The Society and ASCP Issue Joint Letter on Antipsychotics in the Nursing Home to House Ways and Means
AMDA – The Society for Post-Acute and Long-Term Care Medicine and the American Society of Consultant Pharmacists (ASCP) have issued a joint letter in response to a House Ways Means Committee inquiry made by Chairman Richard Neal (D-MA) on the utilization of antipsychotics in the nursing home.
The groups state that while they share in the chairman’s concerns on the inappropriate use of antipsychotics, it is important to note that “the important decision to reduce and/or eliminate medications is one based on diagnosis, evidence, and thorough evaluation of patient welfare. Incorporating medication recommendations from consultant pharmacists and medical directors has been an effective instrument in reducing the inappropriate use of medications, but there are inconsistencies within the current regulatory framework that does not provide a clear path to appropriate antipsychotic documentation and management.”
They note that while diseases such as schizophrenia, Huntington's Disease, or Tourette’s Syndrome are excluded from conditions that count toward antipsychotic use tracking by the Centers for Medicare & Medicaid Services (CMS), it is very “important to note that these conditions are not the only U.S. Food and Drug Administration (FDA) approved indications for necessary antipsychotic use.” The letter states that “Many people living in nursing homes suffer from perceptual and behavioral psychotic disturbances. Patients may suffer from major depression, bipolar disorder, Parkinson’s Disease psychosis, and traumatic brain injury. Some medications for nausea and vomiting happen to fall into the antipsychotic drug class due to their chemical structures. However, since these conditions are not currently exempted under CMS regulations, the data interprets their treatment as unnecessary or inappropriate, when in most cases they are indicated, appropriate, and effective.”
The groups also state that the current quality metrics for antipsychotic are often confusing and do not account for best patient care and clinical rationale. The groups further note that there is currently no mechanism to adjust the quality metrics for antipsychotic use based on facility size, location, or specialty. Based on the current quality metric, rural nursing homes may only have 50 nursing home beds, but because the quality metric is based on percentage, their five patients suffering from bipolar disorder appears to be a bigger issue than a large urban facility with double the amount of patients taking antipsychotics. In both cases, care is appropriate, but the quality metric makes the facility look worse.
In addition, the letter noted that with a rapidly aging population the “number of patients suffering from psychosis will grow as well as the frequency at which skilled nursing home beds will be occupied, so the percentage of patients successfully managed with antipsychotic medications will rise rather than fall. The current quality metric indicates that ‘lower is better’ which fails to adjust for the changing dynamic that patients are cared for in nursing facilities. This will, again, confuse the public and create situations where it may appear a skilled nursing facility is providing worsening care.”
The House Ways and Means Committee is continuing to examine the issue of antipsychotic in the nursing home and the Society will continue to stay engaged with them as they finalize their work.
Click here to read the letter in its entirety.