Evidence suggests that psychotropic medications have been used inappropriately in many nursing homes (Beers et al., 1988; Ray Federspeil, & Schaffner, 1980), with often excessive and clinically unjustified rates of use (Burns & Kamerow, 1988; Gurwitz, Soumerai, & Avorn, 1990). Appropriate use of these drugs is a key measure of nursing home quality, (Castle, 1997), and as such is among the areas of care examined by surveyors who review the quality of these facilities. In the proposed study we will use data from these surveyors and other sources to examine nursing homes with persistent poor quality as it relates to the use of psychotropic medications. State and federal surveyors conduct inspections of nursing homes every 9 to 15 months. When a facility does not meet a standard (or code), the surveyors issue a deficiency citation. Twelve different citations are used for medication use. We will use data describing these citations along with reported levels of psychotropic medications, as our measures of poor quality. Based on a recent General Accounting Office (GAO) report, our definition of persistence in poor quality is a citation on two consecutive inspections. In our initial analysis will use inspections conducted in 1999 and 2000, and we will then examine facilities with deficiencies in three consecutive inspections (1999, 2000, and 2001) because we believe this additional analysis will give us a more thorough understanding of nursing homes with persistent poor quality. We will also examine increases and decreases in nursing homes' use of psychotropic medications between 1999 and 2001 in order to determine the impact over time of the survey process and previous citations on this measure of quality.
