Judith A. Lucas

Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study

Objective To assess risks of mortality associated with use of individual antipsychotic drugs in elderly residents in nursing homes. Design Population based cohort study with linked data from Medicaid, Medicare, the Minimum Data Set, the National Death Index, and a national assessment of nursing home quality. Setting Nursing homes in the United States. Participants 75 445 new users of antipsychotic drugs (haloperidol, aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone). All participants were aged ≥65, were eligible for Medicaid, and lived in a nursing home in 2001-5. Main outcome measures Cox proportional hazards models were used to compare 180 day risks of all cause and cause specific mortality by individual drug, with propensity score adjustment to control for potential confounders. Results Compared with risperidone, users of haloperidol had an increased risk of mortality (hazard ratio 2.07, 95% confidence interval 1.89 to 2.26) and users of quetiapine a decreased risk (0.81, 0.75 to 0.88). The effects were strongest shortly after the start of treatment, remained after adjustment for dose, and were seen for all causes of death examined. No clinically meaningful differences were observed for the other drugs. There was no evidence that the effect measure modification in those with dementia or behavioural disturbances. There was a dose-response relation for all drugs except quetiapine. Conclusions Though these findings cannot prove causality, and we cannot rule out the possibility of residual confounding, they provide more evidence of the risk of using these drugs in older patients, reinforcing the concept that they should not be used in the absence of clear need. The data suggest that the risk of mortality with these drugs is generally increased with higher doses and seems to be highest for haloperidol and least for quetiapine.

Comparative Safety of Antipsychotic Medications in Nursing Home Residents

To compare the risk of major medical events in nursing home residents newly initiated on conventional or atypical antipsychotic medications (APMs).

Depression in the first year of stay for elderly long-term nursing home residents in the U.S.A.

BACKGROUND Understanding the prevalence, incidence and cofactors of depression among long-term elderly nursing home (LTNH) residents domiciled for eight months or more may help optimize depression treatment in this vulnerable group. We quantified first year depression in American LTNH residents and the associations between depression and resident/facility characteristics. METHODS Data were obtained from the Minimum Data Set and Online Survey Certification and Reporting for 634,060 LTNH residents admitted from 1999 to 2005 in 4,216 facilities. Depression first diagnosed at admission and at subsequent quarterly intervals through the first year of stay was examined. Logistic regressions modeled correlates of newly identified depression in each time-period. RESULTS Recorded depression at admission and during the first year increased from 1999 to 2005. By 2005, 54.4% of LTNH residents had depression diagnosed over the first year; 32.8% at admission and a further 21.6% later during the first year. Antidepressant use was reported prior to depression diagnosis for 48% of those first identified depressed after admission. Men, non-Hispanic blacks, never married, and severely-cognitively impaired LTNH residents were less often identified with depression, particularly at admission. Pain and physical comorbidity were positively associated with depression identified throughout the first year. Prior institutionalization was associated with depression at admission, but not new depression after admission. Facility characteristics had weaker associations with depression. CONCLUSIONS High depression rates at admission and during the first year indicate a need to monitor and treat large numbers of American LTNH residents for depression. Reduced associations between demographics and depression as stays progress suggest other factors have increased roles in depression etiology.

No longer undertreated? Depression diagnosis and antidepressant therapy in elderly long-stay nursing home residents, 1999 to 2007.

OBJECTIVES: To examine the evolution of depression identification and use of antidepressants in elderly long‐stay nursing home residents from 1999 through 2007 and the associated sociodemographic and facility characteristics.

Comparative mortality risks of antipsychotic medications in community-dwelling older adults

BACKGROUND All antipsychotic medications carry warnings of increased mortality for older adults, but little is known about comparative mortality risks between individual agents. AIMS To estimate the comparative mortality risks of commonly prescribed antipsychotic agents in older people living in the community. METHOD A retrospective, claims-based cohort study was conducted of people over 65 years old living in the community who had been newly prescribed risperidone, olanzapine, quetiapine, haloperidol, aripiprazole or ziprasidone (n = 136 393). Propensity score-adjusted Cox proportional hazards models assessed the 180-day mortality risk of each antipsychotic compared with risperidone. RESULTS Risperidone, olanzapine and haloperidol showed a dose-response relation in mortality risk. After controlling for propensity score and dose, mortality risk was found to be increased for haloperidol (hazard ratio (HR) = 1.18, 95% CI 1.06-1.33) and decreased for quetiapine (HR = 0.81, 95% CI 0.73-0.89) and olanzapine (HR = 0.82, 95% CI 0.74-0.90). CONCLUSIONS Significant variation in mortality risk across commonly prescribed antipsychotics suggests that antipsychotic selection and dosing may affect survival of older people living in the community.

The Relationship Between Organizational Factors and Resident Satisfaction with Nursing Home Care and Life

Abstract We examined the relationships between nursing home (NH) resident satisfaction and NH organizational characteristics, while controlling for the effect of resident characteristics within facilities. We used a stratified, random sample of NHs (N=72) from two states and a prescreened and randomized sample of 1496 residents. Data sources included resident interviews, an administrator survey, the Minimum Data Set (MDS), and the Online Survey, Certification and Reporting System (OSCAR). Using Hierarchical Linear Modeling (HLM) techniques, we found that non-chain affiliation, certified nursing assistant staffing, and provision of a family council had significant positive effects on total resident satisfaction. The presence of a special care unit was associated with lower levels of satisfaction.

RESPONSE TO REGULATORY STRINGENCY: THE CASE OF ANTIPSYCHOTIC MEDICATION USE IN NURSING HOMES

This paper studies the impact of regulatory stringency, as measured by the statewide deficiency citation rate over the past year, on the quality of care provided in a national sample of nursing homes from 2000 to 2005. The quality measure used is the proportion of residents who are using antipsychotic medication. Although the changing case-mix of nursing home residents accounts for some of the increase in the use of antipsychotics, we find that the use of antipsychotics by nursing homes is responsive to state regulatory enforcement in a manner consistent with the multitasking incentive problem. Specifically, the effect of the regulations is dependent on the degree of complementarity between the regulatory deficiency and the use of antipsychotics.

Algorithm for Identifying Nursing Home Days Using Medicare Claims and Minimum Data Set Assessment Data.

Background:No consensus exists about methods of measuring nursing home (NH) length-of-stay for Medicare beneficiaries to identify long-stay and short-stay NH residents. Objectives:To develop an algorithm measuring NH days of stay to differentiate between residents with long and short stay (≥101 and <101 consecutive days, respectively) and to compare the algorithm with Minimum Data Set (MDS) alone and Medicare claims data. Research Design:We linked 2006–2009 MDS assessments to Medicare Part A skilled nursing facility (SNF) data. This algorithm determined the daily NH stay evidence by MDS and SNF dates. NH length-of-stay and characteristics were reported in the total, long-stay, and short-stay residents. Long-stay residents identified by the algorithm were compared with the NH evidence from MDS-alone and Medicare parts A and B data. Results:Of 276,844 residents identified by our algorithm, 40.8% were long stay. Long-stay versus short-stay residents tended to be older, male, white, unmarried, low-income subsidy recipients, have multiple comorbidities, and have higher mortality but have fewer hospitalizations and SNF services. Higher proportions of long-stay and short-stay residents identified by the MDS/SNF algorithm were classified in the same group using MDS-only (98.9% and 100%, respectively), compared with the parts A and B data (95.0% and 67.1%, respectively). NH length-of-stay was similar between MDS/SNF and MDS-only long-stay residents (mean±SD: 717±422 vs. 720±441 d), but the lengths were longer compared with the parts A and B data (approximately 474±393 d). Conclusions:Our MDS/SNF algorithm allows the differentiation of long-stay and short-stay residents, resulting in an NH group more precise than using Medicare claims data only.

Antipsychotic medication use in nursing homes: a proposed measure of quality

The potential misuse of antipsychotic medications (APMs) is an ongoing quality concern in nursing homes (NHs), especially given recent black box warnings and other evidence regarding the risk of APMs when used in NH populations. One mechanism regulators could use is public reporting of APM use by NHs; however, there is currently no agreed‐upon measure of guideline‐inconsistent APM use. In this paper, we describe a proposed measure of quality of APM use that is based on Centers for Medicare and Medicaid Services (CMS) Interpretive Guidelines, Food and Drug Administration (FDA) indications for APMs, and severity of behavioral symptoms.

Quality of Psychopharmacological Medication Prescribing and Mortality in Medicare Beneficiaries in Nursing Homes

To examine the influence of quality measures of psychopharmacological medication (PPM) prescribing on all‐cause mortality in a Medicare long‐stay nursing home (NH) population.