Longitudinal Trends and Variation in Antipsychotic Use in Older Adults After Cardiac Surgery

Objectives: To evaluate temporal trends and between-hospital variation in off-label antipsychotic medication (APM) use in older adults undergoing cardiac surgery.

Design: Retrospective cohort study.

Setting: National administrative database including 465 U.S. hospitals.

Participants: Individuals aged 65 and older without known indications for APMs who underwent cardiac surgery from 2004 to 2014 (N=293,212).

Measurements: Postoperative exposure to any APMs and potentially excessive dosing were examined. Hospital-level APM prescribing intensity was defined as the proportion of individuals newly treated with APMs in the postoperative period.

Results: The rate of APM use declined from 8.8% in 2004 to 6.2% in 2014 (p<.001). Use of haloperidol (parenteral 7.0% to 4.5%, p<.001; oral: 1.9% to 0.5%, p<.001), and risperidone (1.1% to 0.3%, p<.001) declined, whereas quetiapine use tripled (0.6% to 1.9%, p=.03). Hospital APM prescribing intensity varied widely, from 0.3% to 35.6%, across 465 hospitals. Treated individuals at higher-prescribing hospitals were more likely to receive APMs on the day of discharge (highest vs lowest quintile: 15.1% vs 9.6%; p<.001) and for a longer duration (4.8 vs 3.7 days; p<.001) than those at lower-prescribing hospitals. Delirium was the strongest risk factor for APM exposure (odds ratio=9.73, 95% confidence interval=9.02-10.5), whereas none of the hospital characteristics were significantly associated. The rate of potentially excessive dosing declined (60.7% to 44.9%, p<.001), and risk factors for potentially excessive dosing were similar to those for any APM exposure.

Conclusions: Our findings suggest highly variable prescribing cultures and raise concerns about inappropriate use, highlighting the need for better evidence to guide APM prescribing in hospitalized older adults after cardiac surgery.