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

OBJECTIVE: 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. METHODS: The proposed measure identifies NH residents who receive an APM but do not have an approved indication for APM use. We demonstrate the feasibility of this measure using data from Medicaid-eligible long-stay residents aged 65 years and older in seven states. Using multivariable logistic regressions, we compare it to the current CMS Nursing Home Compare quality measure. RESULTS: We find that nearly 52% of residents receiving an APM lack indications approved by CMS/FDA guidelines compared with 85% for the current CMS quality measure. APM guideline-inconsistent use rates vary significantly across resident and facility characteristics, and states. Only our measure correlates with another quality indicator in that facilities with higher deficiencies have significantly higher odds of APM use. Predictors of inappropriate use are found to be consistent with other measures of NH quality, supporting the validity of our proposed measure. CONCLUSION: The proposed measure provides an important foundation to improve APM prescribing practices without penalizing NHs when there are limited alternative treatments available.

Race, education, and the treatment of depression in nursing homes.

OBJECTIVES: We investigate, among older adult nursing home residents diagnosed with depression, whether depression treatment differs by race and schooling, and whether differences by schooling differ by race. We examine whether Blacks and less educated residents are placed in facilities providing less treatment, and whether differences reflect disparities in care. METHOD: Data from the 2006 Nursing Home Minimum Data Set for 8 states (n = 124,431), are merged with facility information from the Online Survey Certification and Reporting system. Logistic regressions examine whether resident and/or facility characteristics explain treatment differences; treatment includes antidepressants and/or psychotherapy. RESULTS: Blacks receive less treatment (adj. OR = .79); differences by education are small. Facilities with more Medicaid enrollees, fewer high school graduates, or more Blacks provide less treatment. DISCUSSION: We found disparities at the resident and facility level. Facilities serving a low-SES (socioeconomic status), minority clientele tend to provide less depression care, but Blacks also receive less depression treatment than Whites within nursing homes (NHs).

Diagnosis and treatment of depression in older community-dwelling adults: 1992-2005.

OBJECTIVE: To examine evolving patterns of depression diagnosis and treatment in older U.S. adults in the era of newer-generation antidepressants. DESIGN: Trend analysis using data from the Medicare Current Beneficiary Survey, a nationally representative survey of Medicare enrollees, from 1992 to 2005. SETTING: Community, usual care. PARTICIPANTS: Older Medicare fee-for-service beneficiaries. MEASUREMENTS: Depression diagnoses and psychotherapy use identified from Medicare claims; antidepressant use identified from detailed medication inventories conducted by interviewers. RESULTS: The proportion of older adults who received a depression diagnosis doubled, from 3.2% to 6.3%, with rates increasing substantially across all demographic subgroups. Of those diagnosed, the proportion receiving antidepressants increased from 53.7% to 67.1%, whereas the proportion receiving psychotherapy declined from 26.1% to 14.8%. Adjusting for other characteristics, odds of antidepressant treatment in older adults diagnosed with depression were 86% greater for women, 53% greater for men, 89% greater for whites, 13% greater for African Americans, 84% greater for metropolitan-area residents, and 55% greater for nonmetropolitan-area residents. Odds of antidepressant treatment were 54% greater for those diagnosed with major depressive disorder (MDD) and 83% greater for those with other depression diagnoses, whereas the odds of receiving psychotherapy was 29% lower in those with MDD diagnoses and 74% lower in those with other depression diagnoses. CONCLUSION: Overall diagnosis and treatment rates increased over time. Antidepressants are assuming a more-prominent and psychotherapy a less-prominent role. These shifts are most pronounced in groups with less-severe depression, in whom evidence of efficacy of treatment with antidepressants alone is less clear.

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. DESIGN: Annual cross-sectional analysis of merged resident assessment data from the Minimum Data Set (MDS) and facility characteristics from the Online Survey Certification and Reporting data. SETTING: Nursing homes in eight states (5,445 facilities). PARTICIPANTS: Long-stay nursing home residents aged 65 and older (2,564,687 assessments). MEASUREMENTS: Physician-documented depression diagnoses recorded in the MDS were used to identify residents with depression; antidepressant use was measured using MDS information about residents' receipt of an antidepressant in the 7 days before assessment. RESULTS: Diagnosis of depression and antidepressant therapy in residents diagnosed increased at a rapid rate. By 2007, 51.8% of residents were diagnosed with depression, 82.8% of whom received an antidepressant. Adjusted odds of treatment were higher for younger residents, whites, and those with moderate impairment of cognitive function. CONCLUSION: This study demonstrates striking increases in depression diagnosis and treatment with antidepressant medications, but disparities persist without clear evidence about underlying mechanisms. More research is needed to assess effectiveness of antidepressant prescribing.

Psychiatric rehospitalization among elderly persons in the United States.

OBJECTIVE: This study examined predictors of psychiatric rehospitalization among elderly persons. METHODS: Readmission within six months of an index hospitalization was modeled by using Medicare data on all hospitalizations with a primary psychiatric diagnosis in the first half of 2002 (N=41,839). Data were linked with state and community-level information from the U.S. census. RESULTS: Twenty-two percent of beneficiaries were rehospitalized for psychiatric reasons within six months of discharge. After the analyses adjusted for sociodemographic factors, readmission was most likely among persons with a primary diagnosis of schizophrenia (hazard ratio [HR]=2.63), followed by bipolar disorder (HR=2.51), depression (HR=1.75), and substance abuse (HR=1.38) (reference group was "other" psychiatric conditions). A baseline hospital stay of five or more days for an affective disorder was associated with a reduced readmission hazard (HR=.68, relative to shorter stays), yet the opposite was true for a nonaffective disorder (HR=1.26). For persons with nonaffective disorders, an elevated hazard of readmission was associated with comorbid alcohol dependence (HR=1.32), panic disorder (HR=1.76), borderline personality disorder (HR=2.33), and drug dependence (HR=1.17). However, for persons with affective disorders, having a personality disorder other than borderline personality disorder or dependent personality disorder (HR=1.27) and having an "other" anxiety disorder (HR=1.15) were significantly associated with an increased risk of rehospitalization. Obsessive-compulsive disorder increased the readmission hazard in both groups. CONCLUSIONS: Readmission risk factors may differ for affective disorders and nonaffective disorders. Very short hospitalizations were associated with increased risk of rehospitalization among persons with an affective disorder, which underscores the need for adequate stabilization of this group of patients during hospitalization. Results also highlight the specific types of comorbidities associated most strongly with rehospitalization risk.

Hospitalization for psychiatric illness among community-dwelling elderly persons in 1992 and 2002.

OBJECTIVE: The authors evaluated the evolution of inpatient care for psychiatric illness in 1992 and 2002 for senior community-dwelling Medicare beneficiaries. METHODS: National Medicare Provider Analysis and Review files for 1992 and 2002 were analyzed. RESULTS: From 1992 to 2002, rates of inpatient hospital use for treatment of psychiatric illness declined 28%, from 429 to 311 stays per 100,000 eligible beneficiaries, mostly because of reduced hospitalization for depression, and next, for substance use disorder. Inpatient care patterns for patients with schizophrenia and bipolar disorder changed little. Although stays were shorter in 2002 in general, rehospitalization rates remained the same in 2002 as they were in 1992. CONCLUSION: Trends in hospitalizations differed by diagnoses, which may be representative of general changes in treatment philosophy during the 1990s.

Medicare inpatient treatment for elderly non-dementia psychiatric illnesses 1992--2002; length of stay and expenditures by facility type.

We summarize Medicare utilization and payment for inpatient treatment of non-dementia psychiatric illnesses (NDPI) among the elderly during 1992 and 2002. From 1992 to 2002, overall mean Medicare expenditures per elderly NDPI inpatient stay declined by $2,254 (in 2002 dollars) and covered days by 2.8. However, these changes are complicated by expanded use of skilled nursing facilities and hospital psychiatric units, and decreased use of long-stay hospitals and general hospital beds. This suggests that inpatient treatment for NDPI is shifting into less expensive settings which may reflect cost-cutting strategies, preferences for less restrictive settings, and outpatient treatment advances.