0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letters |

Antipsychotic Use Among Nursing Home Residents FREE

Becky A. Briesacher, PhD; Jennifer Tjia, MD, MSCE; Terry Field, DSc; Daniel Peterson, MS; Jerry H. Gurwitz, MD
[+] Author Affiliations

Author Affiliations: Meyers Primary Care Institute and University of Massachusetts Medical School, Worcester.


Letters Section Editor: Jody W. Zylke, MD, Senior Editor.

More Author Information
JAMA. 2013;309(5):440-442. doi:10.1001/jama.2012.211266.
Text Size: A A A
Published online

To the Editor: The prescribing of antipsychotic medications persists at high levels in US nursing homes (NHs) despite extensive data demonstrating marginal clinical benefits and serious adverse effects, including death.1,2 However, imprecise and outdated data have limited the understanding of the current state of antipsychotic medication prescribing in NHs.3 We analyzed recent and detailed NH prescription data to address: (1) What is the current level of antipsychotic use? (2) Does antipsychotic use in NHs display geographic variation? and (3) Which antipsychotics are most commonly prescribed?

We used September 2009 through August 2010 prescription dispensing data from a large, long-term care pharmacy (Omnicare Inc) that serves 48 states and half of all NH residents in the United States. Pharmacy claims data are complete and accurate due to the connection to reimbursement documentation. Data elements include state location, patients' sex, age, and enrollment dates, and national drug codes for all drugs dispensed regardless of payer (eg, Medicare Part D, private insurance, and out of pocket).

Overall and state-level annual prevalence of antipsychotic use was calculated as the percentage of NH residents receiving at least 1 antipsychotic drug. We arrayed the states into distributions of lowest to highest quintiles of antipsychotic use, calculated means and 95% confidence intervals, generated a map to illustrate geographic variation, and tested for differences using a robust regression model with quintile indicators. We identified the name and type of antipsychotic (atypical or conventional) and estimated the median and interquartile range (IQR) of the number of prescriptions and duration of use calculated as days receiving therapy during the first 90 days observed. All analyses were calculated using SAS software version 9.2 (SAS Institute Inc) and 2-sided tests; statistical significance was set at P < .05. The study was approved by the institutional review board of the University of Massachusetts Medical School.

We identified 1 402 039 unique NH residents and a subset of residents observed continuously for at least 90 days (n = 561 681 residents and n = 5038 NHs). Approximately 39.4% of study NHs had more than 100 residents, 76.2% were for profit, and 59.7% had multiple owners.

Of the overall sample of 1 402 039 NH residents, 308 449 (22.0%; 95% CI, 21.9%-22.1%) received 1 or more prescriptions of antipsychotics. Prevalence of antipsychotic drug prescribing in NHs varied significantly (quintile 1 vs quintiles 2-5, P < .001) with the highest quintile states (28.1%; 95% CI, 27.0%-29.1%) located in the central south and the lowest quintile states (17.2%; 95% CI, 16.3%-18.1%) located mostly in the west (Figure). Of 4 338 723 antipsychotic prescriptions in NHs, the majority (68.6%; 95% CI, 68.5-68.7) were for the atypical agents quetiapine fumarate, risperidone, and olanzapine (n = 2 988 573) (Table). Among the 186 076 residents receiving antipsychotics and observed for 90 days, 13 956 (7.5%; 95% CI, 7.3%-7.6%) received only 1 prescription for antipsychotics while the median number was 10 (IQR, 5-14) prescriptions. The median duration of antipsychotic therapy during the 90-day observation period ranged from 30 (IQR, 8-74) days to 77 (IQR, 67-85) days.

Place holder to copy figure label and caption
Figure. State-Level Prevalence of Antipsychotic Prescribing in Nursing Homes
Graphic Jump Location

State-level samples ranged from 767 to 104 460 residents.

Table Graphic Jump LocationTable. Most Commonly Prescribed Antipsychotic Medications in Nursing Homes (NHs)

Our finding that 22.0% of NH residents received antipsychotics in 2009-2010 is within the lower range of rates that were documented 25 years earlier before the passage of the Omnibus Budget Reconciliation Act of 1987, which instituted regulations on the appropriate use of antipsychotics in NHs.4,5

The reasons for our findings are unclear. Geographic variation suggests the absence of an evidence-based approach to the use of these medications in NHs. The most common antipsychotics prescribed are often used for off-label indications related to dementia, and the extended durations of use raise concerns about the care of frail elders residing in NHs.

While our study included data from only 1 long-term care pharmacy, a comparison of our sample with data from NHs in the 2010 Online Survey, Certification and Reporting showed substantial overlap (61.9% vs 66.4% female, respectively; 66.4% vs 71.4% aged ≥75; and 54.5% vs 66.0% eligible for Medicaid). We were unable to assess appropriate vs inappropriate prescribing.

Corresponding Author: Becky A. Briesacher, PhD, University of Massachusetts Medical School, 377 Plantation St, Biotech 4, Ste 315, Worcester, MA 01605 (becky.briesacher@umassmed.edu).

Author Contributions: Dr Briesacher had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Briesacher, Tjia, Gurwitz.

Acquisition of data: Briesacher.

Analysis and interpretation of data: Briesacher, Tjia, Field, Peterson, Gurwitz.

Drafting of the manuscript: Briesacher.

Critical revision of the manuscript for important intellectual content: Briesacher, Tjia, Field, Peterson, Gurwitz.

Statistical analysis: Briesacher, Tjia, Field, Peterson.

Obtained funding: Briesacher, Tjia, Gurwitz.

Administrative, technical, or material support: Briesacher.

Study supervision: Briesacher.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Briesacher reported receiving research support and consulting fees from Novartis. Dr Tjia reported serving as a consultant to Qualidigm. No other disclosures were reported.

Funding/Support: This study was supported by the Agency for Healthcare Research and Quality grant R18HS019351-01. Dr Briesacher was also supported by research scientist award K01AG031836 from the National Institute on Aging.

Role of the Sponsor: The funding organizations had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

Additional Contributions: We thank Kathy M. Mazor, EdD, Leslie R. Harrold, MD, MPH, and Celeste A. Lemay, MPH (Meyers Primary Care Institute and University of Massachusetts Medical School, Worcester), and Jennifer L. Donovan, PharmD, RPh, Abir O. Kanaan, PharmD (Massachusetts College of Pharmacy and Health Sciences, Worcester), for collaborating on the study. We also thank Sarah Foy and Sruthi Valluri (Meyers Primary Care Institute, Worcester, Massachusetts) for administrative assistance in preparing the manuscript. No compensation was received by any of the persons listed.

Briesacher BA, Limcangco MR, Simoni-Wastila L,  et al.  The quality of antipsychotic drug prescribing in nursing homes.  Arch Intern Med. 2005;165(11):1280-1285
PubMed   |  Link to Article
Maher AR, Maglione M, Bagley S,  et al.  Efficacy and comparative effectiveness of atypical antipsychotic medications for off-label uses in adults: a systematic review and meta-analysis.  JAMA. 2011;306(12):1359-1369
PubMed   |  Link to Article
Chen Y, Briesacher BA, Field TS, Tjia J, Lau DT, Gurwitz JH. Unexplained variation across US nursing homes in antipsychotic prescribing rates.  Arch Intern Med. 2010;170(1):89-95
PubMed   |  Link to Article
Shorr RI, Fought RL, Ray WA. Changes in antipsychotic drug use in nursing homes during implementation of the OBRA-87 regulations.  JAMA. 1994;271(5):358-362
PubMed   |  Link to Article
Rovner BW, Edelman BA, Cox MP, Shmuely Y. The impact of antipsychotic drug regulations on psychotropic prescribing practices in nursing homes.  Am J Psychiatry. 1992;149(10):1390-1392
PubMed

Figures

Place holder to copy figure label and caption
Figure. State-Level Prevalence of Antipsychotic Prescribing in Nursing Homes
Graphic Jump Location

State-level samples ranged from 767 to 104 460 residents.

Tables

Table Graphic Jump LocationTable. Most Commonly Prescribed Antipsychotic Medications in Nursing Homes (NHs)

References

Briesacher BA, Limcangco MR, Simoni-Wastila L,  et al.  The quality of antipsychotic drug prescribing in nursing homes.  Arch Intern Med. 2005;165(11):1280-1285
PubMed   |  Link to Article
Maher AR, Maglione M, Bagley S,  et al.  Efficacy and comparative effectiveness of atypical antipsychotic medications for off-label uses in adults: a systematic review and meta-analysis.  JAMA. 2011;306(12):1359-1369
PubMed   |  Link to Article
Chen Y, Briesacher BA, Field TS, Tjia J, Lau DT, Gurwitz JH. Unexplained variation across US nursing homes in antipsychotic prescribing rates.  Arch Intern Med. 2010;170(1):89-95
PubMed   |  Link to Article
Shorr RI, Fought RL, Ray WA. Changes in antipsychotic drug use in nursing homes during implementation of the OBRA-87 regulations.  JAMA. 1994;271(5):358-362
PubMed   |  Link to Article
Rovner BW, Edelman BA, Cox MP, Shmuely Y. The impact of antipsychotic drug regulations on psychotropic prescribing practices in nursing homes.  Am J Psychiatry. 1992;149(10):1390-1392
PubMed

Letters

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 3

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com

Users' Guides to the Medical Literature
Clinical Resolution

Users' Guides to the Medical Literature
Using the Guide—Part 8