Nursing home residents and enrollment in Medicare Part D

Pharmaceutical policies: effects of regulating drug insurance schemes

BACKGROUND

Drug insurance schemes are systems that provide access to medicines on a prepaid basis and could potentially improve access to essential medicines and reduce out-of-pocket payments for vulnerable populations.

OBJECTIVES

To assess the effects on drug use, drug expenditure, healthcare utilisation and healthcare outcomes of alternative policies for regulating drug insurance schemes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases, and two trials registers between November 2014 and September 2020, including a citation search for included studies on 15 September 2021 using Web of Science. We screened reference lists of all the relevant reports that we retrieved and reports from the Background section. Authors of relevant papers, relevant organisations, and discussion lists were contacted to identify additional studies, including unpublished and ongoing studies.

SELECTION CRITERIA

We planned to include randomised trials, non-randomised trials, interrupted time-series studies (including controlled ITS [CITS] and repeated measures [RM] studies), and controlled before-after (CBA) studies. Two review authors independently assessed the search results and reference lists of relevant reports, retrieved the full text of potentially relevant references and independently applied the inclusion criteria to those studies. We resolved disagreements by discussion, and when necessary by including a third review author. We excluded studies of the following pharmaceutical policies covered in other Cochrane Reviews: those that determined how decisions were made about which conditions or drugs were covered; those that placed restrictions on reimbursement for drugs that were covered; and those that regulated out-of-pocket payments for drugs.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies and assessed risk of bias for each study, with disagreements being resolved by consensus. We used the criteria suggested by  Cochrane Effective Practice and Organisation of Care (EPOC)  to assess the risk of bias of included studies. For randomised trials, non-randomised trials and controlled before-after studies, we planned to report relative effects. For dichotomous outcomes, we reported the risk ratio (RR) when possible and adjusted for baseline differences in the outcome measures. For interrupted time series and controlled interrupted time-series studies, we computed changes along two dimensions: change in level; and change in slope. We undertook a structured synthesis following the EPOC guidance on this topic, describing the range of effects found in the studies for each category of outcomes.

MAIN RESULTS

We identified 58 studies that met the inclusion criteria (25 interrupted time-series studies and 33 controlled before-after studies). Most of the studies (54) assessed a single policy implemented in the United States (US) healthcare system: Medicare Part D. The other four assessed other drug insurance schemes from Canada and the US, but only one of them provided analysable data for inclusion in the quantitative synthesis. The introduction of drug insurance schemes may increase prescription drug use (low-certainty evidence). On the other hand, Medicare Part D may decrease drug expenditure measured as both out-of-pocket spending and total drug spending (low-certainty evidence). Regarding healthcare utilisation, drug insurance policies (such as Medicare Part D) may lead to a small increase in visits to the emergency department. However, it is uncertain whether this type of policy increases or decreases hospital admissions or outpatient visits by beneficiaries of the scheme because the certainty of the evidence was very low. Likewise, it is uncertain if the policy increases or reduces health outcomes such as mortality because the certainty of the evidence was very low.

AUTHORS' CONCLUSIONS

The introduction of drug insurance schemes such as Medicare Part D in the US health system may increase prescription drug use and may decrease out-of-pocket payments by the beneficiaries of the scheme and total drug expenditures. It may also lead to a small increase in visits to the emergency department by the beneficiaries of the policy. Its effects on other healthcare utilisation outcomes and on health outcomes are uncertain because of the very low certainty of the evidence. The applicability of this evidence to settings outside US healthcare is limited.

Exploring the Association Between the Quality of HIV Care in Nursing Homes and Hospitalization

ABSTRACT

Persons living with HIV/AIDS (PLWH) are living long enough to need age-related and HIV-related nursing home (NH) care. Nursing home quality of care has been associated with risk for hospitalization, but it is unknown if quality of HIV care in NHs affects hospitalization in this population. We assessed HIV care quality with four national measures adapted for the NH setting. We applied the measures to 2011-2013 Medicare claims linked to Minimum Data Set assessments of resident health, prescription dispensing data, and national reports of NH characteristics. Cox proportional hazards models calculated the risk of all-cause and HIV/AIDS-related hospitalization by HIV care compliance. We identified 1,246 PLWH in 201 NHs with 382 all-cause and 63 HIV/AIDS-related hospitalizations. Nursing home HIV care compliance varied from 24.9% to 64.7%. After regression adjustment, we could detect no difference in all-cause or HIV/AIDS-related hospitalizations by NH HIV care compliance. We postulate that the lack of association may be due to inappropriate HIV care quality measures that do not accurately represent NHs ability to care for PLWH. There is urgent need to create valid NH HIV care quality measures.

Association Between Secondary Prevention Medication Use and Outcomes in Frail Older Adults After Acute Myocardial Infarction

Background Secondary prevention medications are often not prescribed to frail, older adults following acute myocardial infarction, potentially because of the absence of data to support use, perceived lack of benefit, and concern over possible harms. We examined the effect of using more guideline-recommended medications after myocardial infarction on mortality, rehospitalization, and functional decline in the frailest and oldest segment of the US population-long-stay nursing home residents. Methods and Results We conducted a retrospective cohort study of nursing home residents aged ≥65 years using 2007 to 2010 national US Minimum Data Set clinical assessment data and Medicare claims. Exposure was the number of secondary prevention medications (antiplatelets, β-blockers, statins, and renin-angiotensin-aldosterone system inhibitors) initiated after myocardial infarction. Outcomes were 90-day death, rehospitalization, and functional decline. We compared outcomes for new users of 2 versus 1 and 3 or 4 versus 1 medications using the inverse probability of treatment-weighted odds ratios with 95% CI. The cohort comprised 4787 residents, with a total of 509 death, 820 functional decline, and 1226 rehospitalization events. Compared with individuals who initiated 1 medication, mortality odds ratios were 0.98 (95% CI, 0.79-1.22) and 0.74 (95% CI, 0.57-0.97) for users of 2 and 3 or 4 medications, respectively. Rehospitalization odds ratios were 1.00 (95% CI, 0.85-1.17) for 2 and 0.97 (95% CI, 0.8-1.17) for 3 or 4 medications. Functional decline odds ratios were 1.04 (95% CI, 0.85-1.28) for 2 and 1.12 (95% CI, 0.89-1.40) for 3 or 4 medications. In a stability analysis excluding antiplatelet drugs from the exposure definition, more medication use was associated with functional decline. Conclusions Use of more guideline-recommended medications after myocardial infarction was associated with decreased mortality in older, predominantly frail adults, but no difference in rehospitalization. Results for functional decline from the main and stability analyses were discordant and did not rule out an increased risk associated with more medication use.

Effects of Statins for Secondary Prevention on Functioning and Other Outcomes Among Nursing Home Residents

OBJECTIVES

Studies examining the effects of statins after acute myocardial infarction (AMI) excluded frail older adults, especially nursing home (NH) residents, and few examined functional outcomes. Older NH residents may benefit less from statins and be particularly susceptible to adverse drug events like myopathy-related functional decline. We evaluated the effects of statins on 1-year functional decline, rehospitalization, and death in NH residents.

DESIGN

We conducted a retrospective cohort study using 2007-2010 linked national data from Minimum Data Set (MDS) assessments, Medicare claims, and Online Survey Certification and Reporting System records.

SETTING AND PARTICIPANTS

We included US NH residents 65 years and older who were statin nonusers, were hospitalized for AMI between May 2007 and March 2010, and returned to the NH.

MEASURES

Outcomes were functional decline, death, and rehospitalization in the first year after post-AMI NH admission. New statin users were 1:1 propensity-score matched to nonusers to adjust for 92 characteristics. We estimated hazard ratios (HRs) and restricted mean survival time differences with 95% confidence intervals (CIs) comparing individuals who did vs did not initiate statin therapy after AMI hospitalization.

RESULTS

Propensity-score matching yielded a cohort of 5440 residents. Mean age was 83 years and 69% were female. Statin use was associated with a reduction in mortality (HR 0.80, 95% CI 0.73-0.87), corresponding to a mean of 15.9 (95% CI 9.9-22.0) days of extended life expectancy. No overall differences in rehospitalization (HR 1.06, 95% CI 0.98-1.14) or functional decline (HR 1.00, 95% CI 0.88-1.14) were observed.

CONCLUSIONS AND IMPLICATIONS

Statins may reduce 1-year mortality by 20% without affecting function among older NH residents who wish to live longer after AMI. During shared decision making with these patients or their representatives, clinicians should consider communicating that the average benefit of statins is 16 days of additional survival over 1 year.

Adequacy of Prescription Drug Coverage in Long-term Care

RESEARCH OBJECTIVE

Affordable access to medications is important to Medicare enrollees in long-term care (LTC), yet, it is unknown if prescription drug coverage is universal and adequate to meet their high medication needs.

STUDY DESIGN

We assessed enrollment in prescription drug coverage, out-of-pocket (OOP) payments and medication use in a nationwide LTC database of prescription-level, resident-level, and facility-level data for the period 2011-2013. Inadequate drug coverage was defined as ≥50% medications paid for OOP. Risk-adjusted generalized estimation equations models were estimated to identify predictors of inadequate drug coverage and total prescription fills.

POPULATION STUDIED

A nationwide sample of 332,087 Medicare enrollees observed >100 days in LTC.

PRINCIPAL FINDINGS

We found Medicare Part D was the main source of drug coverage (82.4%), followed by private insurance (8.5%), and Veterans Administration (0.2%). No drug coverage could be detected for 8.9% (n=29,378) who paid for all of their medications OOP or received only temporary drug payment assistance. Inadequate drug coverage was identified in another 2721 persons. LTC Medicare enrollees without drug coverage or who had private insurance received significantly fewer prescriptions than if they had been enrolled in Medicare Part D.

CONCLUSION

A substantial proportion of Medicare enrollees in LTC have inadequate or no drug coverage and are receiving less medication than indicated by their health needs.

POLICY IMPLICATIONS

Medicare Part D is an important policy for ensuring affordable access to medications in LTC. However, expansions are needed to increase enrollment and decrease inadequate drug coverage.

People Living With HIV in U.S. Nursing Homes in the Fourth Decade of the Epidemic

As the number of persons living with HIV (PLWH) will continue to increase in the coming years, it is critical to understand factors influencing appropriate nursing home (NH) care planning. This study described the sociodemographic characteristics as well as the antiretroviral therapy treatment and physical and mental health among Medicare-eligible PLWH in NHs. Persons living with HIV were identified and summarized using a 2011-2013 nationwide data set of Medicare claims linked to NH resident health assessments and a prescription dispensing database, comparing new admissions in 2011-2013 with those from 1998 to 2000. We identified 7,188 PLWH from 2011 to 2013 in NHs of whom 4,031 were newly admitted. Of the total, 79% were prescribed antiretroviral therapy. Most were male (73%), Black/African American (51.1%), and a plurality resided in southern NHs (47%). Comparing the data sets, new admissions were older (60 vs. 44), had higher prevalence of viral hepatitis (16.2% vs. 7.5%), and anemia (31.1% vs. 25.1%) but had less pneumonia (11.0% vs. 13.6%) and dementia (8.7% vs. 21.0%). NH nurses can better anticipate health care needs of PLWH using these health profiles, understanding that there have been changes in the health of PLWH at admission over time.

Incidence of Lower-Extremity Fractures in US Nursing Homes

BACKGROUND/OBJECTIVES

Limited studies suggest lower-extremity (LE) fractures are morbid events for nursing home (NH) residents. Our objective was to conduct a nationwide study comparing the incidence and resident characteristics associated with hip (proximal femur) vs nonhip LE (femoral shaft and tibia-fibula) fractures in the NH.

DESIGN

Retrospective cohort study.

SETTING

US NHs.

PARTICIPANTS

We included all long-stay residents, aged 65 years or older, enrolled in Medicare from January 1, 2008, to December 31, 2009 (N = 1 257 279). Residents were followed from long-stay qualification until the first event of LE fracture, death, or end of follow-up (2 years).

MEASUREMENTS

Fractures were classified using Medicare diagnostic and procedural codes. Function, cognition, and medical status were obtained from the Minimum Data Set prior to long-stay qualification. Incidence rates (IRs) were calculated as the total number of fractures divided by person-years.

RESULTS

During 42 800 person-years of follow-up, 52 177 residents had an LE fracture (43 695 hip, 6001 femoral shaft, 2481 tibia-fibula). The unadjusted IRs of LE fractures were 1.32/1000 person-years (95% confidence interval [CI] = 1.27-1.38) for tibia-fibula, 3.20/1000 person-years (95% CI = 3.12-3.29) for femoral shaft, and 23.32/1000 person-years (95% CI = 23.11-23.54) for hip. As compared with hip fracture residents, non-hip LE fracture residents were more likely to be immobile (58.1% vs 18.4%), to be dependent in all activities of daily living (31.6% vs 10.8%), to be transferred mechanically (20.5% vs 4.4%), to be overweight (mean body mass index = 26.6 vs 24.0 kg/m² ), and to have diabetes (34.8% vs 25.7%).

CONCLUSIONS

Our findings that non-hip LE fractures often occur in severely functionally impaired residents suggest these fractures may have a different mechanism of injury than hip fractures. The resident differences in our study highlight the need for distinct prevention strategies for hip and non-hip LE fractures.

Nursing homes underreport antipsychotic prescribing

Objective: Determine the accuracy of nursing home self-reported antipsychotic prescribing before and after implementation of a Medicare campaign to reduce use.Methods: Quasi-experimental study comparing trends in self-reported antipsychotic prescribing relative to claims-based prescribing. Setting is a nationwide sample of 11,912 facilities, 2011-2013. Participants are long-stay nursing home residents (n = 586,281) with prescribing data in Medicare Minimum Data Set 3.0 and Medicare Part D claims database. Verified with a pharmacy dispensing database. Main outcomes are the discrepancies in quarterly prevalence of antipsychotic prescribing between nursing home self-reports and claims data and the characteristics of facilities and residents where discrepancies were identified.Results: Nursing homes underreport their antipsychotic prescribing levels, on average, by 1 percentage point per quarter relative to Medicare Part D claims (0.013, 95% confidence interval (CI), 0.012-0.015; p<.001). After the Medicare campaign, the underreporting gap increased by another half a percentage point (0.004, 95% CI .003-.005; p = .012). Nursing home residents with dementia, Alzheimer's disease or bipolar disorders were at the highest risk for underreported antipsychotic prescribing before the campaign (Adjusted Odds ratio (AOR) 1.385, 95% CI: 1.330-1.444; AOR 1.234, 95% CI: 1.172-1.300; AOR 1.574, 95% CI: 1.444-1.716, respectively) and afterwards. After the launch of the Medicare campaign, underreported antipsychotic prescribing occurred most in for-profit nursing homes (AOR 1.088, 95% CI: 1.005-1.178) and facilities in the US South (AOR 1.262, 95% CI: 1.145-1.391). Agreement was high between claims and dispensing data (99.7%).Conclusion: Nursing homes did not identify up to 6,000 residents per calendar quarter as having received antipsychotics despite these prescriptions being paid by Medicare and dispensed by a pharmacy. Nursing home rates of antipsychotic prescribing from self-reported data may be biased.

Effect of Bisphosphonates on Fracture Outcomes Among Frail Older Adults

BACKGROUND

Bisphosphonates are seldom used in frail, older adults, in part due to lack of direct evidence of efficacy in this population and increasing concerns about safety.

OBJECTIVE

We estimated the effects of bisphosphonates on hip fractures, nonvertebral fractures, and severe esophagitis among frail, older adults.

DESIGN

Population-based retrospective cohort using 2008 to 2013 linked national Minimum Data Set assessments; Online Survey Certification and Reporting System records; and Medicare claims.

SETTING

US nursing homes (NHs).

PARTICIPANTS

Long-stay NH residents 65 years and older without recent osteoporosis medication use (N = 24,571). Bisphosphonate initiators were 1:1 propensity score matched to calcitonin initiators (active comparator).

MEASUREMENTS

Hospitalized hip fracture, nonvertebral fracture, and esophagitis outcomes were measured using part A claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated, controlling for over 100 baseline characteristics.

RESULTS

The matched cohort included 5209 new bisphosphonate users and an equal number of calcitonin users (mean age [SD] = 85 [8] years; 87% female; 52% moderate-severe cognitive impairment). Over a mean follow-up of 2.5 (SD = 1.7) years, 568 residents (5.5%) had a hip fracture, 874 (8.4%) had a nonvertebral fracture, and 199 (1.9%) had a hospitalized esophagitis event. Users of bisphosphonates were less likely than calcitonin users to experience hip fracture (HR = 0.83; 95% CI = 0.71-0.98), with an average gain in time without fracture of 28.4 days (95% CI = 6.0-50.8 days). Bisphosphonate and calcitonin users had similar rates of nonvertebral fracture (HR = 0.91; 95% CI = 0.80-1.03) and esophagitis events (HR = 1.11; 95% CI = 0.84-1.47). The effects of bisphosphonates on fractures and esophagitis were generally homogeneous across subgroups, including those defined by age, sex, history of prior fracture, and baseline fracture risk.

CONCLUSIONS

Use of bisphosphonates is associated with a meaningful reduction in hip fracture among frail, older adults, but little difference in nonvertebral fracture or severe esophagitis. J Am Geriatr Soc 67:768-776, 2019.

Long-acting opioid initiation in US nursing homes

PURPOSE

To estimate the proportion of residents newly initiating long-acting opioids in comparison to residents initiating short-acting opioids and examine variation in long-acting opioid initiation by region and resident characteristics.

METHODS

This cross-sectional study included 182 735 long-stay nursing home residents in 13 881 US nursing homes who were Medicare beneficiaries during 2011 to 2013 and initiated a short-acting or long-acting opioid (excluding residents <50 years old, those with cancer, or receiving hospice care). Medicare Part D prescription claims were used to identify residents as newly initiating short-acting or long-acting opioids, defined as having a prescription claim for an opioid with no prior opioid prescriptions in the preceding 60 days. We estimated the overall proportion of initiators prescribed long-acting opioids. Regional variation was examined by mapping results by state and hospital referral regions. Logistic models were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

RESULTS

Two percent of opioid initiators were prescribed long-acting opioids. State variation in long-acting opioid initiation ranged from 0.6% to 7.5% (5th-95th percentiles: 0.6-6.4%). Resident characteristics associated with increased long-acting opioid initiation included severe physical limitations (vs none/mild limitations; aOR: 2.13, 95% CI: 1.92-2.37) and pain (staff-assessed vs no pain; aOR: 1.59 95% CI: 1.40-1.80), whereas being non-White was inversely associated (non-Hispanic black vs non-Hispanic white; aOR: 0.70, 95% CI: 0.62-0.79).

CONCLUSION

United States nursing home residents predominantly initiate short-acting opioids in accordance with Center for Disease Control and Prevention guidelines. Documented variation by geographic and resident characteristics suggests that improvements are possible.

Age, Sex, and Dose Effects of Nonbenzodiazepine Hypnotics on Hip Fracture in Nursing Home Residents

OBJECTIVE

The Food and Drug Administration recommends a reduced dose of nonbenzodiazepine hypnotics in women, yet little is known about the age-, sex-, and dose-specific effects of these drugs on risk of hip fracture, especially among nursing home (NH) residents. We estimated the age-, sex-, and dose-specific effects of nonbenzodiazepine hypnotics on the rate of hip fracture among NH residents.

DESIGN AND SETTING

Case-crossover study in US NHs.

PARTICIPANTS

A total of 691 women and 179 men with hip fracture sampled from all US long-stay NH residents.

MEASUREMENTS

Measures of patient characteristics were obtained from linked Medicare and the Minimum Data Set (2007-2008). The outcome was hospitalization for hip fracture with surgical repair. We estimated rate ratios (RRs) and 95% confidence intervals (CIs) from conditional logistic regression models for nonbenzodiazepine hypnotics (vs nonuse) comparing 0 to 29 days before hip fracture (hazard period) with 60 to 89 and 120 to 149 days before hip fracture (control periods). We stratified analyses by age, sex, and dose.

RESULTS

The average RR of hip fracture was 1.7 (95% CI 1.5-1.9) for any use. The RR of hip fracture was higher for residents aged ≥90 years vs <70 years (2.2 vs 1.3); however, the CIs overlapped. No differences in the effect of the hypnotic on risk of hip fracture were evident by sex. Point estimates for hip fracture were greater with high-dose versus low-dose hypnotics (RR 1.9 vs 1.6 for any use), but these differences were highly compatible with chance.

CONCLUSIONS

The rate of hip fracture in NH residents due to use of nonbenzodiazepine hypnotics was greater among older patients than among younger patients and, possibly, with higher doses than with lower doses. When clinicians are prescribing a nonbenzodiazepine hypnotic to any NH resident, doses of these drugs should be kept as low as possible, especially among those with advanced age.

Secondary Prevention Medication Use After Myocardial Infarction in U.S. Nursing Home Residents

BACKGROUND/OBJECTIVES

Secondary prevention medications are recommended for older adults after acute myocardial infarction (AMI), but little is known about whether nursing home (NH) residents receive these medications. The objective was to evaluate new use of secondary prevention medications after AMI in NH residents who were previously nonusers and to evaluate what factors were associated with use.

DESIGN

Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims.

SETTING

U.S. NHs.

PARTICIPANTS

National cohort of 11,192 NH residents aged 65 and older who were hospitalized for an AMI between May 2007 and March 2010, had no beta-blocker or statin use for 4 months or longer before the hospitalization, and survived 14 days or more after NH readmission.

MEASUREMENTS

The outcome was the number of secondary prevention medications initiated within 30 days of NH readmission.

RESULTS

Thirty-seven percent of residents had no secondary prevention medications initiated after AMI, 41% had 1 initiated, and 22% had 2 initiated. After covariate adjustment, fewer secondary prevention medications were used in older residents (proportional odds ratio (POR) = 0.48, 95% confidence interval (CI)  = 0.40-0.57 for ≥95 vs 65-74); women (POR = 0.88, 95% CI = 0.80-0.96);and those with a do-not-resuscitate (DNR) order (POR = 0.90, 95% CI = 0.83-0.98), functional impairment (dependent or totally dependent vs independent to limited assistance, POR = 0.77, 95% CI = 0.69-0.86), and cognitive impairment (moderate to severe vs no impairment, POR = 0.79, 95% CI = 0.70-0.89).

CONCLUSION

More than one-third of older NH residents in the United States do not have any secondary prevention medications initiated after AMI, with fewer medications initiated in older residents; women; and those with, DNR orders, poor physical function, and cognitive impairment. A lack of evidence about the safety and effectiveness of secondary preventions medications in the NH population and unmeasured person-centered goals of care are plausible explanations for these findings.

Metformin Safety Warnings and Diabetes Drug Prescribing Patterns for Older Nursing Home Residents

OBJECTIVE

Diabetes mellitus is common in US nursing homes (NHs), and the mainstay treatment, metformin, has US Food and Drug Administration (FDA) boxed warnings indicating safety concerns in those with advanced age, heart failure, or renal disease. Little is known about treatment selection in this setting, especially for metformin. We quantified the determinants of initiating sulfonylureas over metformin with the aim of understanding the impact of FDA-labeled boxed warnings in older NH residents.

DESIGN AND SETTING

National retrospective cohort in US NHs.

PARTICIPANTS

Long-stay NH residents age ≥65 years who initiated metformin or sulfonylurea monotherapy following a period of ≥6 months with no glucose-lowering treatment use between 2008 and 2010 (n = 7295).

MEASUREMENTS

Measures of patient characteristics were obtained from linked national Minimum Data Set assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare claims. Odds ratios (ORs) comparing patient characteristics and treatment initiation were estimated using univariable and multivariable multilevel logistic regression models with NH random intercepts.

RESULTS

Of the 7295 residents in the study population, 3066 (42%) initiated metformin and 4229 (58%) initiated a sulfonylurea. In multivariable analysis, several factors were associated with sulfonylurea initiation over metformin initiation, including heart failure (odds ratio [OR] 1.2, 95% confidence interval [CI] 1.1-1.4) and renal disease (OR 2.1, 95% CI 1.7-2.5). Compared with those aged 65 to <75 years, residents 75 to <85 (OR 1.3, 95% CI 1.2-1.5), 85 to <95 (OR 2.0, 95% CI 1.7-2.3), and ≥95 (OR 4.3, 95% CI 3.2-5.8) years were more likely to initiate sulfonylureas over metformin.

CONCLUSIONS

In response to FDA warnings, providers initiated NH residents on a drug class with a known, common adverse event (hypoglycemia with sulfonylureas) over one with tenuous evidence of a rare adverse event (lactic acidosis with metformin).

Association of β-Blockers With Functional Outcomes, Death, and Rehospitalization in Older Nursing Home Residents After Acute Myocardial Infarction

IMPORTANCE

Although β-blockers are a mainstay of treatment after acute myocardial infarction (AMI), these medications are commonly not prescribed for older nursing home residents after AMI, in part owing to concerns about potential functional harms and uncertainty of benefit.

OBJECTIVE

To study the association of β-blockers after AMI with functional decline, mortality, and rehospitalization among long-stay nursing home residents 65 years or older.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of nursing home residents with AMI from May 1, 2007, to March 31, 2010, used national data from the Minimum Data Set, version 2.0, and Medicare Parts A and D. Individuals with β-blocker use before AMI were excluded. Propensity score-based methods were used to compare outcomes in people who did vs did not initiate β-blocker therapy after AMI hospitalization.

MAIN OUTCOMES AND MEASURES

Functional decline, death, and rehospitalization in the first 90 days after AMI. Functional status was measured using the Morris scale of independence in activities of daily living.

RESULTS

The initial cohort of 15 720 patients (11 140 women [70.9%] and 4580 men [29.1%]; mean [SD] age, 83 [8] years) included 8953 new β-blocker users and 6767 nonusers. The propensity-matched cohort included 5496 new users of β-blockers and an equal number of nonusers for a total cohort of 10 992 participants (7788 women [70.9%]; 3204 men [29.1%]; mean [SD] age, 84 [8] years). Users of β-blockers were more likely than nonusers to experience functional decline (odds ratio [OR], 1.14; 95% CI, 1.02-1.28), with a number needed to harm of 52 (95% CI, 32-141). Conversely, β-blocker users were less likely than nonusers to die (hazard ratio [HR], 0.74; 95% CI, 0.67-0.83) and had similar rates of rehospitalization (HR, 1.06; 95% CI, 0.98-1.14). Nursing home residents with moderate or severe cognitive impairment or severe functional dependency were particularly likely to experience functional decline from β-blockers (OR, 1.34; 95% CI, 1.11-1.61 and OR, 1.32; 95% CI, 1.10-1.59, respectively). In contrast, little evidence of functional decline due to β-blockers was found in participants with intact cognition or mild dementia (OR, 1.03; 95% CI, 0.89-1.20; P = .03 for effect modification) or in those in the best (OR, 0.99; 95% CI, 0.77-1.26) and intermediate (OR, 1.05; 95% CI, 0.86-1.27) tertiles of functional independence (P = .06 for effect modification). Mortality benefits of β-blockers were similar across all subgroups.

CONCLUSIONS AND RELEVANCE

Use of β-blockers after AMI is associated with functional decline in older nursing home residents with substantial cognitive or functional impairment, but not in those with relatively preserved mental and functional abilities. Use of β-blockers yielded a considerable mortality benefit in all groups.

Screening Tool of Older Person's Prescriptions/Screening Tools to Alert Doctors to Right Treatment Medication Criteria Modified for U.S. Nursing Home Setting

OBJECTIVES

To develop a set of prescribing indicators measurable with available data from electronic nursing home (NH) databases by adapting the European-based 2014 Screening Tool of Older Person's Prescriptions (STOPP) and Screening Tools to Alert Doctors to Right Treatment (START) criteria of potentially inappropriate and underused medications for the U.S.

SETTING

DESIGN

A two-stage expert panel process. In the first stage, the investigator team reviewed 114 criteria for compatibility and measurability. In the second stage, an online modified e-Delphi (OMD) panel was convened to rate the validity of criteria, and two webinars were held to identify criteria with highest relevance to U.S. NHs.

PARTICIPANTS

Seventeen experts with recognized reputations in NH care participated in the e-Delphi panel and 12 in the webinar.

MEASUREMENTS

Compatibility and measurability were assessed by comparing criteria with U.S. terminology and setting standards and data elements in NH databases. Validity was rated using a 9-point Likert-type scale (1 = not valid at all, 9 = highly valid). Mean, median, interpercentile ranges, and agreement were determined for each criterion score. Relevance was determined by ranking the mean panel ratings on criteria that reached agreement; the webinar participants reviewed and approved half of the criteria with the highest mean values.

RESULTS

Fifty-three STOPP/START criteria were deemed to be compatible with the U.S. NH setting and measurable using data from electronic NH databases. E-Delphi panelists rated 48 criteria as valid for U.S. NHs. Twenty-four criteria were deemed to be most relevant, consisting of 22 measures of potentially inappropriate medications and two measures of underused medications.

CONCLUSION

This study created the first explicit criteria for assessing the quality of prescribing in U.S. NHs.

Beta-Blocker Use in U.S. Nursing Home Residents After Myocardial Infarction: A National Study

OBJECTIVES

To evaluate how often beta-blockers were started after acute myocardial infarction (AMI) in nursing home (NH) residents who previously did not use these drugs and to evaluate which factors were associated with post-AMI use of beta-blockers.

DESIGN

Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims.

SETTING

U.S. NHs.

PARTICIPANTS

National cohort of 15,720 residents aged 65 and older who were hospitalized for AMI between May 2007 and March 2010, had not taken beta-blockers for at least 4 months before their AMI, and survived 14 days or longer after NH readmission.

MEASUREMENTS

The outcome was beta-blocker initiation within 30 days of NH readmission.

RESULTS

Fifty-seven percent (n = 8,953) of residents initiated a beta-blocker after AMI. After covariate adjustment, use of beta-blockers was less in older residents (ranging from odds ratio (OR) = 0.89, 95% confidence interval (CI) = 0.79-1.00 for aged 75-84 to OR = 0.65, 95% CI = 0.54-0.79 for ≥95 vs 65-74) and less in residents with higher levels of functional impairment (dependent or totally dependent vs independent to limited assistance: OR = 0.84, 95% CI = 0.75-0.94) and medication use (≥15 vs ≤10 medications: OR = 0.89, 95% CI = 0.80-0.99). A wide variety of resident and NH characteristics were not associated with beta-blocker use, including sex, cognitive function, comorbidity burden, and NH ownership.

CONCLUSION

Almost half of older NH residents in the United States do not initiate a beta-blocker after AMI. The absence of observed factors that strongly predict beta-blocker use may indicate a lack of consensus on how to manage older NH residents, suggesting the need to develop and disseminate thoughtful practice standards.

National Trends in Treatment Initiation for Nursing Home Residents With Diabetes Mellitus, 2008 to 2010

OBJECTIVE

Diabetes mellitus is common in the nursing home (NH) population, yet little is known about prescribing of glucose-lowering medications in the NH setting. We describe trends in initiation of glucose-lowering medications in a national cohort of NH residents.

DESIGN AND SETTING

Retrospective cohort study using Part A and D claims for a random 20% of Medicare enrollees linked to NH Minimum Data Set (MDS) and Online Survey, Certification, and Reporting (OSCAR) databases in 7158 US NHs.

PARTICIPANTS

A total of 11,531 long-stay (continuous residence of ≥90 days) NH residents 65 years or older with diabetes who received a glucose-lowering medication between 2008 and 2010 after 4 months of nonuse.

MEASUREMENTS

Medicare Part D drug dispensing of glucose-lowering treatments; resident and facility characteristics preceding medication initiation.

RESULTS

We observed decreasing sulfonylurea initiation from 25.4% of initiations in 2008 to 11.7% in 2010, an average decrease of 1% per quarter (95% CLs -1.5 to -0.5). Thiazolidinedione initiation decreased from 4.7% to 1.9%, an average decrease of 0.3% per quarter (95% CLs -0.4 to -0.2), and meglitinide initiation from 1.5% to 0.3%. No appreciable linear trends were observed for metformin (range 12.0%-18.8%) and dipeptidyl peptidase-4 (DPP-4) inhibitors (range 0.9%-2.7%). In contrast, insulin use increased from 51.7% to 68.3% during the same time period, driven by a marked increase in initiation of rapid-acting insulin (11.0% to 29.4%; average increase of 1.4% per quarter, 95% CLs 0.9-1.9) and a modest increase in short-acting insulin (22.6% to 30.3%; an average increase of 0.6% per quarter, 95% CLs -0.1 to 1.3).

CONCLUSIONS

Between 2008 and 2010, there were substantial decreases in the use of oral glucose-lowering agents and corresponding increases in the use of insulin among long-term residents of US NHs.

Use of atypical antipsychotics in nursing homes and pharmaceutical marketing

OBJECTIVES

To describe the current extent and type of pharmaceutical marketing in nursing homes (NHs) in one state and to provide preliminary evidence for the potential influence of pharmaceutical marketing on the use of atypical antipsychotics in NHs.

DESIGN

Nested mixed-methods, cross-sectional study of NHs in a cluster randomized trial.

SETTING

Forty-one NHs in Connecticut.

PARTICIPANTS

NH administrators, directors of nursing, and medical directors (n = 93, response rate 75.6%).

MEASUREMENTS

Quantitative data, including prescription drug dispensing data (September 2009-August 2010) linked with Nursing Home Compare data (April 2011), were used to determine facility-level prevalence of atypical antipsychotic use, facility-level characteristics, NH staffing, and NH quality. Qualitative data, including semistructured interviews and surveys of NH leaders conducted in the first quarter of 2011, were used to determine encounters with pharmaceutical marketing.

RESULTS

Leadership at 46.3% of NHs (n = 19) reported pharmaceutical marketing encounters, consisting of educational training, written and Internet-based materials, and sponsored training. No association was detected between level of atypical antipsychotic prescribing and reports of any pharmaceutical marketing by at least one NH leader.

CONCLUSION

NH leaders frequently encounter pharmaceutical marketing through a variety of ways, although the impact on atypical antipsychotic prescribing is unclear.

Medicare part D and long-term care: a systematic review of quantitative and qualitative evidence

BACKGROUND

In the largest overhaul to Medicare since its creation in 1965, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 established Part D in 2006 to improve access to essential medication among disabled and older Americans. Despite previous evidence of a positive impact on the general Medicare population, Part D's overall effects on long-term care (LTC) are unknown.

OBJECTIVE

The purpose of this systematic review was to evaluate the literature regarding Part D's impact on the LTC context, specifically costs to LTC residents, providers and payers; prescription drug coverage and utilization; and clinical and administrative outcomes.

DATA SOURCES

Four electronic databases [PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Business Fulltext Elite and Science Citation Index Expanded], selected US government and non-profit websites, and bibliographies were searched for quantitative and qualitative studies characterizing Part D in the LTC context. Searches were limited to studies that may have been published between 1 January 2006 (date of Part D implementation) and 8 January 2013.

STUDY SELECTION

Systematic searches identified 1,624 publications for a three-stage (title, abstract and full-text) review. Included publications were in English language; based in the US; assessed Part D-related outcomes; and included or were directly relevant to LTC residents or settings. News articles, reviews, opinion pieces, letters or commentaries; case reports or case series; simulation or modeling studies; and summaries that did not report original data were excluded.

STUDY APPRAISAL AND SYNTHESIS METHODS

A standardized form was used to abstract study type, study design, LTC setting, sources of data, method of data collection, time periods assessed, unit of observation, outcomes and results. Methodological quality was assessed using modified criteria specific to quantitative and qualitative studies.

RESULTS

Eleven quantitative and eight qualitative studies met inclusion criteria. In the seven years since its implementation, Part D decreased out-of-pocket costs among enrolled nursing home residents and potentially increased costs borne by LTC facilities. Coverage of prescription drugs frequently used by older adults was adequate, except for certain drugs and alternative formulations of importance to LTC residents. The use of medications that raise safety concerns was decreased, but overall drug utilization may have been unaffected. Although there was uncertain impact on clinical outcomes, quantitative studies demonstrated evidence of unintended health consequences. Qualitative studies consistently revealed increased administrative burden among providers.

LIMITATIONS

Empirical evidence of Part D's LTC impact was sparse. Due to limitations in available types of data, quantitative studies were generically lacking in methodological rigor. Qualitative studies suffered from lack of clarity of reporting. As future studies use clinical Medicare data, study quality is expected to improve.

CONCLUSION

Although LTC-specific policies continue to evolve, it appears that the prescription drug benefit may require further modifications to more effectively provide for LTC residents' unique medication needs and improve their health outcomes. Adjustments may be needed for Part D to be more compatible with LTC prescription drug delivery processes.

Medicare Part D plan generosity and medication use among dual-eligible nursing home residents

BACKGROUND

In 2006, dual-eligible nursing home residents were randomly assigned to a Medicare Part D prescription drug plan (PDP). Subsequently, residents not enrolled in qualified plans at the start of the next year were rerandomized. PDPs vary in generosity through differences in medication coverage and utilization management. Therefore, residents' assigned plans may be relatively more or less generous for their particular drugs. The impact of generosity on residents' medication use and health outcomes is unknown.

METHODS

Using data from 2005 to 2008, we estimated logistic regression models of the impact of coverage and utilization management on the risk for medication changes and gaps in use, hospitalizations, and death among elderly nursing home residents using 1 of 6 selected drug classes, adjusting for patient characteristics.

RESULTS

Few current medication users faced noncoverage of their drug (0.4% to 8.7%) or prior authorization or step therapy requirements if the drug was covered (1.1% to 37.4%). After adjusting for individual-level covariates, residents with noncovered drugs were more likely than residents with covered drugs to change medications in most classes studied (eg, for 2006 angiotensin receptor blocker users, the adjusted average probability of medication change was 0.35 when uncovered vs. 0.11 when covered). Those subjected to prior authorization or step therapy were more likely to change in a subset of classes. There were no statistically significant differences in the rates of hospitalization or death after correcting for multiple comparisons.

CONCLUSIONS

The Part D benefit's special protections for nursing home residents may have ameliorated the health impact of coverage limits on this frail elderly population.

Medicare Part D and quality of prescription medication use in older adults

In 2006, the US Centers for Medicare and Medicaid Services implemented Medicare Part D to provide outpatient prescription drug insurance to disabled and older adults. In creating Part D, a key provision to address quality included medication therapy management (MTM) programmes designed to increase proper and safe use of medications among targeted Part D beneficiaries. A preponderance of evidence shows that Part D has increased medication affordability and accessibility; however, what remains less clear is whether it has improved the quality of medication use and optimized health outcomes. Now in its sixth year, Part D is undergoing its first major revision, with the gradual elimination of the coverage gap by 2020. Therefore, now is a good time to review the accumulated evidence on the impact of Part D and MTM programmes on the quality of medication use to help inform future policy decisions and research directions. In this review, we found that Part D's net effect on quality of medication use has mainly been positive. Cost-related medication nonadherence improved moderately and there were fewer than expected treatment interruptions. However, vulnerable subgroups, such as sicker and dual-eligible beneficiaries, experienced lags in improvement. Beneficiaries who entered the coverage gap consistently experienced interruptions and displayed worsening medication adherence after entering the gap, with generic-only gap drug coverage offering limited benefit. Such findings can serve as baseline information as the coverage gap phases out. Limited availability of data is the greatest barrier to research into Part D. Part D's overall effect on health outcomes and adverse medical events, such as hospitalizations, is inconclusive because of inadequate evidence to date. Similarly, no evaluation of quality of medication use is available with respect to utilization management strategies and MTM programmes delivered under Part D. Future research will need to further examine the added value of Part D and address whether Part D optimizes health outcomes in the Medicare population. As the current economic recession increases the pressure to cut costs, the effect of future spending restrictions, such as restrictions on coverage subsidies, will also be of special concern.

Utilization, Spending, and Price Trends for Benzodiazepines in the US Medicaid Program: 1991-2009

Background:

Although it is well-known that drug costs in the US have risen precipitously over the last 25 years, what is much less appreciated is how this rise in cost has occurred across so many seemingly distinct drug markets.

Objective:

To describe trends in the utilization, spending, and average per-prescription cost of benzodiazepines individually, in subgroups, and overall, in the Medicaid program. Medicaid has been the primary public payer for benzodiazepines over the past 2 decades.

Methods:

A retrospective, descriptive analysis was performed for the years 1991-2009 using the publicly available national Summary Files from the Medicaid State Drug Utilization Data maintained by the Centers for Medicare & Medicaid Services. Quarterly prescription counts and reimbursement amounts were calculated for all benzodiazepines reimbursed by Medicaid. Average per-prescription spending as a proxy for drug price was found by dividing reimbursement by the number of prescriptions.

Results:

Prescriptions for benzodiazepines among Medicaid beneficiaries increased from 8.0 million in 1991 to 17.1 million in 2009. Expenditures rose from $131.6 million to $171.1 million over the same time period. The average per-prescription price was a little over $10 in 2009. Whereas utilization of intermediate- and long-acting agents increased over time, prescriptions for short-acting drugs fell from 1.1 million to 0.3 million (1991-2009). The percentage rise in Medicaid spending on benzodiazepines since 1991 (30.0%) was less than the general rate of inflation (57.5%), as measured by the percentage change in the consumer price index over the same time period.

Conclusions:

Relative to the rise in the number of Medicaid beneficiaries (more than doubled over the study period), there is no evidence of an extraordinary rise in the utilization of benzodiazepines. Moreover, both nominal and real average prices of benzodiazepines have fallen, primarily because of generic entry over the last 2 decades.

[The effect of outpatient cost sharing on health care utilization of the elderly]

OBJECTIVES

The purpose of this study was to analyze the effect of outpatient cost-sharing on health care utilization by the elderly.

METHODS

The data in this analysis was the health insurance claims data between July 1999 and December 2008 (114 months). The study group was divided into two age groups, namely 60-64 years old and 65-69 years old. This study evaluated the impact of policy change on office visits, the office visits per person, and the percentage of the copayment-paid visits in total visits. Interrupted time series and segmented regression model were used for statistical analysis.

RESULTS

The results showed that outpatient cost-sharing decreased office visits, but it also decreased the percentage of copayment-paid visits, implying that the intensity of care increased. There was little difference in the results between the two age groups. But after the introduction of the coinsurance system for those patients under age 65, office visits and the percentage of copayment-paid visits decreased, and the 60-64 years old group had a larger decrease than the 65-69 years old group.

CONCLUSIONS

This study evaluated the effects of outpatient cost-sharing on health care utilization by the aged. Cost sharing of the elderly had little effect on controlling health care utilization.

Changes in drug use and out-of-pocket costs associated with Medicare Part D implementation: a systematic review

Medicare Part D was implemented 4 years ago. Despite the fact that public-use Part D data were unavailable until late 2008, researchers have used alternate data to examine the effect of Part D on drug use and out-of-pocket costs. In a systematic review of Medline from 2006 to October 2009, the literature about drug use and costs after implementation and during the transition period and coverage gap was summarized. Studies presenting original results regarding drug use and costs after Part D implementation were included. Case reports and series and simulation studies were excluded. Of 552 originally identified articles, 26 met selection criteria: 13 regarding the overall effect of Part D in the year(s) after implementation, seven describing the Part D transition period, and six concerning the coverage gap. Part D implementation was associated with a 6% to 13% increase in drug use and a 13% to 18% decrease in patient costs. The transition period was associated with no significant changes in use or costs for elderly dual-eligible beneficiaries, but effects in other populations were mixed. Entry into the coverage gap was associated with a 9% to 16% decrease in drug use and increases in costs of up to 89%. In summary, studies examining disparate data regarding the implementation of Part D found consistent positive effects on drug use and costs but revealed unfavorable trends in the coverage gap. The effect of the Part D transition period remains unclear. Although public-use data will validate these results, policymakers can use the existing evidence to inform changes and enhancements to Part D immediately.

Medicare part D's exclusion of benzodiazepines and fracture risk in nursing homes

BACKGROUND

Medicare Part D excludes benzodiazepine medications from coverage, and some state Medicaid programs also limit coverage. We assessed whether such policies decrease the risk of fractures in elderly individuals living in nursing homes.

METHODS

This is a quasi-experimental study with interrupted time-series estimation and extended Cox proportional hazards models comparing changes in outcomes before and after implementation of Medicare Part D in a nationwide sample of nursing home residents in 48 states. The study included 1 068 104 residents and a subsample of 50 874 residents with fracture data from 1 pharmacy. We assessed monthly prescribing rates of benzodiazepines and potential substitutes from January 1, 2005, through June 30, 2007, and hazard ratios for incident hip fracture and falls, adjusted for age, sex, and race/ethnicity. Estimates were stratified by concurrent Medicaid limits on benzodiazepines: no supplemental coverage (1 state), partial supplemental coverage (6 states), or complete supplemental coverage (41 states).

RESULTS

The no-supplemental-coverage policy resulted in an immediate and significant reduction of 10 absolute points in benzodiazepine use (27.0% to 17.0%) after Medicare Part D was implemented (95% confidence interval, -0.11 to -0.09; P < .001). Benzodiazepine use remained stable in the partial-supplemental- and complete-supplemental-coverage states. Hazard ratios for incident hip fracture were 1.60 (95% confidence interval, 1.05 to 2.45; P = .03) in the no-supplemental-coverage state after Medicare Part D implementation and 1.17 (95% confidence interval, 0.93 to 1.46; P = .18) in the partial-supplemental-coverage states, relative to complete-supplemental-coverage states.

CONCLUSION

Supplemental drug coverage exclusion policies affect the medication use of nursing home residents and may not decrease their fracture risk.

Unexplained variation across US nursing homes in antipsychotic prescribing rates

BACKGROUND

Serious safety concerns related to the use of antipsychotics have not decreased the prescribing of these agents to nursing home (NH) residents. We assessed the extent to which resident clinical characteristics and institutional prescribing practice were associated with antipsychotic prescribing.

METHODS

Antipsychotic prescribing was assessed for a nationwide, cross-sectional population of 16 586 newly admitted NH residents in 2006. We computed facility-level antipsychotic rates based on the previous year's (2005) prescribing patterns. Poisson regressions with generalized estimating equations were used to identify the likelihood of resident-level antipsychotic medication use in 2006, given 2005 facility-level prescribing pattern and NH resident indication for antipsychotic therapy (psychosis, dementia, and behavioral disturbance).

RESULTS

More than 29% (n = 4818) of study residents received at least 1 antipsychotic medication in 2006. Of the antipsychotic medication users, 32% (n = 1545) had no identified clinical indication for this therapy. Residents entering NHs with the highest facility-level antipsychotic rates were 1.37 times more likely to receive antipsychotics relative to those entering the lowest prescribing rate NHs, after adjusting for potential clinical indications (risk ratio [RR], 1.37; 95% confidence interval [CI], 1.24-1.51). The elevated risk associated with facility-level prescribing rates was apparent for only NH residents with dementia but no psychosis (RR, 1.40; 95% CI, 1.23-1.59) and residents without dementia or psychosis (RR, 1.54; 95% CI, 1.24-1.91).

CONCLUSIONS

The NH antipsychotic prescribing rate was independently associated with the use of antipsychotics in NH residents. Future research is needed to determine why such a prescribing culture exists and whether it could result in adverse health consequences.