Real-World Burden of Immunosuppressant-Treated Lupus Nephritis: A German Claims Database Analysis.

INTRODUCTION: This retrospective cohort study (GSK213737) aimed to characterize treatment patterns, healthcare resource utilization (HCRU), and costs in patients with lupus nephritis (LN) initiating immunosuppressant therapy in clinical practice in Germany, to better understand the full picture of the real-world burden of LN. METHODS: Adult patients with LN who initiated mycophenolate mofetil (MMF), intravenous cyclophosphamide (CYC), azathioprine (AZA), tacrolimus, cyclosporin A, or rituximab therapy in 2011-2017 (index therapy) were identified from the Betriebskrankenkassen German Sickness Fund database. Treatment patterns, including immunosuppressant discontinuations, and therapy switches, were assessed (maximum follow-up 4 years). Corticosteroid use, HCRU, and total economic costs were also evaluated. HCRU and costs were compared with matched controls (individuals without systemic lupus erythematosus [SLE]/LN matched by age, sex, and baseline Charlson Comorbidity Index). RESULTS: Among 334 patients with LN, the median (interquartile range) duration of index immunosuppressant therapy use was 380.5 (126, 1064) days. Of those patients with 4 years complete enrollment, 70.8% had ≥ 1 discontinuation and 28.8% switched therapy. While most patients (71.2%) received only one immunosuppressant, gaps in treatment were common. After 1 year of follow-up, 41.6% of patients had a prednisone-equivalent corticosteroid dose of ≥ 7.5 mg/day. Patients with LN had greater HCRU use for most categories assessed and increased mean total costs per person-year versus controls (€15,115.99 versus €4,081.88 in the first year of follow-up). CONCLUSIONS: This real-world analysis demonstrated the considerable burden of immunosuppressant-treated LN in Germany, with a high rate of discontinuations, frequent use of high-dose corticosteroids, and substantial HCRU/costs.

Real-World Immunosuppressant Treatment Patterns for Patients with Lupus Nephritis in the United States.

INTRODUCTION: Lupus nephritis (LN) treatment aims to control and prevent flares and irreversible kidney damage. Around 30% of patients are unresponsive to treatment; however, real-world LN treatment patterns have not been reported. Objectives of this retrospective cohort study (GSK 209758) were to quantify the time to switching/re-initiating induction therapy in patients with LN initiating immunosuppressant therapy and conversion from induction to maintenance immunosuppressant therapy, and to assess corticosteroid use. METHODS: Patients with LN initiating induction or maintenance immunosuppressant therapy were identified using claims data. Patients were followed up from the index date (immunosuppressant initiation date) until treatment discontinuation, death, disenrollment, administrative censoring, or the end of follow-up period. The cumulative incidence of switching/re-initiating induction therapy and conversion to maintenance therapy was estimated using outpatient pharmacy claims and procedure codes. Corticosteroid use was estimated using pharmacy claims; a mean daily dose of ≥ 7.5 mg/day was considered high. RESULTS: In total, 5000 patients with LN contributed 5516 treatment episodes (induction cohort, N = 372; maintenance cohort, N = 5144). In the induction cohort, the cumulative incidence (95% confidence interval) of switching between induction therapies was 24.6% (20.1-30.0) at 12 months, while 59.6% (52.4-66.1) of patients converted to maintenance therapy at 12 months. In the maintenance cohort, 21.2% (19.9-22.5) re-initiated induction therapy at 12 months. Oral corticosteroid use decreased during the follow-up in both cohorts, but 21.5% of patients remained on a high dose at 12 months in the induction cohort, while 15.8% in the maintenance cohort were taking a high dose at 24 months. CONCLUSIONS: Around a quarter of patients with LN initiating immunosuppressant therapy switched within 12 months, while a fifth re-initiated induction therapy within 12 months. Use of high corticosteroid doses were observed during 24 months of follow-up. These data suggest that many patients do not respond to existing standard LN therapies.

Evaluating disease control following belimumab treatment in patients with SLE enrolled in the US OBSErve study.

OBJECTIVE: To characterise disease control and remission in patients with SLE receiving belimumab for up to 12 months in the real world. METHODS: This post hoc analysis (GSK Study 213502) used data from the US evaluation Of use of Belimumab in clinical practice SEttings (OBSErve) study (GSK Study 117295), an observational cohort study of adults with SLE initiating and continuing belimumab for ≥6 months. Data were collected every 6 months by physician chart review; details of disease activity using the Safety of Estrogens in Lupus Erythematosus National Assessment-SLE Disease Activity Index (SELENA-SLEDAI) score were collected if routinely used by physicians. Disease control definitions evaluated were SELENA-SLEDAI score of ≤2 at 12 months, SELENA-SLEDAI score of ≤2 and glucocorticoid (prednisone equivalent) dose of ≤5 mg/day at 12 months, SELENA-SLEDAI score of ≤2 and glucocorticoid dose of ≤5 mg/day at both 6 and 12 months. Disease remission definition was SELENA-SLEDAI score=0 at 12 months. Glucocorticoid dose during follow-up was quantified. RESULTS: US OBSErve enrolled 501 patients, 90 of whom had eligible SELENA-SLEDAI scores for inclusion in this analysis. Mean (SD) SELENA-SLEDAI scores were 13.1 (3.0) at baseline and 4.9 (3.4) at 12 months. Disease control at 12 months was achieved by 31.1% of patients when defined as a SELENA-SLEDAI score of ≤2 (95% CI 21.8 to 41.7); this decreased to 25.6% when requiring a SELENA-SLEDAI score of ≤2 and glucocorticoid dose of ≤5 mg/day (95% CI 16.9 to 35.8) and 17.8% when requiring a SELENA-SLEDAI score of ≤2 and glucocorticoid dose of ≤5 mg/day at both 6 and 12 months (95% CI 10.5 to 27.3). No patient achieved remission at 12 months. Glucocorticoids decreased from a baseline median of 20.0 mg/day (IQR 15.0-30.0) to 5.0 mg/day (IQR 0-10.0) at 12 months. CONCLUSION: Improved disease control and reduced glucocorticoid use was achieved for a proportion of patients following up to 12 months of belimumab treatment in a US real-world setting.

Deintensification of Diabetes Medications among Veterans at the End of Life in VA Nursing Homes.

OBJECTIVES: Many older adults with limited life expectancy and/or advanced dementia (LLE/AD) are potentially overtreated for diabetes and may benefit from deintensification. Our aim was to examine the incidence and predictors of diabetes medication deintensification in older Veterans with LLE/AD who were potentially overtreated at admission to Veterans Affairs (VA) nursing homes (community living centers [CLCs]). DESIGN: Retrospective cohort study using linked VA and Medicare clinical/administrative data and Minimum Data Set assessments. SETTING: VA CLCs. PARTICIPANTS: A total of 6960 Veterans with diabetes and LLE/AD admitted to VA CLCs in fiscal years 2009 to 2015 with hemoglobin (Hb)A1c measured within 90 days of admission. MEASUREMENTS: We evaluated treatment deintensification (discontinuation or dose reduction for a consecutive 7-day period) among residents who were potentially overtreated (HbA1c ≤7.5% and receiving hypoglycemic medications). Competing risk models assessed 90-day cumulative incidence of deintensification. RESULTS: More than 40% (n = 3056) of Veteran CLC residents with diabetes were potentially overtreated. The cumulative incidence of deintensification at 90 days was 45.5%. Higher baseline HbA1c values were associated with a lower likelihood of deintensification (e.g., HbA1c 7.0-7.5% vs <6.0%; adjusted risk ratio [aRR] = .57; 95% confidence interval [CI] = .50-.66). Compared with non-sulfonylurea oral agents (e.g., metformin), other treatment regimens were more likely to be deintensified (aRR = 1.31-1.88), except for basal insulin (aRR = .59; 95% CI = .52-.66). The only resident factor associated with increased likelihood of deintensification was documented end-of-life status (aRR = 1.12; 95% CI = 1.01-1.25). Admission from home/assisted living (aRR = .85; 95% CI = .75-.96), obesity (aRR = .88; 95% CI = .78-.99), and peripheral vascular disease (aRR = .90; 95% CI = .81-.99) were associated with decreased likelihood of deintensification. CONCLUSION: Deintensification of treatment regimens occurred in less than one-half of potentially overtreated Veterans and was more strongly associated with low HbA1c values and use of medications with high risk for hypoglycemia, rather than other resident characteristics. J Am Geriatr Soc 68:736-745, 2020.

Adjuvant Use and the Intensification of Pharmacologic Management for Pain in Nursing Home Residents with Cancer: Data from a US National Database.

OBJECTIVES: Our objective was to describe the prevalence of adjuvants to opioid therapy and changes in these agents for pharmacologic management in nursing home residents with cancer. METHODS: We included Medicare beneficiaries with cancer and documented opioid use at nursing home admission in 2011-2013 (N = 3268). The Minimum Data Set 3.0 provided information on sociodemographic and clinical characteristics. Part D claims provided information on opioid and adjuvant use during the 7 days after admission and 90 days later. Proportions of changes in these agents were estimated. Separate logistic models estimated associations between resident characteristics and (1) use of adjuvants at admission and (2) intensification of pharmacologic management at 90 days. RESULTS: Nearly 20% of patients received adjuvants to opioids at admission, with gabapentin the most common adjuvant (34.4%). After 90 days, approximately 25% had maintained or intensified pharmacologic management. While advanced age (≥ 85 vs. 65-74 years, adjusted odds ratio [aOR] 0.80; 95% confidence interval [CI] 0.63-1.02) and comorbidities, including dementia (aOR 0.65; 95% CI 0.53-0.82) and depression (aOR 1.55; 95% CI 1.29-1.87), were associated with adjuvant use at admission, worse cognitive impairment (severe vs. no/mild, aOR 0.80; 95% CI 0.64-0.99) and presence of more severe pain (moderate/severe vs. no pain, aOR 1.60; 95% CI 1.26-2.03) were associated with intensification of drug regimen. CONCLUSION: Given aging-related changes and the presence of comorbid conditions in older adults, safety studies of these practices are warranted.

Missing Data in Marginal Structural Models: A Plasmode Simulation Study Comparing Multiple Imputation and Inverse Probability Weighting.

BACKGROUND: The use of marginal structural models (MSMs) to adjust for time-varying confounding has increased in epidemiologic studies. However, in the setting of MSMs, recommendations for how best to handle missing data are contradictory. We present a plasmode simulation study to compare the validity and precision of MSMs estimates using complete case analysis (CC), multiple imputation (MI), and inverse probability weighting (IPW) in the presence of missing data on time-independent and time-varying confounders. MATERIALS AND METHODS: Simulations were based on a cohort substudy using data from the Osteoarthritis Initiative which estimated the marginal causal effect of intra-articular injection use on yearly changes in knee pain. We simulated 81 scenarios with parameter values varied on missing mechanisms (MCAR, MAR, and MNAR), percentages of missing (10%, 20%, and 30%), type of confounders (time-independent, time-varying, either or both), and analytical approaches (CC, IPW, and MI). The performance of CC, IPW, and MI methods was compared using relative bias, mean squared error of the estimates of interest, and empirical power. RESULTS: Across scenarios defined by missing data mechanism, extent of missing data, and confounder type, MI generally produced less biased estimates (range: 1.2%-6.7%) with better precision (range: 0.17-0.18) compared with IPW (relative bias: -5.3% to 8.0%; precision: 0.19-0.53). Empirical power was constant across the scenarios using MI. CONCLUSIONS: Under simple yet realistically constructed scenarios, MI seems to confer an advantage over IPW in MSMs applications.

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.

Nonmalignant Pain Symptom Subgroups in Nursing Home Residents.

CONTEXT: Despite many nursing home residents experiencing pain, research about the multidimensional nature of nonmalignant pain in these residents is scant. OBJECTIVES: To identify and describe pain symptom subgroups and to evaluate whether subgroups differed by sex. METHODS: Using Minimum Data Set 3.0 data (2011-2012), we identified newly admitted nursing home residents reporting pain (n = 119,379). A latent class analysis included 13 indicators: markers for pain (i.e., severity, frequency, impacts sleep, and function) and depressive symptoms. Sex was evaluated as a grouping variable. Multinomial logistic models identified the association between latent class membership and covariates, including age and cognitive impairment. RESULTS: Four latent subgroups were identified: severe (15.2%), moderate frequent (26.4%), moderate occasional with depressive symptoms (26.4%), and moderate occasional without depressive symptoms (32.0%). Measurement invariance by sex was ruled out. Depressed mood, sleep disturbances, and fatigue distinguished subgroups. Age ≥75 years was inversely associated with belonging to the severe, moderate frequent, or moderate occasional with depressive symptoms subgroups. Residents with severe cognitive impairment had reduced odds of membership in the severe pain subgroup (adjusted odds ratio [aOR]: 0.84; 95% confidence interval [CI]: 0.78-0.90) and moderate frequent pain subgroup (aOR: 0.60; 95% CI: 0.56-0.64) but increased odds in the moderate occasional pain with depressive symptoms subgroup (aOR: 1.12; 95% CI: 1.06-1.18). CONCLUSION: Identifying subgroups of residents with different patterns of pain and depressive symptoms highlights the need to consider physical and psychological components of pain. Expanding knowledge about pain symptom subgroups may provide a promising avenue to improve pain management in nursing home residents.

Depression, Anxiety, and Pain among Newly Admitted Nursing Home Residents.

BACKGROUND: Depression, anxiety, and pain are commonly experienced by older adults living in nursing homes. OBJECTIVES: To describe the prevalence of depression, anxiety disorders, and pain among newly admitted nursing home residents in the United States and to describe the treatment of these disorders. DESIGN: Cross-sectional study of newly admitted residents. SETTING: Residents able to complete a pain assessment (n=783,826) living in Medicare- and Medicaid-certified nursing homes in the United States in 2011-2012. MEASURES: Measures of sociodemographic, mood and behavior, pain, diagnoses, and functioning items from the Minimum Data Set (MDS) version 3.0. RESULTS: Approximately 36% of residents had a diagnosis of depression (other than bipolar disorder) and/or an anxiety disorder (n = 272,311). Of these residents, 25.2% had both depression and an anxiety disorder (95% CI = 25.0-25.4%), 54.3% (95% CI = 54.1-54.5%) had depression without an anxiety disorder, and 20.5% had an anxiety disorder without depression (95% CI = 20.3-20.6%). Fifteen percent had the triad of depression, anxiety, and pain at admission (95% CI = 9.3-23.3%). Depressive symptoms were more commonly reported by residents with pain than by those without pain. Receipt of psychological therapy (range: 0.9%-2.0%) or any psychiatric medication was lacking (range: 35.3%-48.5%), regardless of pain status. Participants reporting pain received a combination of scheduled, pro re nata (PRN)/as-needed, and non-medication pain interventions (range: 59.8% depression without anxiety to 62.9% depression and anxiety disorder). CONCLUSION: Residents often suffer from combinations of depression, anxiety and pain at admission to nursing home. While treatment of pain is more common than treatment of psychiatric treatments, both psychiatric treatment and pain management may be suboptimal in nursing homes.

Commonly Initiated Opioids and Risk of Fracture Hospitalizations in United States Nursing Homes.

OBJECTIVES: The aim of this study was to estimate the comparative safety of initiating commonly used opioids among older, long-stay United States nursing home residents with fracture hospitalizations. METHODS: We conducted a new-user retrospective cohort study of nursing home residents initiating short-acting oxycodone, hydrocodone, or tramadol by merging the 2011-2013 Minimum Data Set 3.0 to Medicare hospitalization and pharmacy claims. Residents (≥ 65 years, no cancer or hospice use) contributed treatment episodes (> 120 days with no prior opioid claims) and were followed for 180 days until incident fracture hospitalization (hip, femur, humerus, pelvis, radius/ulna), death (competing risk), treatment changes (e.g., discontinuation), or administrative censoring. Competing risks models with inverse probability of treatment weighting were used to estimate subdistribution hazard ratios (HRSD) and 95% confidence intervals (CI). RESULTS: Overall, 110,862 residents contributed 134,432 treatment episodes: 14,373 oxycodone; 69,182 hydrocodone; and 50,877 tramadol initiators. The incidences of fracture hospitalizations per 100 person-years were 9.4 (95% CI 7.5-11.7) for oxycodone, 7.9 (95% CI 7.1-8.8) for hydrocodone, and 5.0 (95% CI 4.3-5.7) for tramadol initiators. In weighted models, oxycodone initiators had a similar rate of fractures to hydrocodone initiators (HRSD 1.08, 95% CI 0.79-1.48). Tramadol initiators had lower fracture rates than hydrocodone initiators (HRSD 0.67, 95% CI 0.56-0.80). CONCLUSIONS: The lower rate of fractures that we documented among tramadol initiators compared with hydrocodone initiators is consistent, albeit attenuated compared with prior studies among community-dwelling older adults. However, overall fracture rates were lower than in community settings, potentially due to the limited risk of falling in this population with limited mobility.

Geographic Variation in the Initiation of Commonly Used Opioids and Dosage Strength in United States Nursing Homes.

OBJECTIVES: To examine and quantify geographic variation in the initiation of commonly used opioids and prescribed dosage strength among older US nursing home residents. METHODS: We merged 2011 Minimum Data Set 3.0 to Medicare claims and facility characteristics data to conduct a cross-sectional study among long-stay nursing home residents who initiated short-acting opioids commonly used in nursing homes (oxycodone, hydrocodone, or tramadol). We examined geographic variation in specific opioids initiated and potentially inappropriate doses (≥50 mg oral morphine equivalent/d) across hospital referral regions (HRRs). Multilevel logistic models quantified the proportional change in between-HRR variation and associations between commonly initiated opioids and inappropriate doses after adjusting for resident characteristics, facility characteristics, and state. RESULTS: Oxycodone (9.4%) was initiated less frequently than hydrocodone (56.2%) or tramadol (34.5%) but varied dramatically between HRRs (range, 0%-74.5%). In total, resident/facility characteristics and state of residence, respectively explained 84.1%, 58.2%, 59.1%, and 46.6% of the between-HRR variation for initiating oxycodone, hydrocodone, tramadol, and inappropriate doses. In all cases, state explained the largest proportion of between-HRR variation. Relative to hydrocodone, residents initiating oxycodone were more likely (adjusted odds ratio, 5.00; 95% confidence interval, 4.57-5.47) and those initiating tramadol were less likely (adjusted odds ratio, 0.28; 95% confidence interval, 0.25-0.31) to be prescribed potentially inappropriately high doses. CONCLUSIONS: We documented extensive geographic variation in the opioid and dose initiated for nursing home residents, with state explaining the largest proportion of the observed variation. Further work is needed to understand potential drivers of opioid prescribing patterns at the state level.

Non-Hispanic Black-White disparities in pain and pain management among newly admitted nursing home residents with cancer.

BACKGROUND: Racial disparities in pain management persist across health care settings and likely extend into nursing homes. No recent studies have evaluated racial disparities in pain management among residents with cancer in nursing homes at time of admission. METHODS: Using a cross-sectional study design, we compared reported pain and pain management between non-Hispanic White and non-Hispanic Black newly admitted nursing home residents with cancer (n=342,920) using the de-identified Minimum Data Set version 3.0. Pain management strategies included the use of scheduled analgesics, pro re nata analgesics, and non-pharmacological methods. Presence of pain was based on self-report when residents were able, and staff report when unable. Robust Poisson models provided estimates of adjusted prevalence ratios (aPR) and 95% CIs for reported pain and pain management strategies. RESULTS: Among nursing home residents with cancer, ~60% reported pain with non-Hispanic Blacks less likely to have both self-reported pain (aPR [Black versus White]: 0.98, 95% CI: 0.97-0.99) and staff-reported pain (aPR: 0.89, 95% CI: 0.86-0.93) documentation compared with Non-Hispanic Whites. While most residents received some pharmacologic pain management, Blacks were less likely to receive any compared with Whites (Blacks: 66.6%, Whites: 71.1%; aPR: 0.98, 95% CI: 0.97-0.99), consistent with differences in receipt of non-pharmacologic treatments (Blacks: 25.8%, Whites: 34.0%; aPR: 0.98, 95 CI%: 0.96-0.99). CONCLUSION: Less pain was reported for Black compared with White nursing home residents and White residents subsequently received more frequent pain management at admission. The extent to which unequal reporting and management of pain persists in nursing homes should be further explored.

Cognitive Impairment and Pain Among Nursing Home Residents With Cancer.

CONTEXT: The prevalence of pain and its management has been shown to be inversely associated with greater levels of cognitive impairment. OBJECTIVES: To evaluate whether the documentation and management of pain varies by level of cognitive impairment among nursing home residents with cancer. METHODS: Using a cross-sectional study, we identified all newly admitted U.S. nursing home residents with a cancer diagnosis in 2011-2012 (n = 367,462). Minimum Data Set 3.0 admission assessment was used to evaluate pain/pain management in the past five days and cognitive impairment (assessed via the Brief Interview for Mental Status or the Cognitive Performance Scale for 91.6% and 8.4%, respectively). Adjusted prevalence ratios with 95% CI were estimated from robust Poisson regression models. RESULTS: For those with staff-assessed pain, pain prevalence was 55.5% with no/mild cognitive impairment and 50.5% in those severely impaired. Pain was common in those able to self-report (67.9% no/mild, 55.9% moderate, and 41.8% severe cognitive impairment). Greater cognitive impairment was associated with reduced prevalence of any pain (adjusted prevalence ratio severe vs. no/mild cognitive impairment; self-assessed pain 0.77; 95% CI 0.76-0.78; staff-assessed pain 0.96; 95% CI 0.93-0.99). Pharmacologic pain management was less prevalent in those with severe cognitive impairment (59.4% vs. 74.9% in those with no/mild cognitive impairment). CONCLUSION: In nursing home residents with cancer, pain was less frequently documented in those with severe cognitive impairment, which may lead to less frequent use of treatments for pain. Techniques to improve documentation and treatment of pain in nursing home residents with cognitive impairment are needed.

Prevalence of Long-Term Opioid Use in Long-Stay Nursing Home Residents.

BACKGROUND/OBJECTIVES: Overall and long-term opioid use among older adults have increased since 1999. Less is known about opioid use in older adults in nursing homes (NHs). DESIGN: Cross-sectional. SETTING: U.S. NHs (N = 13,522). PARTICIPANTS: Long-stay NH resident Medicare beneficiaries with a Minimum Data Set 3.0 (MDS) assessment between April 1, 2012, and June 30, 2012, and 120 days of follow-up (N = 315,949). MEASUREMENTS: We used Medicare Part D claims to measure length of opioid use in the 120 days from the index assessment (short-term: ≤30 days, medium-term: >30-89 days, long-term: ≥90 days), adjuvants (e.g., anticonvulsants), and other pain medications (e.g., corticosteroids). MDS assessments in the follow-up period were used to measure nonpharmacological pain management use. Modified Poisson models were used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for age, gender, race and ethnicity, cognitive and physical impairment, and long-term opioid use. RESULTS: Of all long-stay residents, 32.4% were prescribed any opioid, and 15.5% were prescribed opioids long-term. Opioid users (versus nonusers) were more commonly prescribed pain adjuvants (32.9% vs 14.9%), other pain medications (25.5% vs 11.0%), and nonpharmacological pain management (24.5% vs 9.3%). Long-term opioid use was higher in women (aPR = 1.21, 95% CI = 1.18-1.23) and lower in racial and ethnic minorities (non-Hispanic blacks vs whites: APR = 0.93, 95% CI = 0.90-0.94) and those with severe cognitive impairment (vs no or mild impairment, aPR = 0.82, 95% CI = 0.79-0.83). CONCLUSION: One in seven NH residents was prescribed opioids long-term. Recent guidelines on opioid prescribing for pain recommend reducing long-term opioid use, but this is challenging in NHs because residents may not benefit from nonpharmacological and nonopioid interventions. Studies to address concerns about opioid safety and effectiveness (e.g., on pain and functional status) in NHs are needed.

Depression and cognitive impairment among newly admitted nursing home residents in the USA.

OBJECTIVE: The objective of this study is to describe the prevalence of depression and cognitive impairment among newly admitted nursing home residents in the USA and to describe the treatment of depression by level of cognitive impairment. METHODS: We identified 1,088,619 newly admitted older residents between 2011 and 2013 with an active diagnosis of depression documented on the Minimum Data Set 3.0. The prevalence of receiving psychiatric treatment was estimated by cognitive impairment status and depression symptoms. Binary logistic regression using generalized estimating equations provided adjusted odds ratios and 95% confidence intervals for the association between level of cognitive impairment and receipt of psychiatric treatment, adjusted for clustering of residents within nursing homes and resident characteristics. RESULTS: Twenty-six percent of newly admitted residents had depression; 47% of these residents also had cognitive impairment. Of those who had staff assessments of depression, anhedonia, impaired concentration, psychomotor disturbances, and irritability were more commonly experienced by residents with cognitive impairment than residents without cognitive impairment. Forty-eight percent of all residents with depression did not receive any psychiatric treatment. Approximately one-fifth of residents received a combination of treatment. Residents with severe cognitive impairment were less likely than those with intact cognition to receive psychiatric treatment (adjusted odds ratio = 0.95; 95% confidence interval: 0.93-0.98). CONCLUSIONS: Many newly admitted residents with an active diagnosis of depression are untreated, potentially missing an important window to improve symptoms. The extent of comorbid cognitive impairment and depression and lack of treatment suggest opportunities for improved quality of care in this increasingly important healthcare setting. Copyright © 2017 John Wiley & Sons, Ltd.

Association of a Communication Training Program With Use of Antipsychotics in Nursing Homes.

Importance: Off-label antipsychotic prescribing in nursing homes (NHs) is common and is associated with increased risk of mortality in older adults. Prior large-scale, controlled trials in the NH setting failed to show meaningful reductions in antipsychotic use. Objective: To quantify the influence of a large-scale communication training program on NH antipsychotic use called OASIS. Design, Setting, and Participants: This investigation was a quasi-experimental longitudinal study of NHs in Massachusetts enrolled in the OASIS intervention. Participants were residents living in NHs between March 1, 2011, and August 31, 2013. The data were analyzed from December 2015, to March 2016, and from November through December 2016. Exposures: The OASIS educational program targets all NH staff (direct care and nondirect care) using a train-the-trainer model. The program goals were to reframe challenging behaviors of residents with cognitive impairment as the communication of unmet needs, to train staff to anticipate resident needs, and to integrate resident strengths into daily care plans. Main Outcomes and Measures: This study used an interrupted time series model of facility-level prevalence of antipsychotic medication use, other psychotropic medication use (antidepressants, anxiolytics, and hypnotics), and behavioral disturbances to evaluate the intervention's effectiveness in participating facilities compared with control NHs in Massachusetts and New York. The 18-month preintervention (baseline) period was compared with a 3-month training period, a 6-month implementation period, and a 3-month maintenance period. Results: This study included 93 NHs enrolled in the OASIS intervention (27 of which had a high prevalence of antipsychotic use) compared with 831 nonintervention NHs. Among OASIS facilities, prevalences of atypical antipsychotic prescribing were 34.1% at baseline and 26.5% at the study end (absolute reduction of 7.6% and relative reduction of 22.3%) compared with a drop of 22.7% to 18.8% in the comparison facilities (absolute reduction of 3.9% and relative reduction of 17.2%). In the OASIS implementation phase, NHs experienced a reduction in antipsychotic use prevalence among OASIS facilities (-1.20%; 95% CI, -1.85% to -0.09% per quarter) greater than that among non-OASIS facilities (-0.23%; 95% CI, -0.47% to 0.01% per quarter), resulting in a net OASIS influence of -0.97% (95% CI, -1.85% to -0.09%; P = .03). A difference in trend was not sustained in the maintenance phase (difference of 0.93%; 95% CI, -0.66% to 2.54%; P = .48). No increases in other psychotropic medication use or behavioral disturbances were observed. Conclusions and Relevance: Antipsychotic use prevalence declined during OASIS implementation of the intervention, but the decreases did not continue in the maintenance phase. Other psychotropic medication use and behavioral disturbances did not increase. This study adds evidence for nonpharmacological programs to treat behavioral and psychological symptoms of dementia.

Pain and pharmacologic pain management in long-stay nursing home residents.

Previous studies estimate that >40% of long-stay nursing home (NH) residents experience persistent pain, with 20% of residents in pain receiving no analgesics. Strengthened NH surveyor guidance and improved pain measures on the Minimum Data Set 3.0 were introduced in March 2009 and October 2010, respectively. This study aimed to provide estimates after the important initiatives of (1) prevalence and correlates of persistent pain; and (2) prevalence and correlates of untreated or undertreated persistent pain. We identified 1,387,405 long-stay residents in U.S. NHs between 2011 and 2012 with 2 Minimum Data Set assessments 90 days apart. Pain was categorized as persistent (pain on both assessments), intermittent (pain on either assessment), or none. Pharmacologic pain management was classified as untreated pain (no scheduled or as needed medications received) or potentially undertreated (no scheduled received). Modified Poisson models adjusting for resident clustering within NHs provided adjusted prevalence ratios (APRs) estimates and 95% confidence intervals (CIs). The prevalence of persistent and intermittent pain was 19.5% and 19.2%, respectively, but varied substantially by age, sex, race and ethnicity, cognitive impairment, and cancer. Of residents in persistent pain, 6.4% and 32.0% were untreated and undertreated, respectively. Racial and ethnic minorities (non-Hispanic blacks vs whites, APR = 1.19, 95% CI: 1.13-1.25) and severely cognitively impaired residents (severe vs no/mild APR = 1.51, 95% CI: 1.44-1.57) had an increased prevalence of untreated and undertreated pain. One in 5 NH residents has persistent pain. Although this estimate is greatly improved, many residents may be undertreated. The disturbing disparities in untreated and undertreated pain need to be addressed.

Hospice Use and Pain Management in Elderly Nursing Home Residents With Cancer.

CONTEXT: Pain management is suboptimal in nursing homes. OBJECTIVES: To estimate the extent to which receipt of hospice in nursing homes (NHs) increases the receipt of pain management for residents with cancer at the end of life. METHODS: Study participants included Medicare beneficiaries with cancer who were NH residents in the last 90 days of life in 2011-2012 (n = 78,160). Residents in pain on hospice were matched to like residents without hospice by facility, type of pain assessment (self-report/staff assessment), and weeks until death (9064 matched strata, 16,968 unique residents). Minimum Data Set 3.0 provided information on residents' pain prevalence and receipt of pain management (scheduled analgesics, as needed [pro re nata {PRN}] medication, nonpharmacologic interventions). We developed conditional logistic models to estimate the association between hospice use and pain management, stratified by self-reported and staff-assessed pain. RESULTS: We found that pain prevalence was higher in residents using hospice versus those without hospice (e.g., residents who self-reported pain: hospice: 59.9%, 95% CIs = 59.3%-60.5%; nonhospice: 50.0%, 95% CI = 49.4%-50.6%). In matched analyses, untreated pain was uncommon (self-reported pain: 2.9% and 5.6% in hospice users and nonusers, respectively). Hospice use was associated with receipt of scheduled analgesics (self-reported: adjusted odds ratio = 1.85, 95% CI = 1.73-1.971) and PRN medication (self-reported: adjusted odds ratio = 1.31, 95% CI = 1.20-1.43). Pain prevalence and the association between hospice and pain management were similar in residents with staff-assessed pain. CONCLUSION: Untreated pain at the end of life among residents with cancer in NHs is unusual. Hospice is associated with increased pain management among those with documented pain.

Informed Family Member Involvement to Improve the Quality of Dementia Care in Nursing Homes.

OBJECTIVES: To describe the extent to which nursing homes engaged families in antipsychotic initiation decisions in the year before surveyor guidance revisions were implemented. DESIGN: Mixed-methods study based on semistructured interviews. SETTING: U.S. nursing homes (N = 20) from five CMS regions (III, IV, VI, VIII, IX). PARTICIPANTS: Family members of nursing home residents (N = 41). MEASUREMENTS: Family member responses to closed- and open-ended questions regarding involvement in resident care and antipsychotic initiation. Two researchers used a content analytical approach to code open responses to themes of family involvement in behavior management, decision-making, knowledge of risks and benefits, and informed consent. RESULTS: Fifty-four percent of family members felt highly involved in decisions about behavior management. Forty-two percent recalled being asked how to manage resident behavior without medication, and 17% recalled receipt of information about antipsychotic risks and benefits. Sixty-six percent felt highly involved in the process of initiating antipsychotic medication; 24% reported being asked for input into the antipsychotic initiation decision and knowing before the antipsychotic was started. CONCLUSION: Under existing federal regulations but before guidance revisions were implemented in 2013, more than 40% of families reported being involved in nonpharmacological behavior management of family members, but fewer than one in four reported being involved throughout the entire antipsychotic prescribing process. Interventions that standardize family engagement and promote adherence to existing federal regulations are needed. This discussion builds on these findings to weigh the policy options of greater enforcement of existing regulations versus enactment of new legislation to address this challenging issue.