Schizophrenia diagnosis rises among Black nursing home residents following start of Medicare initiative

Racial and ethnic disparities in the quality of care nursing home residents receive is a serious and known problem in the United States. To increase overall patient quality of care, the Centers for Medicare & Medicaid Services (CMS) instituted policies to discourage using sedating antipsychotic drugs to control the behavior of residents with dementia and limit the use of the medication to those with additional specific conditions including schizophrenia. Now, new research led by a researcher at the University of Minnesota School of Public Health reveals an increase in the number of schizophrenia diagnoses among Black nursing home residents with dementia following the start of the policies, raising the potential of treating them with antipsychotic drugs and the existence of systemic racism.

The study, recently published in the Journal of the American Geriatrics Society, was led by Assistant Professor Shekinah Fashaw-Walters when she was a Ph.D. student at Brown University.

The researchers analyzed 2011-2015 Medicare data for 1.2 million long-stay residents aged 65 years and older across nearly 16,000 U.S. facilities. In 2012, CMS implemented an initiative to improve quality across nursing homes and for residents with Alzheimer's disease and related dementia (ADRD), known as the National Partnership to Improve Dementia Care in Nursing Homes. The initiative was a federal response to the continued potentially inappropriate use of antipsychotics in nursing homes, and directed facilities toward non-medicated, person-centered care. With the new policy, nursing homes receive lower ratings for using antipsychotic drugs on patients outside of those who have conditions such as schizophrenia, Tourette Syndrome or Huntington's disease.

The researchers found:

• Among residents without ADRD, Black residents had higher rates of schizophrenia diagnoses compared to their nonblack counterparts prior to the initiative.
• After instituting the policy/initiative, Black residents with ADRD had a significant increase of 1.7% in schizophrenia as compared to non-Black residents with ADRD, who had a decrease of 1.7%.

The researchers say the increase in schizophrenia diagnosis following the start of the new policy raises questions.

"We need to determine if this uptick is related to nursing home dependence on or the use of antipsychotic drugs or if it is related to an actual rise in the rates of schizophrenia—which is usually diagnosed before the age of 40—not later in life while someone is in the nursing home," says Fashaw-Walters.

Fashaw-Walters says the results suggest that further research is needed to examine the impact of the CMS requirements to determine if they are exacerbating racial and and ethnic care inequities and to determine if schizophrenia diagnoses are appropriately applied in nursing home practice, particularly for Black Americans with ADRD.