2010-2015年联邦医疗保险疗养院患者抗精神病药物使用情况

Antipsychotic Medication use inMedicareNursingHomePatients2010-2015 A Medicare fee-for-service claims-based analysis Kyle Pérez,MPHMichele Berrios,CHFPBruce Pyenson, FSA, MAAA Commissioned byOtsuka Pharmaceutical Co., Ltd. Key Findings The portion ofpatientsentering a nursing homereceivinganantipsychoticmedication(AP)decreasedfrom 2011 to 2015The largest decrease was observed in patients withconditions other than thoserecognized by the FDA as an approved indicationfor treatment/managementwithAPsWhether a patient had a conditionmeasured by the CMS antipsychotic quality metric had an impact ontheir APuse. Patients witha measured conditionhad a greaterdecrease between 2011 to 2015 In the early2000s, publichealth expertsexpressed concern that antipsychoticmedications (APs) were beingprescribedinappropriately in the residential nursing home(NH) setting.1,2The Beers Criteria, which provideguidance to prescribers and patients on safedrug selection and dosing, recommend avoidingAPs in patients who are experiencing behavioralissues associated with delirium or dementia,except when patients have failed to respond tonon-pharmacological interventions and are atsignificant risk of harming themselves orothers.3 In 2012,CMS introduced new qualitymetrics aimed at reducingAPmisuseinnursing homes These metrics, part ofthe Minimum Data Set (MDS) andacomponent oftheCMSNursing Home Quality Initiative (NHQI)Five-Star Quality Rating System, are publicly reported for eachNH.The“starmetrics”were intended by CMS to be used asindicators of NH quality of care and for comparisons amongfacilities. The MDS(data that nursing homes self-report)includestwo different quality metricsrelated to AP use:one for short stayresidents (≤100 cumulative days in a NH) and another for long-stay residents (>100 cumulative days in a NH). For short-stay NHresidents, the metricreportsthe percentage of residents whonewly received an AP without prior AP useindicatedon theirentry assessment.For long stay residents,the metricreports thepercentage of residentswhoreceivedAPs, regardless of prior APuse.For both metrics, higherpercentages suggestqualityproblems. The primary concern was that APs, some of which have sedativeeffects, were being used as chemical restraints to manageresidents, including those with disruptive or aggressivebehaviors. In 2004, a study of patients ages 66 and older whowere newly admitted to an NH with no history of major psychosisor neuroleptic drug use in the year prior to admission found that17% of these patients received an AP within 100 days of enteringthe nursing home. Withinthe first year of NH residency, new APuse increasedto 24%.4 Thecurrent CMS long-stay AP use quality metricexcludespatients identified with schizophrenia, Tourette syndrome, and orHuntington’s disease. Both schizophrenia and TourettesyndromeareFDA-approved indications forsome APs. TheexclusionofHuntington’sdiseasefrom the quality metricis consistent with theoff-label use ofsome APs forsuppressing chorea andformanagingpsychiatric symptoms associated with Huntington’s disease, including agitation and psychosis.5However, bipolardisorder and major depressive disorder(MDD)—conditionsdesignatedasFDA-approvedindicationsfor many APs,particularly 2nd generation APs—areincluded.Long-staypatients who receive an APand are not identified withschizophrenia, Tourette syndrome, or Huntington’s diseasewould negatively impact theNH’s quality score.Therefore,NHswith patientsidentified with MDD or bipolar disordertaking APswouldhave lower scores than if these patients did not take APs. Inthe first six months ofNHexperienceof eachentrancecohort,the portion of patients with at least one fillforanAPdecreasedfrom 19.4% in 2011 to 14.4% in 2015. Thisreduction in patientswith AP use in the NHvariedbased on thepatients’condition. Inour analysis,the largest decrease in AP use occurred inNHpatients with off-label AP use–a 43% decrease from 2011 to2015 (14.9% to 8.5%).NH patientswith the smallest change inportion of patients with APusewas thestar excluded(andFDAapproved)group. Thisgroup experienced a 2% decrease in APuse in the first 6 months between 2011 to 2015 (75.6% to74.0%). The fact that someFDA approvedindications are included in the star metricswhile others are excludedraises theconcern that if the FDA approves newindications for APs, the star metrics maynot be adjusted toalign withapproveduses. AP use decreased by 19% over theobservedperiodfor patients withanFDA-approvedconditionnot excludedfrom the CMS APusequality metric. For these patients, the portion on an AP in 2011 was 21.8% anddecreased to 17.7% in 2015.It is also of note thatthe onlycondition cohorts to increase as ashare of total nursing homepatients regardless of AP use werebipolardisorderandMDD(from 34% in 2011 to 40% in 2015). Between 2011and2015,overthree quarters ofall long-stayNHresidentsonan oral APwereidentifiedwith anFDA-approvedconditionincludedinthe star metric(seeFigure 1). NH patients on APsexpe