Improving Medication Safety in Nursing Home Dementia Care

描述(由申请人提供)：抗精神病药物(AP)在护理患有痴呆症的疗养院居民中的使用给居民、家庭、设施、处方医生、监管机构和其他利益相关者带来了重大的患者安全挑战。对于痴呆症经常令人痛苦的行为和心理表现，实施替代管理策略是复杂的，而且往往是困难的。APS继续在疗养院广泛使用，尽管有强有力的证据表明死亡率上升，并由此得到FDA的黑匣子警告。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，发起了改善养老院和同伴州合作伙伴关系中的痴呆症护理的国家伙伴关系，初步目标是在2012年将长期居住居民使用AP的数量减少15%。一些州实现了20%-25%的减排，而另一些州几乎没有变化。目前，各州的使用率从12%到27%不等，不同设施的使用率差异很大。必须研究不同的国家战略对更安全的痴呆症治疗的比较影响，包括痴呆症治疗的其他方面同时发生的变化和潜在的意外后果(如镇静剂/催眠药的替代)。更清楚地了解与启动和随后的治疗管理的变化相关的因素是非常必要的。目前的质量衡量标准侧重于设施报告的AP使用率，而安全风险也因剂量、持续时间、多药联用和其他治疗的具体特征而有很大不同。迫切需要对这些做法进行更具体和更具信息性的衡量，以便更清楚地定义潜在的安全挑战；告知改进的质量措施的发展情况；并确定可修改的干预点。多个定量和定性数据源的集成具有解决这些关键问题的巨大潜力。因此，我们将进行一项利益攸关方参与的多方法研究，将对所有国家长期居留人口的合并行政数据的分析与个案研究和翻译部分结合起来。对关联的最小数据集、联邦医疗保险索赔、设施/监管机构和其他数据源的分析将提供对NHS中AP使用的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，并分析质量改进倡议后国家和州一级使用模式的变化。相辅相成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；确定和记录与持续影响相关的因素；以及确定在设施一级成功利用的战略，以持续改善痴呆症护理安全。在积极的翻译部分，我们将与国家卓越推进运动合作，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，以加强国家和州的倡议，以增加使用更安全的、以人为中心的痴呆症护理实践。

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.