Reducing Off‐Label Antipsychotic Use in Older Adults: Time to Look Beyond the Doors of Nursing Homes

The vexing problem of off-label use of antipsychotics in nursing homes continues to challenge the industry. Food and Drug Administration black box warnings in 2005 and 2008 about the serious adverse effects of offlabel use of antipsychotics in older adults had little effect on the prevalence of antipsychotic use in nursing homes. The 2011 Department of Health and Human Services Officer of Inspector General report noted that 83% of Medicare claims for atypical antipsychotic drugs for nursing home residents were associated with off-label conditions and 88% with dementia. In response, the Centers for Medicare and Medicaid Services (CMS) launched a national initiative to reduce atypical antipsychotic use in nursing homes. The partnerships and other administrative initiatives are working, with a 35% relative reduction in the use of antipsychotics in nursing homes since the launch of the initiative (from 23.9% in fourth quarter 2011 to 15.5% in second quarter 2017). As new, ambitious targets for reductions in off-label antipsychotic use are set for nursing homes, the Government Accountability Office has called for expansion beyond nursing homes to other settings. In this issue of the Journal of the American Geriatrics Society, Zhang and colleagues provide novel data to inform expanded efforts by evaluating where antipsychotics prescribed in nursing homes were first initiated. In their study, which included 454 nursing homes and 10 skilled nursing facilities in Iowa between 2011 and 2014, they identified nearly 7,500 residents with antipsychotic use documented, of which 42% was deemed potentially inappropriate. The majority of use appeared to be initiated in the nursing home. Some may question whether the findings from this study conducted in Iowa are representative of the United States—perhaps not. In Iowa, activities conducted as part of the CMS National Partnership have resulted in a 33.2% relative reduction in antipsychotic prevalence which exceeded the CMS National Partnership goals. In the second quarter of 2017, the prevalence of antipsychotic use in Iowa in long-stay residents was 14.9%, down from 22.3% from the fourth quarter of 2011. The tremendous efforts in Iowa to reduce off-label antipsychotic use may mean that a smaller proportion of nursing home residents in Iowa have antipsychotics initiated in the nursing home, yet we should not let concerns about generalizability dismiss this important work. Zhang and colleagues have provided rare insights into a dimension of the off-label antipsychotic saga that to date have remained unknown. The data that Zhang and colleagues present suggest there are other settings in which intervention efforts may be fruitful to reduce off-label use of antipsychotics in older adults. The authors report that 18.6% of nursing home residents receiving antipsychotics initiated them in the hospital. Physicians initiating antipsychotics in hospitals may have envisioned a short-term course of therapy for their patients, but the transfer of individuals to nursing homes without information regarding clinical indication may lead to antipsychotic use in the nursing home setting in perpetuity. Hospital data also support the notion that the inpatient setting (or transition from inpatient to nursing home) may be a logical point of intervention. Of individuals aged 65 and older discharged to a nursing home, 6% had an antipsychotic initiated during the hospital stay (estimates from the 85 hospitals included ranged from 0% to 15.4%), and 70% had an order in place on the day of hospital discharge. Testing of a hospital-based quality indicator targeting antipsychotics in the hospital setting is underway by CMS, with initial support of such a measure received in the public comment period and constructive feedback regarding suggested improvements for the measure. Given that few states reporting best practices as part of the CMS National Partnership to Improve Dementia Care in Nursing Homes indicated that they engaged hospitals, the roll-out of a hospital-based quality indicator targeting initiation of antipsychotics may provide impetus to engage hospitals in the efforts to reduce off-label antipsychotic use in older adults. Concern over potentially inappropriate antipsychotic use beyond nursing homes and hospitals is also warranted. Zhang and colleagues estimated that 17.5% percent of antipsychotics were initiated in outpatient settings. In Taiwan, one in four older adults attending outpatient visits for dementia received antipsychotics. In the United States, overall use of second-generation antipsychotics for dementia decreased from 11% in 2006 to 8% in 2012. The most common off-label use was for dementia, and the proportion of off-label use for this purpose increased during this time period (2006, 35.8%; 2012, 41.9%). These data suggest that outpatient off-label antipsychotic use in older adults is problematic as well. Zhang and colleagues were unable to estimate the proportion of antipsychotic use in nursing homes initiated in assisted living facilities, which are regulated at the state This editorial comments on the article by Zhang et al.

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