Improving Medication Safety in Nursing Home Dementia Care

描述（由申请人提供）：抗精神病药（AP）在老年痴呆症养老院居民护理中的使用对居民、家庭、设施、处方医师、监管机构和其他利益相关者构成了重大的患者安全挑战。实施替代管理策略往往令人痛苦的痴呆症的行为和心理表现是复杂的，往往是困难的。尽管有强有力的证据表明ap会增加死亡率，FDA也发出了黑框警告，但它仍在养老院广泛使用。2012年，长期护理利益相关者和政策制定者，包括CMS、行业和州领导人，发起了“改善养老院痴呆症护理国家伙伴关系”和各州伙伴关系，2012年的初步目标是长期住院居民使用AP减少15%。一些州减少了20-25%，而其他州几乎没有变化。各州的使用率目前在12%到27%之间，不同设施之间差异很大。对于更安全的痴呆症管理，有必要检查不同的国家策略的比较影响，包括痴呆症管理其他方面的共同发生的变化和潜在的意想不到的后果（如替代镇静剂/催眠药）。更清楚地了解与治疗开始和后续管理的变化有关的因素是非常必要的。目前的质量措施侧重于设施报告的AP使用流行率，而安全风险也因剂量、持续时间、多种药物和其他治疗特征而有很大差异。迫切需要对这些做法进行更具体和更翔实的测量，以更清楚地定义潜在的安全挑战；告知改进质量措施的发展；并确定可修改的干预点。多种定量和定性数据源的整合具有解决这些关键问题的巨大潜力。因此，我们将开展一项利益相关者参与的多方法研究，将对全国长期居留人口的合并行政数据的分析与案例研究和翻译部分相结合。对相关最小数据集、医疗保险索赔、设施/监管和其他数据源的分析将提供对NHs中AP使用安全相关维度的当前模式、变化和预测因素的全面分析。我们将研究与使用相关的居民、设施和政策因素，并分析在质量改进举措之后使用模式的国家和州一级变化。互补的国家和设施案例研究将确定和分析成功的国家干预措施的关键组成部分的影响；识别和记录与持续影响有关的因素；并确定在设施层面成功利用的战略，以可持续地改善痴呆症护理安全。在积极的转化方面，我们将与全国推进卓越运动合作，将项目产生的知识和产品转化为有效、系统的使用。结果将提供可操作的知识，以加强国家和州的倡议，以增加使用更安全的，以人为本的痴呆症护理实践。

DESCRIPTION (provided by applicant): 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.