Facility-Level Differences in Antipsychotic Drug Use: Impact on Quality Outcomes for Nursing Home Residents

Objective: To quantify quality of care following an admission to a nursing home with low or high antipsychotic drug use.

Background: Misuse of antipsychotics in U.S. nursing homes is a huge concern for policymakers.

Methods: We utilized an instrumental variable approach to estimate the effect of facility-level antipsychotic use on patient outcomes. The instrument was the differential distance to the nearest low-use antipsychotic nursing home relative to the nearest high-use antipsychotic nursing home. Post-acute care short-stay and long-stay residents in U.S. nursing homes were identified using Medicare administrative claims and the Minimum Dataset 3.0 (2014-2019). Outcomes included hospitalizations, falls, pressure ulcers, physical restraint use, medication use, and diagnosis of schizophrenia, bipolar disease, anxiety, or depression.

Results: Among long-stay residents, receiving care from a low-use facility reduced the diagnosis of schizophrenia, use of restraints, and hospitalizations. There was also a reduction in the hospitalization rate [-0.9 percentage point (pp)], likelihood of long-stay status (-1.8 pp), and diagnosis of schizophrenia (-0.2 pp) at 90 days among short-stay residents. We also observed larger reductions among residents with dementia and serious mental illness.

Conclusions: Admission to a nursing home with a low use of antipsychotics led to decreased hospitalizations, restraint use, and diagnosis of schizophrenia. Curbing the high use of antipsychotics remains a priority of policymakers as the centers for medicare and medicaid services conducts off-site audits to assess whether nursing homes accurately code residents with schizophrenia. It will be important to monitor if centers for medicare and medicaid services downgrades any quality star ratings due to inappropriate coding and assess the implications on quality of care.