The Effect of De-Prescribing Antipsychotics on Health and Quality of Life for People with Dementia

项目总结 抗精神病药物经常被开给患有阿尔茨海默病和相关痴呆的老年人(ADRD) 用于治疗行为症状，但临床指南建议应限制它们在这一人群中的使用，因为 有可能产生不良副作用。最近，干预利用了行为经济学的工具。 比如通过信件和电子邮件的“催促”来提高处方质量。组织可以部署这些 快速、廉价和大规模的干预。然而，几乎没有证据表明利用这项工作来解决 给ADRD患者开抗精神病药物处方，尽管它在这方面可能有巨大的潜在价值 背景。此外，即使有证据表明干预措施成功地导致了“停药”，考虑到 尽管不分青红皂白地削减开支可能会对患者造成伤害，但这些干预措施值得仔细评估。 我们提出的研究试图填补这一证据空白。我们将分析中心进行的一项新的试验 Medicare和Medicaid Services随机调查了5000多名大容量初级保健医生的处方 奎硫平，美国最常用的抗精神病药物，过度开出由行为告知的信件 经济学。这些信件包含了同龄人比较的“轻推”和过度使用的警告，而且它们减少了新的 奎硫平的起始量在两年内增加了24%。我们的工作重点是这些信件对临床质量的影响， 这些医生对痴呆症患者的生活质量和保健利用情况进行了调查。医生们有超过4万名医生 ADRD患者，这是一个大型队列，将有助于发现停药的好处和危害。我们 将利用丰富的医疗保险数据，包括疗养院评估和医疗保健索赔，并将研究影响 最长可达5年。 我们将分三步走。在目标1中，我们将分析干预对ADRD患者的影响 住在疗养院的处方医生，这是一个特别脆弱的群体，对他们来说，患者的大量数据- 可以获得以结果为中心的结果。通过这些数据，我们将密切跟踪临床和生活质量结果， 包括认知功能、行为症状和抑郁。在目标2中，我们将把分析范围扩大到 包括居住在社区的痴呆症患者，使用索赔数据来跟踪对健康结果的影响，如 如高脂血症和中风，以及住院和初级保健就诊等医疗保健用途。 最后，在目标3中，我们将测试这些字母对患者的影响是否基于护理环境的不同， 社会人口统计群体，或疗养院质量；这些结果将显示字母是寻址还是扩展 在护理质量方面存在差距，并将确定哪些群体(如果有的话)适合今后采取类似的干预措施。 综上所述，我们的结果将表明，简单的、行为知情的停药努力是否可以鼓励 指南--协调一致的护理并改善痴呆症患者的预后，或者此类干预是否会导致 造成意外的伤害。我们的发现将指导未来部署低成本和可扩展干预措施的政策 提高老年ADRD患者的护理质量。

PROJECT SUMMARY Antipsychotics are frequently prescribed to older adults with Alzheimer’s disease and related dementias (ADRD) to treat behavioral symptoms, but clinical guidelines suggest their use should be limited in this population due to the possibility of adverse side effects. Recently, interventions have harnessed tools of behavioral economics such as “nudges” through letters and e-mails to raise prescribing quality. Organizations can deploy these interventions quickly, cheaply, and at scale. However, little evidence exists on using this work to address antipsychotic prescribing to patients with ADRD in spite of the enormous potential value it could have in this context. Moreover, even where evidence exists that interventions successfully cause “deprescribing”, given the possibilities for patient harms from indiscriminate cutbacks, these interventions merit careful evaluation. Our proposed study seeks to fill this evidence gap. We will analyze a novel trial conducted by the Centers for Medicare and Medicaid Services that randomized over 5,000 high-volume primary care physician prescribers of quetiapine, the most commonly used antipsychotic in the U.S., to overprescribing letters informed by behavioral economics. The letters included a peer comparison “nudge” and an overuse warning, and they reduced new initiations of quetiapine by 24% over two years. Our work focuses on the effects of these letters on clinical quality, quality of life, and health care use of dementia patients of these physicians. The physicians had over 40,000 patients with ADRD, a large cohort that will facilitate detection of both benefits and harms of deprescribing. We will exploit rich Medicare data, including nursing home assessments and health care claims, and will study effects for up to 5 years. We will proceed in three steps. In Aim 1, we will analyze effects of the intervention on ADRD patients of study prescribers who live in nursing homes, a particularly vulnerable population for whom extensive data on patient- centered outcomes is available. Through this data, we will closely track clinical and quality of life outcomes, including cognitive function, behavioral symptoms, and depression. In Aim 2, we will broaden our analyses to include dementia patients who live in the community, using claims data to track effects on health outcomes such as hyperlipidemia and stroke and health care use such as inpatient hospitalizations and primary care visits. Finally, in Aim 3 we will test whether effects of the letters differ for patients based on care setting, sociodemographic group, or nursing home quality; these results will show whether letters address or expand gaps in care quality and will determine which groups, if any, are appropriate for similar interventions in the future. Taken together, our results will show whether simple, behaviorally informed deprescribing efforts can encourage guideline-concordant care and improve outcomes for patients with dementia, or whether such interventions lead to unintended harms. Our findings will guide future policy on deploying low-cost and scalable interventions to improve the quality of care for older adults with ADRD.