Federal policies designed to reduce use of antipsychotic medications in nursing homes did not lead to clinically significantly higher rates of schizophrenia diagnoses among dementia patients, finds a new study from researchers at Brown University and the University of Michigan.
Schizophrenia, Tourette’s syndrome and Huntington’s Disease could have been diagnosed more often because the Centers for Medicare & Medicaid Services excluded patients with those conditions from a quality measure the agency added to its star rating program in 2015.
To understand the effect of that and the launch of the National Partnership to Improve Dementia Care in Nursing Homes in 2012, the researchers studied newly admitted long-stay nursing home residents with dementia who had not been previously diagnosed with any of the three excluded conditions.
From 2009 to 2018, the share of long-stay residents given any of the three diagnoses that would have excluded them from quality measure calculations rose from a baseline of about 2.2% but never exceeded 2.9% in the overall patient group.
“Our main takeaway is that nursing homes did not resort to ‘making up’ diagnoses that would allow for the use of antipsychotics in their residents with dementia,” lead researcher Theresa I. Shireman told McKnight’s Long-Term Care News Monday. “This is good news since antipsychotics have a Black Box Warning against their use in people with dementia.”
Shireman is director of the Center for Gerontology and Healthcare Research at Brown University’s School of Public Health. She said the study’s unadjusted findings are statistically significant “but not necessarily what one would consider clinically significant.”
When the researchers stratified nursing homes by patient race and ownership type and other factors, they still did not find rates of any increases to be significant. The study was the first to look only at patients with dementia and their pre-admission diagnoses as they relate to the CMS quality measure diagnoses.
Audits may help refine antipsychotic efforts
CMS is in its second year of auditing providers selected for potentially inappropriate schizophrenia diagnoses, which the agency said should not be happening in large numbers among nursing homes’ largely senior population. The agency is reviewing data from across the larger patient population, including short-stay patients, who many experts have said are admitted to nursing homes with existing diagnoses given in the community or are prescribed antipsychotics during an immediately preceding acute care episode.
The study by Shireman and colleagues was published Friday in the Journal of the American Geriatrics Society. It noted that a “black box” warning for antipsychotics applies only to people with dementia, “who are presumably at the greatest risk of adverse consequences from antipsychotic exposure.”
And for those patients, there have been only minor shifts in diagnosing patterns, despite extensive educational and compliance efforts. New schizophrenia, Tourette’s and Huntington’s diagnoses remained below 5% even in studied subgroups followed for two years after a long-stay admission.
The researchers reported that the National Partnership led to a one-time, 1.29% decrease in diagnoses in nursing homes with an intermediate percentage of Black residents. It also credited the National Partnership with reducing diagnoses of the three conditions among not-for-profit facilities. After that program started, however, for-profit nursing homes saw a small increase in their use of the diagnoses.
And the Quality Rating modifications “had no significant effect” on any of the subgroups studied, nor the overall patient population across the study period.
Shireman said a nursing home could theoretically use one of the targeted diagnoses “to make itself look better on the quality measure,” but that the researchers did not have any specific theories as to what for-profit facilities may be doing differently. She argued there is not strong evidence to tie staffing shortages or other resource issues to their increased diagnosing, especially among the dementia patients this study followed.
Because they did not see “systematic changes stimulated by the Partnership and Five Star Rating System,” the researchers said CMS should continue work to identify a more limited, specific set of nursing homes that need to improve their practices.
Exactly how CMS will proceed with its ongoing audits, and what information it is gleaning to help lower the use of excluded diagnoses or reduce reliance on antipsychotics, is still unclear. Earlier this summer, some providers noted they had been unable to exit the star ratings penalties CMS imposed on them following a failed audit.
Shireman endorsed the current audit strategy of only targeting nursing homes that are “outliers” on antipsychotic use and exclusionary diagnoses.
“This puts less burden on facilities that are seemingly doing the right things by not instituting a widespread policy that all facilities have to respond to,” she told McKnight’s.
