On August 27, 2013, the Centers for Medicare & Medicaid Services (CMS) released data illustrating that nursing homes have significantly decreased the use of antipsychotic drugs. The use of antipsychotic drugs in nursing homes has garnered the attention of the U.S. Department of Justice, the Department of Health and Human Services (HHS) Office of the Inspector General (OIG) and CMS for years. Recently, these government regulators announced plans to increase the scrutiny of antipsychotic drugs in nursing homes.
Among the concerns of the federal government is the safety of those residents who are prescribed antipsychotics “inappropriately.” The newer, second generation antipsychotic drugs are known as “atypical antipsychotic drugs.” The atypical antipsychotic drugs, like their predecessors, have routinely been prescribed to treat dementia, depression and agitation. However, such practices are considered “off-label” because antipsychotic drugs are not approved by the Food and Drug Administration (FDA) for those clinical conditions. (Antipsychotics are approved for the treatment of schizophrenia and bipolar disorder.) The FDA has required its strongest safety warning, known as a “Black Box Warning” for atypical antipsychotic drugs because of the increased risk of death associated with their use.
The prevalence of antipsychotic drug use in nursing facilities cannot be overstated. Nearly one in three nursing home residents received antipsychotics in 2006. According to Daniel R. Levinson, HHS Inspector General, “OIG has found that all too often, nursing home patients receive antipsychotic drugs in ways that violate federal standards designed to prevent overmedication and inappropriate use.”1 A July 2012 investigation by OIG revealed that almost all of the records reviewed for nursing facility residents receiving atypical antipsychotic drugs failed to meet all federal requirements.2 Adding to the OIG’s concerns is the fact that 304,983 residents had Medicare claims amounting to $309 million for atypical antipsychotics in the first half of 2007.3
According to CMS, more than 17% of all nursing home residents had daily doses of antipsychotics drugs that exceeded recommended levels. As a consequence of the widespread and dangerous use of antipsychotic drugs in nursing homes, in 2012, CMS initiated the National Partnership to Improve Dementia Care (Partnership). Its goal is to reduce antipsychotic drug use by 15% by the end of 2013.
The recent news from CMS is both welcome and promising. The data reveal that approximately 30,000 fewer nursing home residents are receiving antipsychotic drugs compared to the pre- Partnership levels. According to CMS, the national prevalence of antipsychotic drug use for long-stay residents has decreased by 9.1% for the first quarter of 2013. Additionally, CMS notes that eleven states have already reduced antipsychotic use in nursing homes by 15% or more, evidencing the effectiveness of the Partnership.4
There are a number of important reasons to reduce antipsychotic use. First and foremost, there is a risk that many residents will die and succumb to other illnesses if administered these drugs. A distant second is the fact the CMS has issued new guidance to its surveyors regarding its increased focus on antipsychotics. Surveyors will examine, among other criteria, whether a facility failed to either discontinue the drug or wean residents to the lowest therapeutic dose by a gradual dose reduction. Additionally, in its 2013 Work Plan, the OIG announced a new initiative whereby it will investigate the percentage of residents receiving atypical antipsychotics and the types of drugs most commonly received.
Nursing facilities can measure their progress at reducing antipsychotic drug use on the CMS Nursing Home Compare website.5 CMS posts the percentage of both short-stay and long-stay residents that receive antipsychotic drugs at every nursing facility. Additionally, CMS lists the average for every state and the national average for both short and long-stay residents.
Numerous resources exist to assist nursing facilities in reducing antipsychotic drug use. Apart from CMS’ substantial online resources, many national and state organizations have created initiatives aimed at reducing antipsychotic drug use. Among those highly recommended and worthy of consideration are the programs and resources of the America Health Care Association, the American Medical Directors Association and Advancing Excellence in America’s Nursing Homes.6