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Winter JD, Kerns JW, Brandt N, Wastila L, Qato D, Sabo RT, Petterson S, Chung Y, Reves S, Winter C, Winter KM, Elonge E, Ewasiuk C, Fu YH, Funk A, Krist A, Etz R. Prescribing Trends and Associated Outcomes of Antiepileptic Drugs and Other Psychotropic Medications in US Nursing Homes: Proposal for a Mixed Methods Investigation. JMIR Res Protoc 2024; 13:e64446. [PMID: 39298758 DOI: 10.2196/64446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 07/21/2024] [Accepted: 07/22/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND Pilot data suggest that off-label, unmonitored antiepileptic drug prescribing for behavioral and psychological symptoms of dementia is increasing, replacing other psychotropic medications targeted by purposeful reduction efforts. This trend accelerated during the COVID-19 pandemic. Although adverse outcomes related to this trend remain unknown, preliminary results hint that harms may be increasing and concentrated in vulnerable populations. OBJECTIVE Using a mixed methods approach including both a retrospective secondary data analysis and a national clinician survey, this study aims to describe appropriate and potentially inappropriate antiepileptic and other psychoactive drug prescribing in US nursing homes (NHs), characteristics and patient-oriented outcomes associated with this prescribing, and how these phenomena may be changing under the combined stressors of the COVID-19 pandemic and the pressure of reduction initiatives. METHODS To accomplish the objective, resident-level, mixed-effects regression models and interrupted time-series analyses will draw on cohort elements linked at an individual level from the Centers for Medicare and Medicaid Services' (CMS) Minimum Data Set, Medicare Part D, Medicare Provider Analysis and Review, and Outpatient and Public Use Files. Quarterly cohorts of NH residents (2009-2021) will incorporate individual-level data, including demographics; health status; disease variables; psychotropic medication claims; comprehensive NH health outcomes; hospital and emergency department adverse events; and NH details, including staffing resources and COVID-19 statistics. To help explain and validate findings, we will conduct a national qualitative survey of NH prescribers regarding their knowledge and beliefs surrounding changing approaches to dementia care and associated outcomes. RESULTS Funding was obtained in September 2022. Institutional review board exemption approval was obtained in January 2023. The CMS Data Use Agreement was submitted in May 2023 and signed in March 2024. Data access was obtained in June 2024. Cohort creation is anticipated by January 2025, with crosswalks finalized by July 2025. The first survey was fielded in October 2023 and published in July 2024. The second survey was fielded in March 2024. The results are in review as of July 2024. Iterative survey cycles will continue biannually until December 2026. Multidisciplinary dissemination of survey analysis results began in July 2023, and dissemination of secondary data findings is anticipated to begin January 2025. These processes are ongoing, with investigation to wrap up by June 2027. CONCLUSIONS This study will detail appropriate and inappropriate antiepileptic drug use and related outcomes in NHs and describe disparities in long-stay subpopulations treated or not treated with psychotropics. It will delineate the impact of the pandemic in combination with national policies on dementia management and outcomes. We believe this mixed methods approach, including processes that link multiple CMS data sets at an individual level and survey-relevant stakeholders, can be replicated and applied to evaluate a variety of patient-oriented questions in diverse clinical populations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/64446.
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Affiliation(s)
- Jonathan D Winter
- Department of Family Medicine and Population Health, School of Medicine, Viginia Commonwealth University, Richmond, VA, United States
| | - J William Kerns
- Department of Family Medicine and Population Health, School of Medicine, Viginia Commonwealth University, Richmond, VA, United States
| | - Nicole Brandt
- Peter Lamy Center on Drug Therapy and Aging, School of Pharmacy, University of Maryland, Baltimore, MD, United States
| | - Linda Wastila
- Peter Lamy Center on Drug Therapy and Aging, School of Pharmacy, University of Maryland, Baltimore, MD, United States
| | - Danya Qato
- Peter Lamy Center on Drug Therapy and Aging, School of Pharmacy, University of Maryland, Baltimore, MD, United States
| | - Roy T Sabo
- Department of Biostatistics, School of Population Health, Virginia Commonwealth University, Richmond, VA, United States
| | - Stephen Petterson
- Department of Family Medicine and Population Health, School of Medicine, Viginia Commonwealth University, Richmond, VA, United States
| | - YoonKyung Chung
- Harvey L. Neiman Health Policy Institute, Reston, VA, United States
| | - Sarah Reves
- Larry A. Green Center, Richmond, VA, United States
| | - Christopher Winter
- Department of Family Medicine and Population Health, School of Medicine, Viginia Commonwealth University, Richmond, VA, United States
| | - Katherine M Winter
- Department of Family Medicine and Population Health, School of Medicine, Viginia Commonwealth University, Richmond, VA, United States
| | - Eposi Elonge
- Peter Lamy Center on Drug Therapy and Aging, School of Pharmacy, University of Maryland, Baltimore, MD, United States
| | - Craig Ewasiuk
- Department of Family Medicine and Population Health, School of Medicine, Viginia Commonwealth University, Richmond, VA, United States
| | - Yu-Hua Fu
- Peter Lamy Center on Drug Therapy and Aging, School of Pharmacy, University of Maryland, Baltimore, MD, United States
| | - Adam Funk
- Department of Biostatistics, School of Population Health, Virginia Commonwealth University, Richmond, VA, United States
| | - Alex Krist
- Department of Family Medicine and Population Health, School of Medicine, Viginia Commonwealth University, Richmond, VA, United States
| | - Rebecca Etz
- Larry A. Green Center, Richmond, VA, United States
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Winter JD, Kerns JW, Winter KM, Winter C, Krist A, Etz RS. Lessons learned from CMS's National Partnership to Improve Dementia Care: a thematic synthesis of multiple stakeholder-engaged studies. Psychogeriatrics 2024; 24:1045-1050. [PMID: 38924586 PMCID: PMC11368649 DOI: 10.1111/psyg.13157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Antipsychotic prescribing in United States nursing homes (NHs) has decreased since the Center for Medicare & Medicaid Service debuted the National Partnership to Improve Dementia Care in Nursing Homes (NP); however, reductions have stalled. To help explain persistent antipsychotic use despite the NP's reduction efforts, the perspectives of diverse NP stakeholders were qualitatively assessed. This study aimed to re-evaluate these individual perspectives in combined thematic synthesis to discover NP improvement opportunities undetectable in single stakeholder assessments. METHODS Thematic synthesis. Through immersive crystallisation, original source coding results were organised into related descriptive themes. Similarities and differences were identified, and descriptive themes were regrouped into new, increasingly abstract, analytical themes. This cycle continued until variances were resolved and analytic themes sufficiently described and explained all initial descriptive themes. RESULTS Three analytic themes emerged regarding NP improvement opportunities. The NP's positive impacts would be augmented by: (i) a deeper and expanded appreciation of stakeholder perspectives; (ii) more urgent and rapid adaptation to unintended adverse outcomes; and (iii) greater recognition of the contextual and environmental factors influencing decisions to prescribe or not prescribe antipsychotic medications. Stakeholder groups described: perspectives they perceived as inadequately considered by the NP; insufficient NP engagement with the stakeholders capable of creating evidenced, affordable, and available non-pharmacologic therapies for dementia symptoms; recognition that dementia interventions effective for a specific individual at a specific time in a specific community may not generalise; and diverse ongoing undesirable outcomes from NP policies that could be mitigated by NP modifications. CONCLUSIONS The NP has done much to advance dementia care in NHs. Notwithstanding, these results suggest the NP would only be improved through increasingly comprehensive inclusion of stakeholder perspectives, enhanced incorporation of individual contextual factors, and a more decisive mechanism for ongoing and continual adaptation.
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Affiliation(s)
- Jonathan D Winter
- VCU-Shenandoah Family Practice Residency, Front Royal, Virginia, USA
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia, USA
| | - J William Kerns
- VCU-Shenandoah Family Practice Residency, Front Royal, Virginia, USA
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia, USA
| | | | - Christopher Winter
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Alex Krist
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Rebecca S Etz
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia, USA
- Larry A. Green Center, Richmond, Virginia, USA
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Rataj A, Alcusky M, Baek J, Ott B, Lapane KL. Geographic Variation of Antidementia and Antipsychotic Medication Use Among US Nursing Home Residents With Dementia. Med Care 2024; 62:511-520. [PMID: 38833712 DOI: 10.1097/mlr.0000000000002016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
BACKGROUND Several antidementia medications have been approved for symptomatic treatment of cognitive and functional impairment due to Alzheimer disease. Antipsychotics are often prescribed off-label for behavioral symptoms. OBJECTIVE The aim of this study was to describe the basis for regional variation in antidementia and antipsychotic medication use. SETTING US nursing homes (n=9735), hospital referral regions (HRR; n=289). SUBJECTS Long-stay residents with dementia (n=273,004). METHODS Using 2018 Minimum Data Set 3.0 linked to Medicare data, facility information, and Dartmouth Atlas files, we calculated prevalence of use and separate multilevel logistic models [outcomes: memantine, cholinesterase inhibitor (ChEI), antipsychotic use] estimated adjusted odds ratios (aOR) and 95% CIs for resident, facility, and HRR characteristics. We then fit a series of cross-classified multilevel logistic models to estimate the proportional change in cluster variance (PCV). RESULTS Overall, 20.9% used antipsychotics, 16.1% used memantine, and 23.3% used ChEIs. For antipsychotics, facility factors [eg, use of physical restraints (aOR: 1.08; 95% CI: 1.05-1.11) or poor staffing ratings (aOR: 1.10; 95% CI: 1.06-1.14)] were associated with more antipsychotic use. Nursing homes in HRRs with the highest health care utilization had greater antidementia drug use (aOR memantine: 1.68; 95% CI: 1.44-1.96). Resident/facility factors accounted for much regional variation in antipsychotics (PCV STATE : 27.80%; PCV HRR : 39.54%). For antidementia medications, HRR-level factors accounted for most regional variation (memantine PCV STATE : 37.44%; ChEI PCV STATE : 39.02%). CONCLUSION Regional variations exist in antipsychotic and antidementia medication use among nursing home residents with dementia suggesting the need for evidence-based protocols to guide the use of these medications.
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Affiliation(s)
- Alison Rataj
- Department of Population and Quantitative Health Sciences, Division of Epidemiology, University of Massachusetts Chan Medical School, Worcester, MA
| | - Matthew Alcusky
- Department of Population and Quantitative Health Sciences, Division of Epidemiology, University of Massachusetts Chan Medical School, Worcester, MA
| | - Jonggyu Baek
- Department of Population and Quantitative Health Sciences, Division of Biostatistics and Health Services Research, University of Massachusetts Chan Medical School, Worcester, MA
| | - Brian Ott
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI
| | - Kate L Lapane
- Department of Population and Quantitative Health Sciences, Division of Epidemiology, University of Massachusetts Chan Medical School, Worcester, MA
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Winter JD, Kerns JW, Winter KM, Richards A, Sabo RT. Community, Social, and Facility Factors and Long-stay Antipsychotic Use. Clin Gerontol 2022; 45:1180-1188. [PMID: 35443876 PMCID: PMC9806733 DOI: 10.1080/07317115.2022.2063777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Compare Virginia nursing homes in the top- and bottom-quintiles of antipsychotic use for variation in community, social, and facility factors. METHODS 2018 CMS data ascertained Virginia nursing homes in the top and bottom quintiles for antipsychotic use. The Virginia Health Department provided social determinant of health (SDOH) statistics for each facility's county/city while claims identified facility demographics. Chi square and independent two-sample t-tests compared quintiles for regional, social, and demographic differences. RESULTS Quintiles averaged 3000 residents and 56 facilities. Facilities with the lowest rates of antipsychotic use were more likely to be privately owned and had fewer African-American and minority residents and more white residents. All 18 SDOH statistics were superior for the communities of facilities with the lowest antipsychotic rates. Nine of these differences were statistically significant, including the aggregated "Health Opportunity Index." CONCLUSIONS The antipsychotic prevalence rate for facilities in the top-quintile of antipsychotic use is fivefold the bottom-quintile's rate. Antipsychotic prescribing in nursing homes is associated with regional, demographic, and social factors not addressed by existing antipsychotic reduction measures, with vulnerable populations at greatest risk. CLINICAL IMPLICATIONS The efficacy of measures aimed at curbing long-stay antipsychotic prescribing could be improved by addressing SDOH including economic opportunities.
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Affiliation(s)
- Jonathan D Winter
- Shenandoah Family Practice Residency, Deparment of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia, USA
| | - J William Kerns
- Shenandoah Family Practice Residency, Deparment of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Katherine M Winter
- Shenandoah Family Practice Residency, Deparment of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Alicia Richards
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Roy T Sabo
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia, USA
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