Antipsychotic reduction in nursing home residents with Alzheimer's disease: Impact on state, facility, and resident psychopharmacological medication use and outcomes

2012年，改善痴呆症护理的国家伙伴关系发起了一项减少抗精神病药物使用的倡议 在患有阿尔茨海默病和相关痴呆(ADRD)的疗养院居民中。在5年内， 所有疗养院居民的抗精神病药物使用率下降了34.1%，全国患病率为15.7%。那里 围绕抗精神病药物减少计划(ARP)的结果仍然是重要的悬而未决的问题， 包括：哪些居民经历了抗精神病药物使用的减少；哪些居民经历了 抗精神病药物的减少转向了其他精神药理药物(PPM)； 变化会影响他们的健康结果吗？该项目的主要目标是进行一系列分析 使用与居民和养老院调查数据相关联的国家行政索赔数据来评估影响 关于国家、疗养院和个人层面的抗精神病药物和PPM(镇静催眠药、阿片类药物、 抗抑郁药、抗焦虑药和抗惊厥药)在疗养院的使用和健康结果 患有ADRD的人口。我们的中心假设是，抗精神病药物的减少会导致意外 使脆弱的养老院居民接触到潜在有害的PPM的后果，导致 下游的不利健康后果。拟议的研究利用了具有全国代表性的100% 2010-2016年间居住在长期护理机构的联邦医疗保险受益人样本 医疗保健利用率数据与疗养院和护理住院医生调查数据相吻合。我们会 实现以下具体目标：1)预测ARP对抗精神病药物和PPM使用的影响 养老院居民的模式，按州和人口层面的特点；2)找出影响 疗养院居民中抗精神病药物和PPM使用模式的ARP，按设施水平特征分类；以及 3)测试ARP实施影响关键个人级别公共卫生结果的预测(例如， 死亡率、护理环境的转变和跌倒/骨折)和以患者为中心的健康结果(例如，身体状况 ADRD患者的约束使用、行为症状出现、功能状态、疼痛)。 使用先进的方法，我们的多学科研究团队将评估国家、设施、 以及个人层面的特征，这些特征可能调解了一项影响了 养老院居民140万人。我们的发现有可能指导卫生政策和规划 完善，并将增加我们对精神药理药物使用及其贡献的理解 对患有ADRD的老年人的健康后果。结果将为未来的研究提供信息，使颗粒状研究 审查疗养院其他弱势群体的用药政策，如少数族裔 以及那些患有严重精神疾病、慢性疼痛和/或神经疾病的人。调查结果将提供一个 为实现我们的最终目标奠定基础：为供应商和政策制定者提供如何优化 制定支持疗养院患者健康和生活质量的决定和政策。

In 2012, the National Partnership to Improve Dementia Care launched an initiative to reduce antipsychotic use among nursing home residents with Alzheimer’s Disease and Related Dementias (ADRD). Within 5 years, antipsychotic use decreased by 34.1% in all nursing home residents to a national prevalence of 15.7%. There remain important unanswered questions surrounding outcomes of the antipsychotic reduction program (ARP), including: which residents experienced reduced antipsychotic use; were residents who experienced antipsychotic reductions switched to other psychopharmacological medications (PPM); and did medication changes influence their health outcomes? The primary goal of this project is to conduct a series of analyses using national administrative claims data linked to resident and nursing home survey data to assess the impact of the ARP on state-, nursing home-, and individual- level antipsychotic and PPM (sedative-hypnotics, opioids, antidepressants, anxiolytics, and anticonvulsants) utilization and health outcomes in the nursing home population with ADRD. Our central hypothesis is that antipsychotic reductions resulted in unintended consequences that exposed vulnerable nursing home residents to potentially harmful PPMs, leading to downstream adverse health consequences. The proposed study utilizes a nationally-representative, 100% sample of Medicare beneficiaries residing in long-stay nursing facilities from 2010–2016 that links prescription and healthcare utilization claims data to nursing home- and nursing resident- level survey data. We will accomplish the following specific aims: 1) To predict the impact of the ARP on antipsychotic and PPM use patterns in nursing home residents, by state- and population- level characteristics; 2) To identify the impact of the ARP on antipsychotic and PPM use patterns in nursing home residents, by facility-level characteristics; and 3) To test the prediction that ARP implementation affected critical individual-level public health outcomes (e.g., mortality, transitions in care settings, and falls/fractures) and patient-centered health outcomes (e.g., physical restraint use, behavioral symptom emergence, functional status, pain) in nursing home residents with ADRD. Using advanced methodological approaches, our multidisciplinary research team will assess state-, facility-, and individual- level characteristics that may have mediated the impact of a sweeping policy that affected over 1.4 million nursing home residents. Our findings have the potential to guide health policy and program refinement, and will add to our understanding of psychopharmacological medication use and their contribution to health consequences in older adults with ADRD. Results will inform future studies that allow granular examination of medication policies on other vulnerable nursing home subpopulations, such as racial minorities and those with serious mental illness, chronic pain, and/or neurologic conditions. Findings will provide a foundation to achieve our ultimate goal: to provide guidance to providers and policy-makers on how to optimize prescribing decisions and policies that support nursing-home patients’ health and quality of life.