Public reporting of physical restraint use led to 36% increase in antipsychotic prescribing for dementia, researchers find

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Residents refused meds, tried to flee secure unit since talking to surveyor, nursing home charges
Residents refused meds, tried to flee secure unit since talking to surveyor, nursing home charges

Public reporting of physical restraint use in nursing homes caused a spike in the use of antipsychotic medications to control residents' dementia symptoms, according to a recently published analysis. These results suggest that policymakers should consider unintended negative consequences of publicly reporting quality measures, the researchers emphasized.

Investigators at the University of Chicago and the University of Pennsylvania examined Minimum Data Set 2.0 data from six states that account for about one-fifth of all nursing home residents: California, Florida, Illinois, New York, Ohio and Texas. They considered data from 1999 to 2008.

Nursing Home Compare, the government database that makes facilities' physical restraint numbers available to the public, launched in 2002. Starting that year, the decline in physical restraint use was sharper in nursing homes that were subject to public reporting than in small facilities exempt from reporting, the researchers found.

The facilities that had to publicly report restraint use increased their antipsychotic prescribing between 2002 and 2005, when the Food and Drug Administration issued a “black box warning” about the dangers of using antipsychotics to treat dementia, the researchers determined. The non-reporting facilities did not have a comparable increase in antipsychotic use during that time period.

Overall, about 36% of the increase in antipsychotic use between 2002 and early 2005 could be “plausibly attributable” to the public reporting of physical restraints, the investigators concluded.

The findings “expose an important and unintended consequence” of public reporting, which is that efforts to improve care through greater transparency might actually erode overall quality of care, the authors wrote. They compared the phenomenon to “teaching to the test” in the education system, in which instructors focus on areas likely to appear on standardized tests to the “detriment of the broader educational experience.”

Long-term care providers and regulators have addressed the increase in antipsychotic use through high-profile reduction initiatives, including the decision to add an antipsychotics measure to publicly available nursing home report cards. This could help improve overall nursing home quality, the researchers noted. But they cautioned that reporting on both restraints and antipsychotic usage could lead facilities to tighten admissions policies to exclude dementia residents with challenging behavioral symptoms, or to increase hospitalizations of these residents.

“This highlights the challenges associated with targeting difficult-to-improve quality problems,” they wrote.

The study was funded through an Agency for Healthcare Research and Quality grant. The findings appear in the Journal of the American Geriatrics Society.

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