Antipsychotic (AP) use in the care of nursing home residents with dementia poses major patient safety challenges for residents, families, facilities, prescribers, regulators, and other stakeholders. Implementing alternative management strategies for the often-distressing behavioral and psychological manifestations of dementia is complex and often difficult. APs continue to be widely used in nursing homes, despite strong evidence of increased mortality and a resulting FDA black box warning. In 2012, long-term care stakeholders and policymakers including CMS, industry, and state leaders initiated the National Partnership to Improve Dementia Care in Nursing Homes and companion state partnerships, with an initial goal for 2012 of a 15% reduction in AP use by long-stay residents. Some states achieved 20-25% reductions while others saw little change. State use rates currently range from 12% to 27%, with wide variation across facilities. It is essential to examine the comparative impact of the varied state strategies for safer dementia management, including co- occurring changes in other dimensions of dementia management and potential unintended consequences (such as substitution of sedative/hypnotics). A clearer understanding of the factors associated with variations in initiation and subsequent management of treatments is much needed. Current quality measures focus on facility-reported prevalence of AP use, while safety risks also vary substantially by dosage, duration, polypharmacy, and other specific characteristics of treatment. There is a critical need for more specific and informative measurement of these practices, to more clearly define the underlying safety challenge; inform development of improved quality measures; and identify modifiable points of intervention. Integration of multiple quantitative and qualitative data sources has great potential to address these crucial questions. We will therefore conduct a stakeholder-engaged, multi-method study that integrates analysis of merged administrative data on the full national long-stay population with case-study and translational components. Analyses of linked Minimum Data Set, Medicare claims, facility/regulatory, and other data sources will provide a comprehensive analysis of current patterns, variations, and predictors of safety-related dimensions of AP use in NHs. We will examine resident, facility, and policy factors associated with use, and analyze national and state-level changes in use patterns following the quality improvement initiatives. Complementary state and facility case studies will identify and analyze impact of key components of successful state interventions; identify and document factors associated with sustained impact; and identify strategies successfully utilized at the facility level for sustainable improvement in dementia care safety. In an active translational component, we will partner with the national Advancing Excellence campaign to translate project-generated knowledge and products into effective, systemic use. Results will provide actionable knowledge to strengthen national and state initiatives to increase use of safer, person-centered dementia care practices.

Public Health Relevance

This project addresses the critical patient safety issues posed by antipsychotic (AP) use in nursing home dementia care, which continues to be widespread despite strong evidence of mortality risk and a resulting FDA black box warning. We will examine the factors associated with variations in initiation and subsequent management of treatments, and the comparative impact of state initiatives for safer dementia management, with a multi-method design that integrates analyses of merged national administrative datasets with state and facility case studies and a strong dissemination and translation component to put project results into practice in strengthened safety improvement initiatives. The project will provide essential information on evolving patterns of exposure to AP-related risks and the effectiveness of implementation strategies, to increase the use of safer care practices for these vulnerable patients.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Demonstration and Dissemination Projects (R18)
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Healthcare Patient Safety and Quality Improvement Research (HSQR)
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Perfetto, Deborah
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Rutgers University
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United States
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