Disparities in diabetes and hypertension care for individuals with serious mental illness.

OBJECTIVES: People with serious mental illnesses (SMI), including schizophrenia, bipolar disorder, and major depression, experience early mortality, partly due to comorbid physical health conditions such as diabetes and hypertension. This study examined the quality of diabetes and hypertension care for Medicaid and Medicare enrollees with SMI. STUDY DESIGN: We conducted a retrospective analysis of medical records and claims data from 3 health plans: a Medicaid plan for disabled adults, a Medicaid plan for low-income adults, and a Special Needs Plan for individuals dually enrolled in Medicaid and Medicare. The study population included 258 adults with SMI and diabetes and 241 adults with SMI and hypertension. METHODS: Existing quality measures for diabetes and hypertension from the Healthcare Effectiveness Data and Information Set (HEDIS) were adapted and applied to the SMI population for the 2012 calendar year. The rates of diabetes care and hypertension control for people with SMI were compared with national averages for Medicaid and Medicare managed care plans to examine disparities in care. RESULTS: Adults with SMI receive poor-quality care for diabetes and hypertension. Depending on the health plan, performance on the diabetes care and hypertension control HEDIS measures was 14 to 49 percentage points lower among the SMI population than the general Medicaid and Medicare populations. CONCLUSIONS: Findings highlight disparities in care for individuals with SMI compared with the general Medicaid and Medicare populations. Health plans demonstrated substantial room for improvement on almost all diabetes and hypertension HEDIS measures for the SMI population.

The Current State of Behavioral Health Quality Measures: Where Are the Gaps?

OBJECTIVE: This review examined the extent to which existing behavioral health quality measures address the priority areas of the National Behavioral Health Quality Framework (NBHQF) as well as the extent to which the measures have received National Quality Forum endorsement and are used in major reporting programs. METHODS: This review identified behavioral health quality measures in widely used measure inventories, including the National Quality Measures Clearinghouse, National Quality Forum, and the Center for Quality Assessment in Mental Health. Additional measures were identified through outreach to federal agencies. Measures were categorized by type, condition, target population, data source, reporting unit, endorsement status, and use in reporting programs. RESULTS: The review identified 510 measures. Nearly one-third of these measures address broad mental health or substance use conditions rather than a specific condition or diagnosis. Seventy-two percent are process measures. The most common data source for measures is administrative claims, and very few measures rely on electronic health records or surveys. Fifty-three (10%) measures have received National Quality Forum (NQF) endorsement, and 28 (5%) unique measures are used in major quality reporting programs. Several subdomains of the NBHQF, such as treatment intensification, financial barriers to care, and continuity of care, lack measures that are NQF endorsed. CONCLUSIONS: Despite the wide array of behavioral health quality measures, relatively few have received endorsement or are used in reporting programs. Future efforts should seek to fill gaps in measurement and to identify the most salient and strongest measures in each priority area.

Users of Medicaid home and community-based services are especially vulnerable to costly avoidable hospital admissions.

Although Medicaid's coverage of home and community-based services and the program's capacity to provide such services have increased markedly in recent years, relatively little is known about the population that uses these services. We combined Medicaid and Medicare data to characterize the national Medicaid population of service users by key demographic and health-related attributes. We also assessed one important dimension of their health outcomes: potentially avoidable hospital admissions. We found that in 2005 there were 2.2 million users of Medicaid home and community-based services-almost 4 percent of the total Medicaid population-and that two-thirds of these users were dually eligible for Medicare and Medicaid. Users of home and community-based services were particularly vulnerable to avoidable hospital admissions, compared to the full Medicaid and US populations, and these hospitalizations occur at substantial cost to public payers. For the dual eligibles using home and community-based services, Medicare pays most of the costs of these avoidable hospital stays. Our findings emphasize the need for further research to establish policies and practices that can best meet the needs of users of Medicaid home and community-based services.

Risk factors associated with the occurrence of fractures in U.S. nursing homes: resident and facility characteristics and prescription medications.

OBJECTIVES: To determine whether resident and facility characteristics and prescription medications influence the occurrence of fractures in nursing homes (NHs). DESIGN: Panel study with 1-year follow-up. SETTING: A nationally representative sample of NHs from the Medical Expenditure Panel Survey (MEPS). PARTICIPANTS: Residents aged 65 and older who were in sample NHs on January 1, 1996. MEASUREMENTS: Health status measures were collected from facility records and abstracted using a computer-assisted personal interview instrument. Fracture and drug data were updated every 4 months to provide a full year of information. Drug data were obtained from monthly medication administration records. The occurrences of fractures were obtained from medical records. Administered medications were classified using the Department of Veterans Affairs medication classification system. Facility characteristics were based on MEPS survey data collected from NH sources. RESULTS: In 1996, 6% of residents in a NH at the beginning of the year experienced a fracture during their NH stay(s). Resident risk factors included aged 85 and older, admitted from the community, exhibited agitated behaviors, and used both wheelchair and cane or walker. Use of anticonvulsants, antidepressants, opioid analgesics, iron supplements, bisphosphonates, thiazides, and laxatives were associated with fractures. A high certified nurse aide ratio was negatively associated with fractures. CONCLUSION: The findings indicate that fractures are associated with resident and facility characteristics and prescribing practices. It reaffirms the importance of medication review with special attention on opioid analgesics, antidepressants, and anticonvulsants to reduce the risk of fractures.

Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents.

BACKGROUND: This study examines the association of potentially inappropriate medication prescribing (PIRx) with hospitalization and death among elderly long-stay nursing home residents. METHODS: We defined PIRx using the combined version of the Beers criteria. Data were from the 1996 Medical Expenditure Panel Survey Nursing Home Component. The study sample included 3372 residents, 65 years and older, who had nursing home stays of 3 consecutive months or longer in 1996. We performed multivariate logistic regression analyses of longitudinal data using generalized estimating equations. RESULTS: Residents who received any PIRx had greater odds (odds ratio [OR], 1.27; P = .002) of being hospitalized in the following month than those receiving no PIRx. Residents with PIRx exposure for 2 consecutive months were at increased risk (OR, 1.27; P = .004) of hospitalization, as were those receiving PIRx in the second month only (OR, 1.80; P = .001), compared with those receiving no PIRx. Residents who received PIRx were at greater risk of death (OR, 1.28; P = .01) that month or the next. Residents with intermittent PIRx exposures were at greater odds of death (OR, 1.89; P<.001), compared with those with no PIRx exposure. CONCLUSIONS: The association of PIRx with subsequent adverse outcomes (hospitalization and death) provides new evidence of the importance of improving prescribing practices in the nursing home setting.

Potentially inappropriate medication prescriptions among elderly nursing home residents: their scope and associated resident and facility characteristics.

OBJECTIVE: To estimate the scope of potentially inappropriate medication prescriptions (PIRx) among elderly residents in U.S. nursing homes (NHs), and to examine associated resident and facility characteristics. DATA SOURCES: The 1996 Medical Expenditure Panel Survey Nursing Home Component (MEPS NHC), a survey of a nationally representative sample of NHs and residents. STUDY DESIGN: The PIRx, defined by Beers's consensus criteria (1991, 1997), was identified using up to a year's worth of NH prescribed medicine data for each resident. The study sample represented 1.6 million NH residents (n=3,372). RESULTS: At a minimum, 50 percent of all residents aged 65 or older, with an NH stay of three months or longer received at least one PIRx in 1996. The most common PIRx involved propoxyphene, diphenhydramine, hydroxyzine, oxybutynin, amitriptyline, cyproheptadine, iron supplements, and ranitidine. Resident factors associated with greater odds of PIRx were Medicaid coverage, no high school diploma, and nondementia mental disorders. Facility factors were more beds and lower RN-to-resident ratio. Factors associated with lower odds of PIRx were fewer medications, residents with communication problems, and being in an accredited NH. Onsite availability of pharmacists or mental health providers was not related. IMPLICATIONS: With quality of care and patient safety as major public health concerns, effective policies are needed to avoid PIRx occurrences and improve the quality of prescribing among elderly residents in NHs. Additional studies are needed to determine the impact of PIRx on this NH population.