Evaluation of Antipsychotic Reduction Efforts in Patients With Dementia in Veterans Health Administration Nursing Homes

Antipsychotic Discontinuation and New Trazodone Use in Ontario Nursing Homes: Evidence of Medication Substitution

OBJECTIVES

An unintended consequence of efforts to reduce antipsychotic medications in nursing homes is the increase in use of other psychotropic medications; however, evidence of substitution remains limited. Our objective was to measure individual-level prescribing patterns consistent with substitution of trazodone for antipsychotics.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Residents of Ontario nursing homes aged 66-105 years with an admission assessment between April 1, 2010, and March 31, 2019, who were receiving an antipsychotic and had no antidepressant medication use at admission to the nursing home.

METHODS

We used linked health administrative data to examine changes in medication use over three quarterly assessments following admission. Antipsychotic and trazodone use were measured at each assessment. The rate of trazodone initiation was compared between residents no longer dispensed an antipsychotic (discontinued) and those with an ongoing antipsychotic (continued) using discrete time survival analysis, controlling for baseline resident characteristics.

RESULTS

We identified 13,306 residents dispensed an antipsychotic with no antidepressant use at admission (mean age 84 years, 61.5% women, 82.8% with dementia). As of the first quarterly assessment, nearly 20% of residents no longer received an antipsychotic and 9% received a new trazodone medication. Over time, residents who discontinued antipsychotics had a rate of trazodone initiation that was 82% higher compared to residents who continued (adjusted hazard ratio 1.82, 95% CI 1.66-2.00).

CONCLUSIONS AND IMPLICATIONS

Residents admitted to a nursing home with antipsychotic use had a higher rate of trazodone initiation if they discontinued (vs continued) an antipsychotic. These findings suggest antipsychotic substitution with trazodone after entering a nursing home.

Nursing Home Characteristics Associated with Antipsychotic Prescribing After Implementation of the National Antipsychotic Reduction Initiative (ARI)

OBJECTIVES

To describe nursing home (NH) characteristics associated with antipsychotic use and test whether associations changed after implementation of the National Partnership to Improve Dementia Care's antipsychotic reduction initiative (ARI).

METHODS

Longitudinal quasi-experimental design using data from multiple sources and piecewise linear mixed models were used for statistical analyses.

RESULTS

There was a significant decrease in monthly antipsychotic use across the study period (pre-ARI b = -0.0003, p <.001; post-ARI b = -0.0012, p <.001), which held after adjusting for NH characteristics. Registered nurse hours (b = -0.0026, p <.001), licensed practical nurse hours (b = -0.0019, p <.001), facility chain membership (b = -0.0013, p <.01), and health inspection ratings (b = -0.0003, p >.01) were associated with decreased antipsychotic use. Post-ARI changes in associations between NH characteristics and antipsychotic use were small and not statistically significant.

CONCLUSIONS

Decreases in antipsychotic use were associated with most NH characteristics, and associations persisted post-ARI. Further research is warranted to examine the interactions between ARI policy and NH characteristics on antipsychotic prescribing, as well as other NH factors, such as facility prescribing cultures and clinical specialty of staff.

CLINICAL IMPLICATIONS

Decreases in monthly antipsychotic use were observed following the ARI. The decreases in monthly antipsychotic use were associated with most NH characteristics, and these associations persisted during the post-ARI period.

Relationship between facility number of clinicians and prescribing intensity of psychotropic medications, opioids, and antibiotics in ambulatory practice

BACKGROUND

Promoting appropriate pharmacotherapy requires understanding the factors that influence how clinicians prescribe medications. While prior work has focused on patient and clinician factors, features of the organizational setting have received less attention, though identifying sources of variation in prescribing may help identify opportunities to improve patient safety and outcomes.

OBJECTIVE

To evaluate the relationship between the number of clinicians who prescribe medications in a facility and facility prescribing intensity of six individual medication classes by clinician specialty: benzodiazepines, antipsychotics, antiepileptics, and antidepressants by psychiatrists and antibiotics, opioids, antiepileptics, and antidepressants by primary care clinicians (PCPs).

DESIGN

We used 2017 Veterans Health Administration (VHA) administrative data.

SUBJECTS

We included patient-clinician dyads of older patients (> 55 years) with an outpatient encounter with a clinician in 2017. Patient-clinician data from 140 VHA facilities were included (n = 13,347,658). Analysis was repeated for years 2014 to 2016.

MAIN MEASURES

For each medication, facility prescribing intensity measures were calculated as clinician prescribing intensity averaged over all clinicians at each facility. Clinician prescribing intensity measures included percentage of each clinician's patients prescribed the medication and mean number of days supply per patient among all patients of each clinician.

KEY RESULTS

As the number of prescribing clinicians in a facility increased, the intensity of prescribing decreased. Every increase of 10 facility clinicians was associated with a significant decline in prescribing intensity for both specialties for different medication classes: for psychiatrists, declines ranged from 6 to 11%, and for PCPs, from 2 to 3%. The pattern of more clinicians less prescribing was significant across all years.

CONCLUSION

Future work should explore the mechanisms that link the number of facility clinicians with prescribing intensity for benzodiazepines, antipsychotics, antiepileptics, antidepressants, antibiotics, and opioids. Facilities with fewer clinicians may need additional resources to avoid unwanted prescribing of potentially harmful or unnecessary medications.

Central Nervous System-Active Prescriptions in Older Veterans: Trends in Prevalence, Prescribers, and High-risk Populations

BACKGROUND

Little is known about the prevalence or chronicity of prescriptions of central nervous system-active (CNS-active) medications in older Veterans.

OBJECTIVE

We sought to describe (1) the prevalence and trends in prescription of CNS-active medications in older Veterans over time; (2) variation in prescriptions across high-risk groups; and (3) where the prescription originated (VA or Medicare Part D).

DESIGN

Retrospective cohort study from 2015 to 2019.

PARTICIPANTS

Veterans age ≥ 65 enrolled in the Medicare and the VA residing in Veterans Integrated Service Network 4 (incorporating Pennsylvania and parts of surrounding states).

MAIN MEASURES

Drug classes included antipsychotics, gabapentinoids, muscle relaxants, opioids, sedative-hypnotics, and anticholinergics. We described prescribing patterns overall and in three subgroups: Veterans with a diagnosis of dementia, Veterans with high predicted utilization, and frail Veterans. We calculated both prevalence (any fill) and percent of days covered (chronicity) for each drug class, and CNS-active polypharmacy (≥ 2 CNS-active medications) rates in each year in these groups.

KEY RESULTS

The sample included 460,142 Veterans and 1,862,544 person-years. While opioid and sedative-hypnotic prevalence decreased, gabapentinoids exhibited the largest increase in both prevalence and percent of days covered. Each subgroup exhibited different patterns of prescribing, but all had double the rates of CNS-active polypharmacy compared to the overall study population. Opioid and sedative-hypnotic prevalence was higher in Medicare Part D prescriptions, but the percent of days covered of nearly all drug classes was higher in VA prescriptions.

CONCLUSIONS

The concurrent increase of gabapentinoid prescribing paralleling a decrease in opioid and sedative-hypnotics is a new phenomenon that merits further evaluation of patient safety outcomes. In addition, we found substantial potential opportunities for deprescribing CNS-active medications in high-risk groups. Finally, the increased chronicity of VA prescriptions versus Medicare Part D is novel and should be further evaluated in terms of its mechanism and impact on Medicare-VA dual users.

Fall-related Injuries and Opioid Administration Among Veterans With Dementia in US Department of Veterans Affairs Community Living Centers

OBJECTIVES

Opioid use is associated with fall-related injuries (FRI) among older adults, especially those with dementia. We examined FRI following changes in national opioid safety initiatives over 3 regulatory periods [preinitiatives baseline (period 1): October 2012 to June 2013; post-Veteran Affairs (VA) opioid safety initiative (period 2): January 2014 to November 2015; post-VA and CDC opioid prescribing guidelines (period 3): March 2017 to September 2018] among Department of VA Community Living Center (CLC) long-stay residents with dementia.

DATA

VA provided and purchased care records, Medicare claims, CLC Minimum Data Set (MDS) assessments. VA bar-code medication administration data, VA outpatient prescription refill data, and Medicare Part D data were used to capture medication from inpatient, outpatient, and Medicare sources.

SETTINGS AND PARTICIPANTS

A total of 12,229 long-stay CLC residents with dementia between October 2012 and September 2018.

METHODS

We applied Veteran-regulatory period level (1) generalized linear model to examine the unadjusted and adjusted trends of FRI, and (2) difference-in-difference model with propensity score weighting to examine the relationship between opioid safety initiatives and FRI in 3 regulatory periods. We applied propensity score weighting to enable the cohorts in periods 2 and 3 had similar indications for opioid administration as in period 1.

RESULTS

FRI prevalence per month among CLC residents with Alzheimer disease and related dementias decreased from 3.1% in period 1 to 1.6% and 1.2% in periods 2 and 3, and the adjusted probability of FRI was 17% and 40% lower in periods 2 and 3 compared with period 1. The any, incident, and continued opioid administration were significantly associated with higher FRI, whereas the differences in FRI probabilities between opioid and nonopioid users had no significant changes over the 3 regulatory periods.

CONCLUSIONS

FRI was reduced among CLC residents with Alzheimer disease and related dementias receiving care in VA CLCs over the 3 regulatory periods, but the FRI reduction was not significantly associated with opioid safety initiatives. Other interventions that potentially targeted falls are likely to have helped reduce these fall events. Future studies could examine whether opioid use reduction ultimately benefitted nursing home residents by focusing on other possible outcomes or whether such reduction only resulted in more untreated pain.

Federal Nursing Home Policies on Antipsychotics had Similar Impacts by Race and Ethnicity for Residents With Dementia

OBJECTIVES

Federal initiatives have been successful in reducing antipsychotic exposure in nursing home residents with dementia. We assessed if these initiatives were implemented equally across racial and ethnic minority groups.

DESIGN

Retrospective, cross-sectional trends study.

SETTING AND PARTICIPANTS

National long-stay nursing home residents with dementia from 2011 to 2017.

METHODS

We examined trends in psychotropic drug class exposures from the Minimum Data Set assessments for non-Hispanic Black (NHB), Hispanic, and non-Hispanic White (NHW) residents using interrupted time-series analyses with age-sex standardized quarterly outcomes and time points to denote the National Partnership (2012) and Five Star Rating changes (2015).

RESULTS

Initially, antipsychotic (33.0%) and sedative (6.8%) exposure was highest for Hispanic residents; antidepressant (59.8%) and anxiolytic (23.4%) exposure was highest for NHW residents; NHB residents had the lowest use of each. Antipsychotic use dropped at the time of the Partnership (β = -0.8807, P = .0023) and the slope declined further after the Partnership (β = -0.6611, P < .0001) for NHW. In comparison to NHW, the level and slope changes for NHB and Hispanics were not significantly different. The Five Star Rating change did not impact the level of antipsychotic use (β = 0.027, P = .9467), but the slope changed to indicate a slowed rate of decline (β = 0.1317, P = .4075) for NHW. As to the other psychotropic drug classes, there were few significant differences between trends seen in the racial and ethnic subgroups. The following exceptions were noted: antidepressant use decreased at a faster rate for NHB residents post-Partnership (β = -0.1485, P = .0371), and after the Five Star Rating change, NHB residents (β = -0.0428, P = .0312) and Hispanic residents (β = -0.0834, P < .0001) saw antidepressant use decrease faster than NHW. Sedative use in slope post-Partnership period (β = -0.086, P = .0275) and post-Five Star Rating (β = -0.0775, P < .0001) declined faster among Hispanic residents.

CONCLUSIONS AND IMPLICATIONS

We found little evidence of clinically meaningful differences in changes to 4 classes of psychotropic medication use among racial and ethnic minority nursing home residents with dementia following 2 major federal initiatives.

Nursing Homes Underreport Antipsychotic Use but Overreport Diagnoses Qualifying for Appropriate Use

Antipsychotic drug use in U.S. nursing homes remains a priority concern, but less is understood about the characteristics associated with reporting. Using linked Medicare claims and Minimum Data Set (MDS) assessments for long-stay nursing home residents from January 2018 to December 2019, we assessed the consistency of antipsychotic drug reporting and diagnosis of conditions (schizophrenia, Tourette's syndrome, and Huntington's disease) which qualify as appropriate drug use across data sources by calculating reporting rates in facility-reported MDS and Medicare claims. The antipsychotic reporting outcome is conditional on claims reporting while the condition reporting outcomes are conditional on MDS reporting. We found underreporting (87% reporting rate) in facility-reported antipsychotic use relative to Medicare claims. In contrast, we found overreporting of the qualifying conditions with a number of facility-reported diagnoses unsupported by a corresponding claims diagnosis. Only 54.8% of schizophrenia, 46.5% of Tourette's syndrome, and 72.4% of Huntington's disease diagnoses reported in the MDS had a claims diagnosis. There was also variation in reporting odds for antipsychotic drug use by dual-eligibility status and race, with higher odds for dual-eligible and lower odds for Black residents These findings suggest CMS should continue investigating the source of reporting discrepancies in antipsychotic drug use and qualifying diagnoses.

Unintended impacts of a national antipsychotic reduction initiative among nursing facility residents with and without Alzheimer's disease

BACKGROUND

In July 2012, the Centers for Medicare & Medicaid services launched an antipsychotic reduction initiative (ARI) to improve care for nursing facility residents with Alzheimer's disease and related dementias (ADRD). We examined the impact of this policy on antipsychotic and psychotropic medication (PM) utilization and diagnosis patterns in long-stay nursing facility residents with ADRD and other conditions in which antipsychotics are indicated.

METHODS

Using an 80% sample of fee-for-service Medicare beneficiaries with Part D, we conducted a retrospective cohort study of nursing facility residents with ADRD, bipolar disorder, psychosis, Parkinson's disease, and residents exempt from the policy due to diagnoses of schizophrenia, Tourette syndrome, and/or Huntington's disease. We used interrupted time-series analyses to compare changes in diagnoses, antipsychotic use, and PM utilization before (January 1, 2011-June 30, 2012) and after (July 1, 2012-September 30, 2015) ARI implementation.

RESULTS

We identified 874,487 long-stay nursing facility residents with a diagnosis of ADRD (n = 358,518), exempt (n = 92,859), bipolar (n = 128,298), psychosis (n = 93,402), and Parkinson's disease (n = 80,211). In all cohorts, antipsychotic use declined prior to the ARI; upon policy implementation, antipsychotic use reductions were sustained throughout the study period, including statistically significant ARI-associated accelerated declines in all cohorts. PM changes varied by cohort, with ARI-associated increases in non-benzodiazepine sedatives and/or muscle relaxants noted in ADRD, psychosis, and Parkinson's cohorts. Although anticonvulsant use increased throughout the study period in all groups, with the exception of the bipolar cohort, these increases were not associated with ARI implementation. Findings are minimally explained by increased post-ARI membership in the psychosis and Parkinson's cohorts.

CONCLUSIONS

Our study documents antipsychotic use significantly declined in non-ADRD clinical and exempt cohorts, where such reductions may not be clinically warranted. Furthermore, ARI-associated compensatory increases in PMs do not offset these reductions. Changes in PM utilization and diagnostic make-up of residents using PMs require further investigation to assess the potential for adverse clinical and economic outcomes.

Recent Hospitalization and Initiation of Antiepileptics Among Persons With Alzheimer's Disease

OBJECTIVES

Antiepileptic drugs (AEDs) are frequently prescribed for persons with Alzheimer's disease (AD), but little is known on factors associated with AED initiation in this population. We investigated whether recent hospitalization is associated with AED initiation in persons with AD.

DESIGN

Nested case-control study in the nationwide register-based Medication use and Alzheimer's disease (MEDALZ) cohort.

PARTICIPANTS AND SETTINGS

The MEDALZ cohort includes 70,718 persons diagnosed with AD during 2005-2011 in Finland. Altogether 6814 AED initiators and 6814 age-, sex-, and time since AD diagnosis-matched noninitiators were included in this study. Matching date was the date of AED initiation.

METHODS

AED purchases were identified from the Prescription Register and hospitalizations from the Care Register for Health Care. Recent hospitalization was defined as hospitalization ending within 2 weeks before the matching date. Association between recent hospitalization and AED initiation was assessed with conditional logistic regression.

RESULTS

The most frequently initiated AEDs were pregabalin (42.9%) and valproic acid (32.2%). A bigger proportion of AED initiators (36.9%) than noninitiators (5.3%) were recently hospitalized [odds ratio (OR) 10.5, 95% CI 9.22-11.9]. Dementia was the most frequent discharge diagnosis among AED initiators (29.1%) and noninitiators (27.9%). Among AED initiators, the next most frequent diagnosis was epilepsy (20.6%). Musculoskeletal diagnoses and use of analgesics including opioids was more common among gabapentinoid initiators compared with other AED initiators.

CONCLUSIONS AND IMPLICATIONS

Recent hospitalization was significantly related to AED initiation. Initiations of AED might have been related to common symptoms in persons with AD like neuropathic pain, epilepsy, and neuropsychiatric symptoms.

Psychotropic medication prescribing in assisted living and nursing home residents with dementia after the National Partnership

BACKGROUND

The Centers for Medicare & Medicaid Services implemented the National Partnership to Improve Dementia Care in Nursing Homes (the Partnership) to decrease antipsychotic use and improve care for nursing home (NH) residents with dementia. We determined whether the extent of antipsychotic and other psychotropic medication prescribing in AL residents with dementia mirrored that of long-stay NH (LSNH) residents after the Partnership.

METHODS

Using a 20% sample of fee-for-service Medicare beneficiaries with Part D, we conducted a retrospective cohort study including AL and LSNH residents with dementia. The monthly prevalence of psychotropic medication prescribing (antipsychotics, antidepressants, anxiolytics/sedative-hypnotics, anticonvulsants/mood stabilizers, benzodiazepines, and antidementia medications) was examined. We used an interrupted time-series analysis to compare medication prescribing before (July 1, 2010-March 31, 2012) and after (April 1, 2012-December 31, 2017) the Partnership in both settings.

RESULTS

We identified 107,931 beneficiaries with ≥1 month as an AL resident and 323,766 beneficiaries with ≥1 month as a LSNH resident with dementia, including 1,923,867 person-months and 4,984,405 person-months, respectively. Antipsychotic prescribing declined over the study period in both settings. After the launch of the Partnership, the rate of decline in antipsychotic prescribing slowed in AL residents with dementia (slope change = 0.03 [95% CLs: 0.02, 0.04]) while the rate of decline in antipsychotic prescribing increased in LSNH residents with dementia (slope change = -0.12 [95% CLs: -0.16, -0.08]). Antidepressants were the most prevalent medication prescribed, anticonvulsant/mood stabilizer prescribing increased, and anxiolytic/sedative-hypnotic and antidementia medication prescribing declined.

CONCLUSIONS

The federal Partnership to reduce antipsychotic prescribing in NH residents did not appear to affect antipsychotic prescribing in AL residents with dementia. Given the increase in the prescribing of mood stabilizers/anticonvulsants that occurred after the launch of the Partnership, monitoring may be warranted for all psychotropic medications in AL and NH settings.