District nursing homes win high marks for quality, but antipsychotic prescribing remains problematic
The District of Columbia Department of Health (DOH) has released a study by the George Washington University School of Public Health and Health Services (SPHHS) investigating prescribing of antipsychotics to District seniors. The study combines pharmaceutical marketing data collected by the District with publicly available data on nursing home quality and Medicare drug claims.
"The good news is that nursing homes in the District of Columbia generally are not prescribing antipsychotic medication at rates higher than the rest of the country," says Susan F. Wood, PhD, lead researcher and an associate professor of health policy and of environmental and occupational health at SPHHS. "However, there are still concerns that District providers are too quick to prescribe these drugs to District seniors and Medicaid beneficiaries."
Antipsychotics are one of the top-selling drug classes, despite widely reported side effects that include weight gain and sedation. Elderly patients suffering from dementia or agitation may be dosed with antipsychotics for their sedative effects, an off-label use that raises ethical questions. Use of antipsychotics puts seniors at increased risk of serious adverse events, including cognitive decline, hip fractures, and death.
"Senior citizens living in the District of Columbia are the city's most vulnerable population," said Dr. Joxel Garcia, Director, DC Department of Health. "The Department of Health will continue to invest in educating physicians on effective use of antipsychotic medications to provide the better health outcomes for all District residents."
The report fulfills the requirement of a 2004 law in the District of Columbia that requires pharmaceutical companies to file annual reports describing their prescription-drug marketing activities in the District. The AccessRx Act also requires analysis of these reports to determine how pharmaceutical marketing may affect healthcare services in the District.
SPHHS researchers searched District of Columbia marketing data for reports of drug-company gifts made in 2007 - 2011 to physicians who currently serve as nursing home medical directors. The search was done to see if pharmaceutical companies were targeting marketing efforts at the medical directors of nursing homes. The report found that nine of the district's 19 nursing home medical directors received no gifts from pharmaceutical companies between 2007 and 2011. Three received cash or checks for speaking or consulting, which totaled $34,639 over five years. Only four received gifts totaling over $1,000 in at least one of the years studied; six received gifts, mostly food or books, totaling $100 to $800 in at least one year.
The study also examined nursing home quality ratings and rates of antipsychotic prescriptions across eight wards in the district, using ratings from the Nursing Home Compare website run by the Centers for Medicare and Medicaid Services (CMS). Thirteen of the District's 19 nursing homes received above-average ratings (four or five stars) for overall quality. The two nursing homes with the lowest ratings (two stars, or "below average") are both located in Ward 7.
Nursing Home Compare also reports the percentage of short-stay nursing home patients receiving new antipsychotic prescriptions and the percentage of long-stay patients receiving antipsychotic medications. In the District, seven out of 18 nursing homes have above‐average prescribing rates for short‐stay patients, and six out of 19 have above‐average rates of long‐stay patients taking antipsychotics. (Average US rates are 2.7 percent for short-stay patients and 22.4 percent for long-stay patients.)
Researchers also examined data on prescriptions of antipsychotics for Medicare Part D patients, the majority of whom are seniors. The SPHHS report compiles information on 67 District providers who wrote antipsychotic prescriptions for large numbers of Part D patients. Nearly one-third (22 of 67) of these prescribed at least one antipsychotic to 70 percent or more of their Part D patients.
"Many doctors in the District write significant numbers of prescriptions of antipsychotic medication to Medicare patients. This provides a window into prescribing practices here," says Adriane Fugh-Berman, MD, a co-author of the report and an associate professor of pharmacology and physiology at Georgetown University Medical Center.
"As we noted in an earlier report for the Department of Health, the District has a very high percentage of Medicaid beneficiaries receiving antipsychotic medications," Wood says. Data released by CMS just after this report was written indicate that nearly 11 percent of the District's Medicaid beneficiaries filled antipsychotic prescriptions in 2009. "High rates of prescribing antipsychotics, whether to children or elders, raises concerns about the quality of care provided to low-income District residents and the role of pharmaceutical marketing in prescribing practices."
The study can be found on the D.C. Department of Health Website by clicking here.