title: Variation in antipsychotic treatment choice across US nursing homes.
abstract: OBJECTIVE
  Despite serious safety concerns, antipsychotic medications continue to be used widely in US nursing homes. The objective of this study was to quantify the variation in antipsychotic treatment choice across US nursing homes, and to characterize its correlates.
  
  
  METHODS
  Prescribing practices were assessed in a cohort of 65,618 patients 65 years or older in 45 states who initiated treatment with an antipsychotic medication after nursing home admission between 2001 and 2005, using merged Medicaid; Medicare; Minimum Data Set; and Online Survey, Certification, and Reporting data. We fit mixed-effects logistic regression models to examine how antipsychotic treatment choice at the patient-level depends on patient and nursing home fixed and random effects.
  
  
  RESULTS
  Among antipsychotic medication users, 9% of patients initiated treatment with a conventional agent. After adjustment for case-mix and facility characteristics, 95% of nursing homes had a predicted conventional antipsychotic prescribing rate between 2% and 20%. Individually, patient characteristics accounted for 36% of the explained variation, facility characteristics for 23%, and nursing home prescribing tendency for 81%. Results were consistent in the subgroup of nursing home patients with a diagnosis of dementia. The prescribing physician was not considered as a determinant of treatment choice owing to data limitations.
  
  
  CONCLUSIONS
  These findings indicate that antipsychotic treatment choice is to some extent influenced by a nursing home's underling prescribing "culture." This culture may reveal strategies for targeting quality improvement interventions. In addition, these findings suggest that a nursing home's tendency for specific antipsychotics merits further exploration as an instrumental variable for improved confounding adjustment in comparative effectiveness studies.
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA. khuybrechts@partners.org
authors.forename: Krista F
authors.initials: KF
authors.lastname: Huybrechts
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Rothman
authors.forename: M Alan
authors.initials: MA
authors.lastname: Brookhart
authors.forename: Rebecca A
authors.initials: RA
authors.lastname: Silliman
authors.forename: Stephen
authors.initials: S
authors.lastname: Crystal
authors.forename: Tobias
authors.initials: T
authors.lastname: Gerhard
authors.forename: Sebastian
authors.initials: S
authors.lastname: Schneeweiss
mesh_terms: D000368:Aged; D014150:Antipsychotic Agents / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D003704:Dementia / Q000188:drug therapy*; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D006707:Homes for the Aged / Q000706:statistics & numerical data*; D006801:Humans; D007345:Insurance Claim Review / Q000592:standards; D008297:Male; D008484:Medicaid / Q000191:economics; D006278:Medicare / Q000191:economics; D008875:Middle Aged; D009735:Nursing Homes / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000592:standards / Q000706:statistics & numerical data; D058996:Quality Improvement; D014481:United States
chemical_list: D014150:Antipsychotic Agents