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Nursing Home Characteristics Associated with High and Low Levels of Antipsychotic, Benzodiazepine, and Opioid Prescribing to Residents with Alzheimer’s Disease and Related Dementias: A Cross-Sectional Analysis

  • Molly Candon
    Correspondence
    Address correspondence to Molly Candon, PhD, Penn Center for Mental Health, Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Room 3014, Philadelphia, PA 19104, USA.
    Affiliations
    Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA

    Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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  • Julie Strominger
    Affiliations
    Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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  • Evelyn Gotlieb
    Affiliations
    Icahn School of Medicine at Mount Sinai, New York, NY, USA
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  • Donovan T. Maust
    Affiliations
    Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA

    Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA

    Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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      Abstract

      Objectives

      We examined the association between nursing home (NH) characteristics and whether NHs had high or low levels of antipsychotic, benzodiazepine, or opioid prescribing to residents with Alzheimer’s disease and related dementias (ADRD). We then measured the likelihood that NHs who were high (low) prescribers of antipsychotics were also high (low) prescribers of benzodiazepines or opioids.

      Design

      A retrospective, cross-sectional analysis.

      Setting and Participants

      The sample included 448,128 Medicare beneficiaries diagnosed with ADRD, who resided in 13,151 NHs in 2017.

      Methods

      Using Medicare claims, the Minimum Data Set, and LTCFocus, we measured the share of NH residents with ADRD who filled ≥1 antipsychotic, benzodiazepine, or opioid prescription in 2017. Using linear probability models with state-clustered SEs, we identified which NH characteristics were associated with being in the top (bottom) quartile of the prescribing distribution for each drug class. Finally, we measured whether NHs who were top-quartile (bottom-quartile) antipsychotic prescribers were more likely to be top-quartile (bottom-quartile) benzodiazepine or opioid prescribers.

      Results

      Across NHs, an average of 29.1% of residents with ADRD received an antipsychotic, 30.2% received a benzodiazepine, and 40.9% received an opioid. Smaller NHs and NHs with a larger share of Medicaid-enrolled residents were more likely to be top-quartile prescribers; NHs with more registered nursing care were more likely to be bottom-quartile prescribers. Antipsychotic prescribing tracked closely with benzodiazepine prescribing, but not opioid prescribing.

      Conclusions and Implications

      The overlap between antipsychotic and benzodiazepine prescribing and our finding that some NH characteristics were consistently associated with prescribing across drug classes may support the idea of an organizational culture of prescribing in NHs, which could inform efforts to improve prescribing quality in NHs. Our results also highlight benzodiazepine and opioid use for ADRD, which were more commonly prescribed than antipsychotics in NHs but have received less regulatory attention.

      Keywords

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