We indentified 16,586 long-stay NH residents who were newly-admitted to 1,257 NHs in 2006. The facility-level antipsychotic prescribing rates of these NHs in the preceding year ranged from 0%–24.4% in Q1 to 43.8%–100% in Q5. About 30% (5,005) of all residents received at least one antipsychotic medication in 2006. Residents with psychosis (n=972) had the highest level of use with 77% using at least one antipsychotic, followed by residents with dementia and no psychosis (43%, n=2,694) and then residents without dementia or psychosis (17%, n=9,426). () About 32% (1,605/5005) of antipsychotics were dispensed to residents without any clinical indication.
describes the study NHs by their antipsychotic prescribing rates quintiles in 2005. Comparing Q5 and Q1 NHs, we found that a higher proportion of Q5 NHs were more likely to be located in the South and have fewer than 250 residents. A higher proportion ofQ1 NHs were located in the Mid-West, and had more than 250 residents.
Characteristics of nursing homes by facility-level antipsychotic prescribing rate
describes the study population by quintiles of facility-level antipsychotic prescribing rates. Compared to residents in Q5 NHs, those in Q1 NHs tended to be older (age > 75: 75% vs. 59%, p<0.001), female (69.4% vs. 60.9%, p<0.001), and white (85% vs. 71.9%, p<0.001). More residents in Q1 NHs were frail (CHESS 3–5: 24.7% vs. 14.0%, p<0.001) and had a higher CPS score (CPS 0–1: 39.2% vs. 31.4%, p<0.001) than residents in Q5 NHs. More residents in Q5 NHs had moderate or severe behavioral problems (Behavioral Index moderate/severe: 23.5%vs. 12.6%, p<0.001), dementia (52.3% vs. 41.4% p<0.001) and psychosis (10.3% vs. 4.0% p<0.001), as compared to those in Q1 NHs.
Facility-level antipsychotic prescribing rate quintile by resident characteristics
shows the distribution individual characteristics between antipsychotic users and non-users. Residents who were prescribed antipsychotic medications were younger (age ≥ 65: 13.8% vs. 10.1%; 66–75: 20.1 vs. 18.7, p<0.001), male (37.8% vs. 33.9%, p<0.001) and less frail (CHESS score of 0: 25.1% vs. 17.4%, p<0.001) as compared to those who were not on antipsychotics. Antipsychotics tended to be given to residents with moderate and severe behavioral problems (32.3% vs. 8.5%, p<0.001), dementia (68.7% vs. 36.5%, p<0.001) and psychosis (15.1% vs. 1.9%, p<0.001).
Resident-level use of antipsychotics by resident characteristics
The association between resident use of antipsychotics and facility-level prescribing rates in the full sample is shown in . Residents in Q5 NHs had nearly double the relative risk (RR)of receiving antipsychotics (Model 1: RR=1.94, 95% Confidence Interval [CI]: 1.75–2.15) compared to residents in Q1 NHs. Adjusting for NH characteristics did not change the magnitude of the association (Q5 vs. Q1 Model 2: RR=1.91, 95%CI: 1.71–2.13). Adjusting for demographics and health status, reduced the RR (Q5 vs. Q1 Model 3: RR=1.62, 95% CI: 1.46–1.80). The RR was further reduced after controlling for potential indication of antipsychotics; however, compared with residents in Q1 NHs, those in Q5 NHs still had higher risk of being prescribed antipsychotics (Model 4, RR=1.34, 95% CI: 1.22–1.47).
Adjusted relative risks of resident-level use of antipsychotics by facility-level antipsychotic prescribing rate, according to resident clinical subgroups **
also shows that antipsychotic use across the quintiles of facility-level prescribing rates varied by clinical subgroups. Among the residents with psychosis, antipsychotic use did not vary significantly across quintile sin the full model. After adjusting for all covariate sets (Model 4 for psychosis), the RR forQ5 to Q1 NHs was 1.10 (95% CI, 0.96–1.25).
However, facility-level prescribing quintile did predict use of antipsychotics for the two other clinical subgroups. For residents with dementia and no psychosis, those residing in Q5 NHs were more likely to be prescribed antipsychotics (Model1: RR=1.62; 95% CI: 1.43–1.78) relative to those in Q1 NHs, and the magnitude and significance of RR changed little after adjusting for facility characteristics (Model 2: RR=1.56, 95% CI 1.38–1.77), and then for demographics and health status (Model 3: RR=1.47, 95% CI 1.29–1.66). After adjusting for Behavioral Index, the RR was still significant (Model 4: RR=1.37, 95% CI 1.21–1.54).
Among the residents without psychosis or dementia, facility-level prescribing quintile was significantly associated with use of antipsychotics (Q5 vs. Q1 Model 1: RR=1.76, 95% CI: 1.43–2.17). After full adjustment the association remained statistically significant (Q5 vs. Q1 Model 5: RR=1.51; 95% CI: 1.23–1.86).