The Effects of Antipsychotic Quality Reporting on Antipsychotic and Psychoactive Medication Use.

Following the Food Drug Administration (FDA) approval of atypical antipsychotics in the late 1990s, the use of antipsychotic medications among nursing home residents increased rapidly over the next 15 years. Many of these residents were receiving antipsychotics to manage behavioral and psychiatric symptoms associated with dementia (Briesacher et al. 2005; Office of Inspector General [OIG] 2011). This led to widespread off-label use of antipsychotics, often viewed as a form of “chemical restraint” (Hughes, Lapane, and Mor 1999). In the mid-2000s, it became evident that these medications could result in significant negative health outcomes in persons with dementia.1 Subsequently, the FDA issued public health advisories cautioning that atypical antipsychotics (2005), and later all antipsychotics (2008), are associated with increased risk of mortality in persons with dementia. Even with the public health advisories of the FDA, the quantity of antipsychotic medication use is still a concern as the national rates of antipsychotic use remain high (Kales et al. 2011). In March of 2012, the Centers for Medicare and Medicaid Services (CMS) launched a national initiative, the Partnership to Improve Dementia Care in Nursing Homes, in an attempt to reduce the unnecessary use of antipsychotic medications, especially for nursing home residents with dementia (CMS 2012, 2013). As part of this initiative, CMS distributed for public comment revised surveyor guidance related to antipsychotics, launched a website (https://www.nhqualitycampaign.org/), and began public reporting new quality measures on antipsychotic medication use on the Nursing Home Compare (NHC) website. The purpose of this initiative, including the public reporting of antipsychotic quality, was to improve behavioral health care practices and reduce inappropriate use of antipsychotics. The focus of this paper is the public reporting of antipsychotic use on the NHC website. Since 2002, NHC has publically reported various measures of nursing home quality, with the intent of allowing consumers to compare the quality of nursing home care in their local area. By logging onto the NHC website, consumers and administrators are able to search nursing homes within a geographic area and compare their quality performance. Quality is currently reported using a 5-star system, but data on specific quality measures are also available, such as number of deficiencies, staffing levels, financial penalties, and a set of resident care quality measures. NHC did not initially include antipsychotic use as a measure of quality. Starting in July of 2012, CMS began publically reporting an antipsychotic quality measure on NHC that attempts to approximate “inappropriate” use.2 This measure is also included in the calculations of the 5-star quality scores of facilities. The public reporting of an antipsychotic quality measure should reduce the use of antipsychotics in nursing homes subject to public reporting. But one of the unintended effects is that nursing homes may substitute other medications that have similar sedating properties for antipsychotics. This paper studies this issue by examining the changes in the use of antipsychotics and other psychoactive medications just prior to and after the period in which NHC began publicly reporting the long-stay antipsychotic quality measure.