Practical advice on reducing antipsychotics
Jerome Wilborn, M.D., F.C.C.P
Approximately half of all nursing home residents may be given inappropriate prescriptions for antipsychotics, increasing the risk of expensive and unnecessary hospitalization. In March 2012, the Centers for Medicare & Medicaid Services implemented a campaign to help address the problems of antipsychotic misuse in nursing homes. In addition to education and outreach to both providers and consumers, the program addressed oversight and provider accountability for providing appropriate, resident-centered dementia care.
Two of the CMS data tags —F-Tag 329, which addresses unnecessarily using antipsychotic drugs, and F-Tag 309, which addresses taking steps to reduce antipsychotic drug use — are used by nursing home surveyors to identify specific federal nursing home regulations in order to evaluate whether a nursing home is meeting quality of care, quality of life, safety, among other standards.
Despite CMS' campaign to decrease the inappropriate use of antipsychotic drugs in nursing homes, medication management is less than optimal in nursing home residents. In fact, polypharmacy, also known as the excessive or unnecessary use of medications, is often more the rule than the exception. It is not uncommon to find patients on an average number of 15 to 20 medications (if not more) in a given nursing home. Polypharmacy is potentially dangerous because as people take more drugs, their risk for complications increases. Moreover, many of these medications prove to be deleterious or don't have the desired benefit or impact they're designed to have and predispose patients to an adverse drug event. Drug errors, as well as ADRs, can cause complications that can lead to illness, injury, hospitalization and unnecessary re-hospitalization. These adverse drug events can even be fatal.
From a practical standpoint, a good clinical approach to better medication optimization and management is to take a step back, look at the patient, gauge a patient's prognosis, understand a patient's wishes and desires (or Power of Attorney/patient representative) and treat the patient accordingly. It is rare and unusual that anyone living in a nursing home would require 20 or more medications. CMS' regulatory language defines an unnecessary drug as “…any drug used: in excessive dose (including duplicate therapy); for excessive duration; without adequate monitoring; without adequate indications; in the presence of adverse consequences which indicate the drug should be discontinued; any combination of the previous points…”.
A practical approach to starting to reduce the number of antipsychotic medications in patients would be to look at a patient cohort in a given nursing home and choose anyone who's on more than 15 medications and start there. Tailoring and optimizing these medications more appropriately and following the patient's clinical course as a result of changing medications leads to the very best outcomes for these frail elderly institutionalized seniors.
A case study from IPC Healthcare shows how it is possible to limit antipsychotic drug use and instead use non-pharmacologic interventions in a skilled nursing facility. The project was undertaken as part of the Fellowship for Hospital Leaders leadership program, an exclusive partnership formed by IPC Healthcare with the University of California, San Francisco Division of Hospital Medicine in 2010. As part of the year-long program, IPC physician participants work closely with the facility administration in which they practice to define, design and lead an improvement project relevant to the strategic goals of the facility. The IPC-UCSF partnership has the goal of improving the quality of care and the efficiencies of the inpatient care delivery system. Graduates of the Fellowship program complete an intensive one-year training and education program designed to provide leadership skills to the facilities they serve.
At the beginning of this case study, approximately 65% of the residents in the SNF were taking antipsychotic medications. The goal of the project was to reduce antipsychotic use for three consecutive months by 3% per month.
As a first step, an antipsychotic committee was formed, which met twice weekly to discuss patient behavioral changes and assess them for possible recurrences of behavioral and psychological symptoms of dementia. The goal of the committee was to identify those patients who would be a candidate for gradual dose reduction of their medications. Ultimately, 20 patients were identified; 10 were receiving doses of 2 mg twice daily of risperidone and 10 were receiving daily 20 mg doses of olanzapine. The patients on risperidone were ultimately reduced to 1 mg twice daily and those on olanzapine were reduced to 15 mg daily.
At the end of the three-month test period, those patients were taking fewer unnecessary dosages of antipsychotic medications leading to fewer side effects, such as increased risk of falls, as well as fewer behavioral disturbances. The facility saw an 18% reduction of antipsychotic drug doses for those patients, 6% per month.
Additionally, there were measurable results in cost savings for the facility—and ultimately the healthcare system. Within the three month period, there was a total savings of $17,100, approximately $300 per month per patient for those taking olanzapine and $270 per month per patient for those taking risperidone.
The program goal is to continue the dose reduction until patients can, if feasible and with continued monitoring and reassessment, be taken off their medications completely.
As post-acute care facilities grapple with the complexities revolving around providing quality, clinically appropriate patient care and meeting new patient safety criteria, as well as financial challenges that include dwindling reimbursement, a focus on polypharmacy can provide significant benefits. As our observation project proves, not only can patients be the beneficiary of reduced medications leading to better health outcomes, but the facility can see significant cost reductions in the medication spend that it is currently absorbing.
Jerome Wilborn, M.D., is the national medical director of post-acute services for IPC Healthcare.