title: Antipsychotic medication use in nursing homes: a proposed measure of quality.
abstract: 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.
  
  
  CONCLUSIONS
  The proposed measure provides an important foundation to improve APM prescribing practices without penalizing NHs when there are limited alternative treatments available.
authors.affiliation: Seton Hall University and Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA.
authors.forename: Judith A
authors.initials: JA
authors.lastname: Lucas
authors.forename: Sujoy
authors.initials: S
authors.lastname: Chakravarty
authors.forename: John R
authors.initials: JR
authors.lastname: Bowblis
authors.forename: Tobias
authors.initials: T
authors.lastname: Gerhard
authors.forename: Ece
authors.initials: E
authors.lastname: Kalay
authors.forename: Eun Kwang
authors.initials: EK
authors.lastname: Paek
authors.forename: Stephen
authors.initials: S
authors.lastname: Crystal
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D014150:Antipsychotic Agents / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D017723:Drug Utilization Review; D005240:Feasibility Studies; D005260:Female; D019983:Guideline Adherence / Q000592:standards; D006707:Homes for the Aged / Q000592:standards*; D006801:Humans; D016015:Logistic Models; D008297:Male; D009735:Nursing Homes / Q000592:standards*; D017410:Practice Guidelines as Topic; D011618:Psychotic Disorders / Q000188:drug therapy*; D011787:Quality of Health Care / Q000592:standards*; D014481:United States
chemical_list: D014150:Antipsychotic Agents
keywords: antipsychotics; behavioral symptoms; dementia; long-term care; nursing homes; quality measurement