Improving Medication Safety in Nursing Home Dementia Care

描述（由申请人提供）：抗精神病药（AP）在护理老年痴呆症疗养院居民中的使用对居民、家庭、设施、处方医生、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，往往令人痛苦的行为和心理表现的痴呆症是复杂的，往往是困难的。AP继续在养老院广泛使用，尽管有强有力的证据表明死亡率增加，并由此产生FDA黑匣子警告。2012年，包括CMS、行业和州领导人在内的长期护理利益相关者和政策制定者发起了全国合作伙伴关系，以改善养老院和同伴州的痴呆症护理，其最初目标是到2012年将长期居住居民的AP使用减少15%。一些州实现了20-25%的减排，而另一些州几乎没有变化。州使用率目前在12%至27%之间，各设施之间差异很大。至关重要的是要检查不同的国家战略对更安全的痴呆症管理的比较影响，包括痴呆症管理其他方面的共同发生的变化和潜在的意外后果（如镇静/催眠药的替代）。非常需要更清楚地了解与治疗开始和后续管理变化相关的因素。目前的质量措施侧重于机构报告的AP使用的流行率，而安全性风险也因剂量、持续时间、多种药物和治疗的其他具体特征而存在很大差异。迫切需要对这些做法进行更具体和更有信息量的衡量，以更清楚地界定潜在的安全挑战;为改进质量措施的制定提供信息;并确定可修改的干预点。多个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，我们将进行一项由持有人参与的多方法研究，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组成部分相结合。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NH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。我们将研究居民，设施和政策因素与使用，并分析国家和州一级的变化，使用模式的质量改进措施。补充国家和设施的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;确定和记录与持续影响相关的因素;并确定在设施一级成功利用的战略，以可持续地改善痴呆症护理安全。在积极的转化部分，我们将与国家推进卓越运动的合作伙伴，将项目产生的知识和产品转化为有效的，系统的使用。结果将提供可操作的知识，以加强国家和州的举措，以增加使用更安全，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.