Mood Stabilizer Use Among Long-Term Care Patients Declines Following CMS Program

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Prior to the start of the partnership, psychotropic use had demonstrated patterns of decline among patients receiving nursing care.
Prior to the start of the partnership, psychotropic use had demonstrated patterns of decline among patients receiving nursing care.

Authors of an interrupted time-series analysis published in JAMA Internal Medicine report that the initiation of the Centers for Medicare & Medicaid Services' National Partnership to Improve Dementia Care in Nursing Homes was associated with increased use of mood stabilizers among long-term care residents between 2009 and 2014. Additionally, initiation of the partnership may have accelerated the decline in antipsychotic prescriptions observed prior to partnership implementation.

A total of 637,426 fee-for-service patients receiving long-term nursing home care (≥100 days) were enrolled in the study. Investigators evaluated the association between initiation of the partnership and prescribing practices for antipsychotic and non-antipsychotic psychotropic medications (ie, antidepressants, benzodiazepines, mood stabilizers [valproic acid and carbamazepine], and other anxiolytics or sedative-hypnotics).

Prior to the start of the partnership, psychotropic use demonstrated patterns of decline among patients receiving nursing care. Conversely, the rate of mood stabilizer use steadily increased before partnership initiation and subsequently accelerated after initiation (rate, 0.22%; 95% CI, 0.18%-0.25%; P <.001; rate change, 0.14%; 95% CI, 0.10%-0.18%; P <.001).

During the first 3 months of partnership adoption, 21.3% of participants were prescribed antipsychotic medications. The quarterly rate of decline until initiation of the partnership was -0.53% (95% CI, -0.63% to -0.44%; P <.001). Following the start of the partnership, the quarterly decline rate was -0.29% (95% CI, -0.39% to -0.20%; P <.001), which represented a postpartnership slowing of 0.24% per quarter (95% CI, 0.09%-0.39%; P =.003). By the final quarter of 2014, the use of antipsychotic medications had fallen to 11.5%.

Similar to antipsychotics, antidepressant use also declined prior to and following partnership initiation, a decrease that appeared to slow between period 1 (prior to partnership initiation) and period 2 (after partnership initiation) (rate change, 0.34%; 95% CI, 0.18%-0.50%; P <.001).

The strict inclusion of patients with only continuous fee-for-service and Part D Medicare coverage limits the generalizability of these findings.

Further initiatives “focused on improving psychotropic prescribing for patients with dementia should monitor use of other psychotropics — including mood stabilizers — as well as consider how to measure and incentivize structured, evidence-based, nonpharmacologic alternatives.”

Reference

Maust DT, Kim HM, Chiang C, Kales HC. Association of the Centers for Medicare & Medicaid Services' National Partnership to Improve Dementia Care with the use of antipsychotics and other psychotropics in long-term care in the United States from 2009 to 2014 [published online March 17, 2018]. JAMA Intern Med. doi: 10.1001/jamainternmed.2018.0379

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