 2004 information from the Minimum Data Set and other government reporting systems.

For the average nursing home in the sample set, about 52% of residents on an antipsychotic did not fit the researchers' guidelines for indicated use. This is compared to about 85% who did not fit the currently defined quality measure for appropriate use.

Significantly, the facilities with the most survey deficiencies were more likely to have inappropriate antipsychotic use as defined by the researchers' measure. This correlation between poorer overall quality and greater odds of antipsychotic use did not exist with the current CMS measure, according to the investigators. They argued that this finding supports the “validity” of their measure.

“Our proposed measure provides an important foundation to improve [antipsychotic] prescribing practices without penalizing nursing homes when there are limited alternative treatments available” for severe behavioral issues, they concluded.

Since 2004 — the year the researchers pulled data from — long-term care facilities have engaged in concerted efforts to reduce antipsychotic prescribing, and they are drawing nearer to goals. Advocates have touted behavioral therapy to address residents whose dementia causes them to act disruptively.

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