by Tim Gieseke, MD, CMD

On May 31, the California Department of Public Health released the above study.  This report follows the Department of Health and Human Services Office of Inspector General (OIG) May 2011 report on Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents.  In that report, potentially inappropriate use of antipsychotics was defined as off-label use (FDA approval only for Schizophrenia and Bipolar Disorder) or use despite a black box warning (e.g.  Not indicated for Dementia).  Their review of prescribing from January 1 through June 30, 2007 found:

• 14% of nursing home residents were prescribed at least 1 antipsychotic
• 20% of all Medicare Rx for antipsychotics were for NH residents
• 83% of Rx was for off label indications
• 88% of Rx was associated with a condition specified in the black box warning
• 51% of claims were erroneous
• 22% were not administered in accordance with federal regulations for nursing homes

The California DPH has had similar concerns that led to this just released collaborative study.  Nationwide, 27.6% of nursing home residents receive antipsychotics.  Of these, more than half (58%) represent inappropriate use as defined by CMS.
Beginning in May 2010, the collaborative conducted 42 on-site surveys in California nursing homes based on DHCS claims data indicating dual-eligible (Medi-Medi) residents who were prescribed two antipsychotic medications or at least one antipsychotic medication in a resident with a diagnosis of dementia.  These surveys were considered “complaint” investigations, even though no actual complaint had been made in any of these cases.  CDPH found:

• In 85% of investigations, the consulting pharmacist failed to identify and notify facility of the inappropriate antipsychotic use.
• In 62% of the facilities, the pharmacist consultant services were below cost (State regulations forbid facilities from receiving services below cost)
• 55% of nursing care plans for antipsychotic use was inadequate
• 48% had inadequate compliance to informed consent regulatory requirements (See link to AFL April 2011)

This report recommends:

• Expansion of collaborative targeting residents who meet criteria for inappropriate antipsychotic use.
• Expanded training of surveyors with new survey tool for identifying potential inappropriate antipsychotic drug use to be completed by August 1, 2012
• Use of MDS 3.0 Data to target facilities with a high rate of antipsychotic medication use.
• Expanded education for nursing home personnel using collaborative interventions with multiple stakeholder organizations like CALTCM and CAHF

At CALTCM, we encourage an interdisciplinary approach to problem behaviors. The usual first step should be to understand the root cause of these behaviors.  In most cases, this provides an effective approach that maximizes safer non-pharmacologic approaches, and ensures safe and appropriate use of psychotropic meds.   Please see the last WAVE for a helpful facility tool.  In addition, on June 14, 2012 the President of AMDA sent out a helpful letter on this subject.

There is no doubt that all of us in long-term care support the goal of reducing unnecessary use of these dangerous medications, but we also need to balance the risks with the known benefits of these agents in reducing psychotic symptoms and distress in selected residents.  Informed consent must be obtained when we do choose to use these medications in situations where they are indeed necessary.   We must all work together to ensure that the best interests of the vulnerable patients under our care are met, and that they receive what they need, and don’t receive what they don’t need.

Reports and Letters mentioned in this article:
CDPH Report
OIG Report
AFL April 2011
June Wave facility tool
AMDA letter