Association of nursing home antipsychotic reduction policies with antipsychotic use in community dwellers with dementia.

BACKGROUND: Antipsychotic and other psychotropic medication use is prevalent among community-dwelling older adults with dementia despite the potential for adverse effects. Two Centers for Medicare & Medicaid Services (CMS) initiatives, the National Partnership to Improve Dementia Care ("the Partnership") and the Five Star Quality Rating System for antipsychotic use reporting, have been successful in reducing antipsychotic use in nursing home residents. We assessed if these initiatives had a spillover effect in antipsychotic and other psychotropic medication use among community dwellers with dementia due to potential overlap in prescribers across settings. METHODS: Among community-dwelling older adults with dementia, we examined psychotropic medication class use (i.e., antipsychotics, antidepressants, anxiolytics, anticonvulsants/mood stabilizers, antidementia) in 2010-2017 Medicare fee-for-service claims using interrupted time series analyses across three periods ("Pre-Partnership": July 1, 2010 to March 31, 2012; "Post-Partnership": April 1, 2012 to January 31, 2015; "Five Star Quality Rating": February 1, 2015 to December 31, 2017). RESULTS: We included 1,289,401 community dwellers with dementia contributing 26,609,697 person-months. The mean age was 80 years, most were female (70%), approximately 80% were non-Hispanic Whites, 10% were non-Hispanic Blacks, and 5% were Hispanic ethnicity. Antipsychotic use was declining pre-Partnership (ß = -0.06, 95% CI: -0.08, -0.05) and post-Partnership (ß = -0.02, 95% CI: -0.02, -0.01). Post-Five Star Quality Rating, antipsychotic use remained stable with a nearly flat slope (ß = -0.01, 95% CI: -0.01, 0.00). Anticonvulsant and antidepressant use increased and anxiolytic and antidementia medication use decreased among community-dwelling older adults with dementia. CONCLUSIONS: These two CMS policies on antipsychotic use for nursing home residents were not associated with a spillover effect to community-dwelling older adults with dementia. Strategies to monitor the appropriateness of psychotropic medication use may be warranted for community-dwellers with dementia.

Impact of federal antipsychotic use policy in nursing homes on new diagnoses for approved indications in dementia residents.

BACKGROUND: Federal policies targeting antipsychotic use among nursing home (NH) residents may have increased reporting of diagnoses for approved uses, including schizophrenia, Tourette's syndrome, and Huntington's Disease (called "exclusionary diagnoses" because they exclude residents from the antipsychotic quality metric). We assessed changes in new exclusionary diagnoses among long-stay NH admissions specifically with dementia following federal policies. METHODS: Retrospective, quarterly, interrupted time-series analysis (2009-2018) of new long-stay NH residents with dementia and no exclusionary diagnoses reported before NH admission. The National Partnership and the addition of facility level antipsychotic use to the Five Star Quality Rating system were key time exposures. Outcome was quarterly facility level predicted percentage of exclusionary diagnoses within 2 years of admission stratified by NH characteristics. RESULTS: For 264,095 long-stay admissions, mean percentage of new exclusionary diagnoses was 2.2% before the Partnership. After the Partnership, there was an unadjusted increase in the percentage over time (slope change, 0.044, p = 0.018), but the percentage never exceeded 2.9%. The Partnership contributed to a one-time decrease in diagnoses in NHs with an intermediate percentage of Black residents (-1.29%, p = 0.004). Before the Partnership, diagnoses were increasing among not-for-profit relative to for-profit NHs (0.044; p = 0.012), but after the Partnership, the pattern reversed. For-profit NHs saw an increase (+0.034, p = 0.002); not-for-profit NHs experienced a decrease (-0.014, p = 0.039). Quality Rating modifications had no significant effect. CONCLUSIONS: Exclusionary diagnosis reporting among long-stay NH residents with dementia, the group most at risk from antipsychotics, did not increase in response to federal policies. Evaluation of reasons for the observed increase in exclusionary diagnoses among non-dementia NH residents is warranted along with continued attention to how to incentivize the appropriate use of medications in residents with dementia that is crucial for high-quality NH care.

Regional variation in diagnostic intensity of dementia among older U.S. adults: An observational study.

INTRODUCTION: Geographic variation in diagnosed cases of Alzheimer's disease and related dementias (ADRD) could be due to underlying population risk or differences in intensity of new case identification. Areas with low ADRD diagnostic intensity could be targeted for additional surveillance efforts. METHODS: Medicare claims were used for a cohort of older adults across hospital referral regions (HRRs). ADRD-specific regional diagnosis intensity was measured as the ratio of expected new ADRD cases (estimated using population demographics, risk factors, and practice intensity) compared to observed ADRD-diagnosed cases. RESULTS: Crude new ADRD diagnosis rate ranged from 1.7 to 5.4 per 100 across HRRs. ADRD-specific diagnosis intensity ranged from 0.69 to 1.47 and varied most for Black, Hispanic, and the youngest (66-74) subgroups. Across all subgroups, ADRD diagnosis intensity was associated with 2-fold difference in receiving an ADRD diagnosis. DISCUSSION: Where one resides influences the likelihood of receiving an ADRD diagnosis, particularly among those 66-74 years of age and minoritized groups. HIGHLIGHTS: Rate of new Alzheimer's disease and related dementias (ADRD) case identification varies geographically across the United States. Variation in case identification is greatest in Black, Hispanic, and young-old groups. Intensity of diagnosis (ie, case identification) unrelated to population risk differs across place. Likelihood of receiving an ADRD diagnosis varies 2-fold based on place of residence.

Prevalence and Factors Associated with De-escalation of Anti-TNFs in Older Adults with Rheumatoid Arthritis: A Medicare Claims-Based Observational Study.

OBJECTIVE: The aim was to evaluate prevalence and factors associated with anti-tumor necrosis factor (anti-TNF) de-escalation in older adults with rheumatoid arthritis (RA). METHODS: We identified adults ≥ 66 years of age with RA on anti-TNF therapy within 6 months after RA diagnosis with at least 6-7 months duration of use (proxy for stable use), using 20% Medicare data from 2008-2017. Patient demographic and clinical characteristics, including concomitant use of glucocorticoid (GC), were collected. Anti-TNF use was categorized as either de-escalation (identified by dosing interval increase, dose reduction, or cessation of use) or continuation. We used (1) an observational cohort design with Cox regression to assess patient characteristics associated with de-escalation and (2) a case-control design with propensity score-adjusted logistic regression to assess the association of de-escalation with different clinical conditions and concomitant medication use. RESULTS: We identified 5106 Medicare beneficiaries with RA on anti-TNF, 65.5% of whom had de-escalation. De-escalation was more likely with older age (hazard ratio [HR] 1.01, 95% confidence interval [CI] 1.01-1.02) or greater comorbidity (HR 1.07, 95% CI 1.05-1.09), but was less likely with low-income subsidy status (HR 0.85, 95% CI 0.78-0.92), adjusting for patient sex and race/ethnicity. Lower odds of de-escalation were associated with serious infection (odds ratio [OR] 0.79, 95% CI 0.66-0.94), new heart failure diagnosis (OR 0.70, 95% CI 0.52-0.95), and long-term GC use (OR 0.84, 95% CI 0.74-0.95), whereas higher odds were associated with concomitant methotrexate use (OR 1.16, 95% CI 1.03-1.31). CONCLUSIONS: Anti-TNFs are de-escalated in two-thirds of older adults with RA in usual care. Further study is needed on RA outcomes after anti-TNF de-escalation.

Care Fragmentation, Care Continuity, and Care Coordination-How They Differ and Why It Matters.

This Viewpoint considers why fragmentation occurs and suggests a potential path forward for developing evidenced-based strategies that can reduce the occurrence of fragmentation and its associated harms.

Identification of Dementia in Medicare Claims Compared to Rigorous Clinical Assessments in African Americans.

BACKGROUND: Evidence indicates the health care system disproportionately misses dementia in African American compared to White individuals. In preliminary data, we examined factors related to dementia identification by the health care system among African Americans. METHODS: We leveraged linked Medicare fee-for-service claims and detailed annual cohort evaluations in African Americans from 4 cohorts at Rush Alzheimer's Disease Center. RESULTS: Among 88 African Americans with cognitive impairment (mean = 10 years follow-up), Medicare claims identified dementia <2 years from cohort diagnosis in 55%; 27% were identified 2-9.9 years after cohort diagnosis, and in 18% there was either no claims diagnosis during the study period, or claims identified dementia 10+ years after cohort diagnosis. Claims identification of dementia was related to older age at cohort diagnosis (eg, <2 years between cohort and claims: mean = 82 years; 10+ years/no diagnosis: mean = 77 years, p = .04), lower Mini-Mental State Examination (MMSE) score (<2 years: mean = 24; 10+ years/no diagnosis: mean = 26, p = .04), more depressive symptoms (<2 years: mean = 2.1 symptoms; 10+ years/no diagnosis: mean = 1.2, p = .04), and more comorbidity (<2 years: mean = 5.6 comorbidities; 10+ years/no diagnosis, mean = 3.0, p = .02). CONCLUSIONS: Among African Americans, preliminary data indicate the health care system most rapidly identifies dementia in older individuals, with worse cognitive and physical health. The health care system may miss opportunities for early support of African Americans with dementia, and caregivers.

Accountable Care Organization Attribution and Post-Acute Skilled Nursing Facility Outcomes for People Living With Dementia.

OBJECTIVES: Under the Accountable Care Organization (ACO) model, reductions in healthcare spending have been achieved by targeting post-acute care, particularly in skilled nursing facilities (SNFs). People with Alzheimer disease and related dementias (ADRD) are frequently discharged to SNF for post-acute care and may be at particular risk for unintended consequences of SNF cost reduction efforts. We examined SNF length of stay (LOS) and outcomes among ACO-attributed and non-ACO-attributed ADRD patients. DESIGN: Observational serial cross-sectional study. SETTING AND PARTICIPANTS: Twenty percent national random sample of fee-for-service Medicare beneficiaries (2013-2017) to identify beneficiaries with a diagnosis of ADRD and with a hospitalization followed by SNF admission (n = 263,676). METHODS: Our primary covariate of interest was ACO (n = 66,842) and non-ACO (n = 196,834) attribution. Hospital readmission and death were measured for 3 time periods (<30, 31-90, and 91-180 days) following hospital discharge. We used 2-stage least squares regression to predict LOS as a function of ACO attribution, and patient and facility characteristics. RESULTS: ACO-attributed ADRD patients have shorter SNF LOS than their non-ACO counterparts (31.7 vs 32.8 days; P < .001). Hospital readmission rates for ACO vs non-ACO differed at ≤30 days (13.9% vs 14.6%; P < .001) but were similar at 31-90 days and 91-180 days. No significant difference was observed in mortality post-hospital discharge for ACO vs non-ACO at ≤30 days; however, slightly higher mortality was observed at 31-90 days (8.4% vs 8.8%; P = .002) and 91-180 days (7.6% vs 7.9%; P = .011). No significant association was found between LOS and readmission, with small effects on mortality favoring ACOs in fully adjusted models. CONCLUSIONS AND IMPLICATIONS: Being an ACO-attributed patient is associated with shorter SNF LOS but is not associated with changes in readmission or mortality after controlling for other factors. Policies that shorten LOS may not have adverse effects on outcomes for people living with dementia.

Transfer Trauma Among Nursing Home Residents: Development of a Composite Measure.

BACKGROUND AND OBJECTIVES: Nursing home (NH)-to-NH transfers place NH residents at risk for developing transfer trauma. We aimed to develop a composite measure of transfer trauma and apply it among those transferring before and during the pandemic. RESEARCH DESIGN AND METHODS: Cross-sectional cohort analysis of long-stay NH residents with a NH-to-NH transfer. Minimum Data Set data (2018-2020) were used to create the cohorts. A composite measure of transfer trauma was developed (2018 cohort) and applied to the 2019 and 2020 cohorts. We analyzed resident characteristics and conducted logistic regression analyses to compare rates of transfer trauma between periods. RESULTS: In 2018, 794 residents were transferred; 242 (30.5%) met the criteria for transfer trauma. In the 2019 and 2020, 750 residents (2019) and 795 (2020) were transferred. In 2019 cohort, 30.7% met the criteria for transfer trauma, and 21.9% in 2020 cohort. During the pandemic, a higher proportion of transferred residents left the facility before the first quarterly assessment. Among residents who stayed in NH for their quarterly assessment, after adjusting for demographic characteristics, residents in the 2020 cohort were less likely to experience transfer trauma than those in the 2019 cohort (adjusted odds ratio [AOR] = 0.64, 95% confidence interval [CI]: 0.51, 0.81). However, residents in 2020 cohort were two times more likely to die (AOR = 1.94, 95% CI: 1.15, 3.26) and 3 times more likely to discharge within 90 days after transfer (AOR = 2.86, 95% CI: 2.30, 3.56) compared with those in 2019 cohort. DISCUSSION AND IMPLICATIONS: These findings highlight how common transfer trauma is after NH-to-NH transfer and the need for further research to mitigate negative outcomes associated with the transfer in this vulnerable population.

Initiation of Disease-Modifying Antirheumatic Drugs in Older Medicare Beneficiaries With New Diagnosis of Late-Onset Rheumatoid Arthritis.

OBJECTIVE: Older adults with rheumatoid arthritis (RA) account for up to one-third of the RA population and are less likely to receive optimal treatment. For the subgroup of older adults with late-onset RA (LORA), who experience more symptomatic and progressive disease, suboptimal treatment could be more consequential than the general population who age with RA. We evaluated use of disease-modifying antirheumatic drugs (DMARDs) in older adults with a new diagnosis of LORA. METHODS: In this retrospective observational study, we identified adults 66 years of age or older with a new diagnosis of LORA using Medicare data from 2008 to 2017. Information on baseline patient characteristics and DMARD initiation during the first 12 months after LORA diagnosis were collected. We also assessed concomitant use of glucocorticoids (GCs). RESULTS: We identified 33,373 older adults with new diagnosis of LORA. Average age at LORA diagnosis was 76.7 (SD 7.6); 75.4% were female, 76.9% were White, and 35.6% had low-income subsidy (LIS). Less than one-third were initiated on a DMARD (28.9%). In multivariable analyses, DMARD initiation was associated with younger age, fewer comorbidities, and absence of LIS status. Concomitant long-term (>3 months) GC use was higher among those on any DMARD (44.3%) compared with those without (15.2%). CONCLUSIONS: DMARD initiation after new diagnosis of LORA is low despite current clinical practice guidelines recommending early aggressive initiation of treatment. Long-term GC use is common among those on any DMARDs, raising concern for suboptimal DMARD use. Further studies are needed to understand drivers of DMARD use in older adults.

Treatment for Urinary Incontinence in Women Older Than 65 Years.

IMPORTANCE: Urinary incontinence (UI) is common among women older than 65 years and negatively affects quality of life. However, the prevalence of UI treatment and determinants of treatment are largely unknown. OBJECTIVES: The aim of this study was to identify rates of UI treatment and factors associated with treatment in older women with self-reported UI. STUDY DESIGN: This is a retrospective cohort analysis of a data set linking UI symptoms from the Nurses' Health Study to Medicare claims. We evaluated use of pharmacotherapy, noninvasive, and procedural treatments for UI within 1 year before symptom survey. For pharmacotherapy, we used multivariable logistic regression to estimate odds ratios (ORs) of UI treatment. RESULTS: Of the 67,587 Nurses' Health Study respondents, 15,088 had linkage to Medicare, subscribed to part D, and answered UI questions. Of these, 8,332 (55.2%) women reported UI, and 10.9% with UI had a Medicare claim for treatment; pharmacotherapy represented 94.6% of all treatments.On regression analysis, women with more severe and longer-term UI had higher odds of treatment (severe vs slight UI: OR, 3.1; 95% confidence interval [CI], 2.2-4.3) (longer vs new UI: OR, 1.9; 95% CI, 1.5-2.3). Women with mixed (OR, 2.5; 95% CI, 1.9-3.2) or urgency UI (OR, 3.0; 95% CI, 2.2-3.9) had greater odds of treatment compared with women with stress UI. CONCLUSIONS: We estimate that only approximately 1 in 9 older women with self-reported UI underwent treatment within the year before reporting symptoms, of which pharmacotherapy was the most common UI intervention, and women with more severe and longer duration of symptoms were most often treated.

Characteristics of Emergency Department Visits Among Older Adults With Dementia.

This cross-sectional study examines emergency department use among older adults with Alzheimer disease and related dementias.

Accountable care organizations and use of surgery among patients with Alzheimer disease and related dementias.

OBJECTIVE: To understand the effects of accountable care organizations (ACOs) on use of surgery in patients with Alzheimer disease and related dementias (ADRD). STUDY DESIGN: Retrospective national cohort study of all Medicare beneficiaries identified in a 20% sample between 2010 and 2017. The primary exposure was participation in ACOs. The primary outcome was use of 1 of 6 common surgical procedures (aortic valve replacement [AVR], abdominal aortic aneurysm [AAA] repair, colectomy, carotid artery repair, major joint repair, and prostatectomy). METHODS: Multivariable logistic regression models were fit using beneficiary-year as the unit of analysis to estimate the likelihood of undergoing each procedure among patients with ADRD and without ADRD, stratified by ACO participation. Additional models were fit to determine how the relationship between ACO participation and surgery was altered based on procedure urgency and the availability of minimally invasive technology. RESULTS: Adjusted odds for use of surgery were lower among patients with ADRD compared with patients without ADRD for all procedures. ACO participation had varying impact on patients with ADRD, with higher odds of AVR and major joint surgery and lower odds of carotid artery repair. Availability of minimally invasive technology increased the likelihood of AVR and AAA repair among patients with ADRD; however, ACO participation reduced these effects. The effect of ACO participation on the likelihood of undergoing surgery did not vary by urgency of the procedure. CONCLUSIONS: The likelihood of undergoing surgery is overall lower among patients with ADRD and may vary by ACO participation for specific procedures.

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 (ß = -0.8807, P = .0023) and the slope declined further after the Partnership (ß = -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 (ß = 0.027, P = .9467), but the slope changed to indicate a slowed rate of decline (ß = 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 (ß = -0.1485, P = .0371), and after the Five Star Rating change, NHB residents (ß = -0.0428, P = .0312) and Hispanic residents (ß = -0.0834, P < .0001) saw antidepressant use decrease faster than NHW. Sedative use in slope post-Partnership period (ß = -0.086, P = .0275) and post-Five Star Rating (ß = -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.

Factors Associated With Benzodiazepine and Antipsychotic Prescribing in Hospice: A Qualitative Study of Hospice Prescribers.

OBJECTIVES: Benzodiazepine and antipsychotic medications are common components of the hospice toolkit and are routinely prescribed for behavioral symptom management at end of life. These medications have significant associated risks but, despite their frequent use, little is known about how clinicians weigh prescribing decisions for individuals in hospice. In this qualitative study, we examined the key factors that influence the decision to initiate a benzodiazepine and antipsychotic medication for management of behavioral symptoms at end of life. DESIGN: A qualitative study using semi-structured interviews and descriptive qualitative analysis. SETTING AND PARTICIPANTS: We conducted semi-structured interviews with prescribing hospice physicians and nurse practitioners working in hospice settings across the United States. METHODS: Hospice clinicians were asked to describe factors that influence prescribing decisions to initiate benzodiazepine and antipsychotic medications for the management of behavioral symptoms. Data from audio-recorded sessions were transcribed, coded to identify relevant concepts, and reduced to determine major themes. RESULTS: We completed 23 interviews with hospice physicians and nurse practitioners. On average, participants had worked in a hospice setting for a mean of 14.3 years (SD: 10.9); 39% had geriatrics training. Major themes related to benzodiazepine and antipsychotic prescribing were (1) caregiving factors strongly influence the use of medications, (2) patient and caregiver stigma and concerns regarding medication use limit prescribing, (3) medications are initiated to avoid hospitalization or transition to a higher level of care, and (4) nursing home hospice care brings unique challenges. CONCLUSION AND IMPLICATIONS: Caregiver factors and the setting of hospice care strongly influence clinician decisions to initiate benzodiazepines and antipsychotics in hospice. Caregiver education about medication use at end of life and support in managing challenging behaviors may help promote optimal prescribing.

Potentially Harmful Medication Prescribing by the Degree of Physician Specialization in Nursing Home Practice: An Observational Study.

OBJECTIVES: The use of anticholinergics, antipsychotics, benzodiazepines, and other potentially harmful medications (PHMs) is associated with particularly poor outcomes in nursing home (NH) residents with Alzheimer's disease and related dementias (ADRD). Our objective was to compare PHM prescribing by NH physicians and advanced practitioners who focus their practice on NH residents (NH specialists) vs non-NH specialists. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: We included a 20% random sample of Medicare beneficiaries with ADRD who resided in 12,278 US NHs in 2017. Long-stay NH residents with ADRD were identified using MDS, Medicare Parts A and B claims. Residents <65 years old or without continuous Part D coverage were excluded. METHODS: Physicians in generalist specialties and advanced practitioners with ≥90% of Part B claims for NH care were considered NH specialists. Residents were assigned to NH specialists vs non-NH specialists based on plurality of Part D claims submitted for that resident. Any PHM use (defined using the Beers Criteria) and the proportion of NH days on a PHM were modeled using generalized estimating equations. Models included resident demographics, clinical characteristics, cognitive and functional status, behavioral assessments, and facility characteristics. RESULTS: Of the 54,713 residents in the sample, 27.9% were managed by an NH specialist and 72.1% by a non-NH specialist. There was no statistically significant difference in any PHM use [odds ratio (OR) 0.97, 95% CI 0.93-1.02, P = .23]. There were lower odds of prolonged PHM use (OR 0.87, 95% CI 0.81-0.94, P < .001, for PHM use on >75% vs >0%-<25% of NH days) for NH specialists vs non-NH specialists. CONCLUSIONS AND IMPLICATIONS: Although the use of PHMs among NH residents with ADRD managed by NH specialists was not lower, they were less likely to receive PHMs over longer periods of time. Future work should evaluate the underlying causes of these differences to inform interventions to improve prescribing for NH residents.

Mortality After Exposure to a Hurricane Among Older Adults Living With Dementia.

This cohort study examines mortality after hurricane exposure in older adults living with Alzheimer disease and other related dementias.

Hospice agency characteristics associated with benzodiazepine and antipsychotic prescribing.

BACKGROUND: Benzodiazepine and antipsychotic medications are routinely prescribed for symptom management in hospice patients, but have significant risks for older adults. We explored the extent to which patient and hospice agency characteristics are associated with variations in their prescribing. METHODS: Cross-sectional analysis of hospice-enrolled Medicare beneficiaries aged ≥65 years in 2017 (N = 1,393,622 in 4219 hospice agencies). The main outcome was the hospice agency-level rate of enrollees with benzodiazepine and antipsychotic prescription fills divided into quintiles. Rate ratios were used to compare the agencies with the highest and lowest prescription across patient and agency characteristics. RESULTS: In 2017, hospice agency prescribing rates varied widely: for benzodiazepines, from a median of 11.9% (IQR 5.9,22.2) in the lowest-prescribing quintile to 80.0% (IQR 76.9,84.2) in the highest-prescribing quintile; for antipsychotics, it ranged from 5.5% (IQR 2.9,7.7) in the lowest to 63.9% (IQR 56.1,72.0) in the highest. Among the highest benzodiazepine- and antipsychotic- prescribing hospice agencies, there was a smaller proportion of patients from minoritized populations (benzodiazepine: non-Hispanic Black rate ratio [RR] [Q5/Q1] 0.7, 95% CI 0.6-0.7, Hispanic RR 0.4, 95% CI 0.3-0.5; antipsychotic: non-Hispanic Black RR 0.7, 95% CI 0.6-0.8, Hispanic RR 0.4, 95% CI 0.3-0.5). A greater proportion of rural beneficiaries were in the highest benzodiazepine-prescribing quintile (RR 1.3, 95% CI 1.2-1.4), whereas this relationship was not present for antipsychotics. Larger hospice agencies were over-represented in the highest prescribing quintile for both benzodiazepines (RR 2.6, 95% CI 2.5-2.7) and antipsychotics (RR 2.7, 95% CI 2.6-2.8), as were for-profit agencies (benzodiazepine: RR 2.4, 95% CI 2.3-2.4; antipsychotic: RR 2.3, 95% CI 2.2-2.4). Prescribing rates varied widely across Census regions. CONCLUSIONS: Prescribing in hospice settings varies markedly across factors other than the clinical characteristics of enrolled patients.

Nursing Home to Nursing Home Transfers during the Early COVID-19 Pandemic.

OBJECTIVES: To examine the nursing home to nursing home transfer rates before and during the early COVID-19 pandemic and to identify risk factors associated with those transfers in a state with a policy to create COVID-19-care nursing homes. DESIGN: Cross-sectional cohorts of nursing home residents in prepandemic (2019) and COVID-19 (2020) periods. SETTING AND PARTICIPANTS: Michigan long-term nursing home residents were identified from the Minimum Data Set. METHODS: Each year, we identified transfer events as a resident's first nursing home to nursing home transfer between March and December. We included residents' characteristics, health status, and nursing home characteristics to identify risk factors for transfer. Logistic regression models were conducted to determine risk factors for each period and changes in transfer rates between the 2 periods. RESULTS: Compared to the prepandemic period, the COVID-19 period had a higher transfer rate per 100 (7.7 vs 5.3, P < .05). Age ≥80 years, female sex, and Medicaid enrollment were associated with a lower likelihood of transfer for both periods. During the COVID-19 period, residents who were Black, with severe cognitive impairment, or had COVID-19 infection were associated with a higher risk of transfer [adjusted odds ratio (AOR) (95% CI): 1.46 (1.01-2.11), 1.88 (1.11-3.16), and 4.70 (3.30-6.68), respectively]. After adjusting for resident characteristics, health status, and nursing home characteristics, residents had 46% higher odds [AOR (95% CI): 1.46 (1.14-1.88)] of being transferred to another nursing home during the COVID-19 period compared to the prepandemic period. CONCLUSIONS AND IMPLICATIONS: In the early COVID-19 pandemic, Michigan designated 38 nursing homes to care for residents with COVID-19. We found a higher transfer rate during the pandemic than during the prepandemic period, especially among Black residents, residents with COVID-19 infection, or residents with severe cognitive impairment. Further investigation is warranted to understand the transfer practice better and if any policies would mitigate the transfer risk for these subgroups.

The Impact of Nurse Practitioner Care and Accountable Care Organization Assignment on Skilled Nursing Services and Hospital Readmissions.

BACKGROUND: Accountable care organizations (ACOs) and the employment of nurse practitioners (NP) in place of physicians are strategies that aim to reduce the cost and improve the quality of routine care delivered in skilled nursing facilities (SNF). The recent expansion of ACOs and nurse practitioners into SNF settings in the United States may be associated with improved health outcomes for patients. OBJECTIVES: To determine the relationship between ACO attribution and NP care delivery during SNF visits and the relationship between NP care delivery during SNF visits and unplanned hospital readmissions. METHODS: We obtained a sample of 527,329 fee-for-service Medicare beneficiaries with 1 or more SNF stays between 2012 and 2017. We used logistic regression to measure the association between patient ACO attribution and evaluation and management care delivered by NPs in addition to the relationship between evaluation and management services delivered by NPs and hospital readmissions. RESULTS: ACO beneficiaries were 1.26% points more likely to receive 1 or more E&M services delivered by an NP during their SNF visits [Marginal Effect (ME): 0.0126; 95% CI: (0.009, 0.0160)]. ACO-attributed beneficiaries receiving most of their E&M services from NPs during their SNF visits were at a lower risk of readmission than ACO-attributed beneficiaries receiving no NP E&M care (5.9% vs. 7.1%; P <0.001). CONCLUSIONS: Greater participation by the NPs in care delivery in SNFs was associated with a reduced risk of patient readmission to hospitals. ACOs attributed beneficiaries were more likely to obtain the benefits of greater nurse practitioner involvement in their care.