tinuously in a nursing home (NH) throughout the year, July. 1975 through June 1976. ... icaid program's 1976 annual NH inspection provided NH characteristics: ...
A Study of Antipsychotic Drug Use in Nursing Homes: Epidemiologic Evidence Suggesting Misuse WAYNE A. RAY, MS, CHARLES F. FEDERSPIEL, PHD, AND WILLIAM SCHAFFNER, MD
Abstract: We reviewed 384,326 prescriptions for 5,902 Medicaid patients residing continuously for one year in 173 Tennessee nursing homes. Of these patients, 43 per cent received antipsychotic drugs; 9 per cent were chronic recipients (received at least 365 daily doses per year). Of the 1,580 physicians who cared for these patients, 42 per cent prescribed antipsychotic medication. Physicians with large nursing home practices (10 or more patients) prescribed 81 per cent of the total antipsychotic medication, and were usually family practitioners (78 per cent) and in rural practice (47 per cent). As nursing home practice size increased, doctors prescribed more drug per patient (p < .001). Wide variation in antipsychotic drug use occurred
The prescribing of antipsychotic drugs for patients in nursing homes is controversial. The powerful tranquilizing effect of these drugs* has led to their use among the aged for the control of both disruptive behavior and nocturnal restlessness. Yet, these agents have major mental and physical side-effects: they decrease alertness, may increase confusion, and can cause toxic psychosis' 2 as well as irreversible tardive dyskinesia3-5, and other adverse effects." 6 7 Most authorities discuss the use of antipsychotic medication in the elderly patient with mental illness.8-" Although these drugs are used to treat both acute behavioral disorders or chronic disturbed behavior resulting from dementia, opinions differ as to the appropriate indications for antipsychotic drug use. Several authorities state these drugs should be reserved for acute conditions and discontinued as soon as possible, concluding that the risks of long-term therapy outweigh the benefits for the elderly.2 7.10,12 In contrast, one author has suggested that antipsychotic drugs be given to improve the emotional state of aged patients in nursing homes,'3 and another that the drugs be added "to the tea or soup" to manage confused patients. ' Widely circulated anecdotal reports in both the medical and lay press that antipsychotic drugs are indiscriminately used to fit patients into From the Division of Biostatistics, Department of Preventive Medicine, and the Department of Medicine, Vanderbilt University School of Medicine. Address reprint requests to Mr. Wayne A. Ray, Vanderbilt University School of Medicine, Nashville, TN 37232. This paper, submitted to the Journal August 10, 1979, was revised and accepted for publication December 12, 1979. *In the Tennessee Medicaid program, the most frequently used drugs are thioridazine (Mellaril0), chlorpromazine (Thorazinet'), and haloperidol (Haldol0).
AJPH May 1980, Vol. 70, No. 5
among nursing homes; the chronic recipient rate ranged from 0 to 46 per cent. More drug was given per patient in larger homes (r = .18, p < .05). Typically, one physician (the "dominant" physician) provided care for the majority of a nursing home's patients. The proportion of a home's patients seen by the dominant physician was correlated with the chronic recipient rate (r = .17, p < .05). These findings provide epidemiologic evidence suggesting misuse of antipsychotic drugs in nursing homes. They illustrate the need for investigations of techniques for patient management in nursing homes which rely less upon psychtropic drugs. (Am J Public
Health 70:485-491, 1980.)
nursing home routine ("chemical strait jackets") have amplified the controversy.2' 1 5-1'7 We have employed claims-files of the Tennessee Medicaid program to provide objective data pertinent to this controversy. Unlike previous studies of drugs received in nursing homes,I8-20 the Medicaid data base permits longitudinal study of large, heterogeneous populations of non-psychiatric patients, and the facilities and physicians caring for them.2'
Materials and Methods The subjects were Medicaid recipients who resided continuously in a nursing home (NH) throughout the year, July 1975 through June 1976. This definition excluded individuals who entered the home during the year and those persons who died or left the home for any reason. Also excluded were all patients in homes which specialized in psychiatric care. Information recorded in Medicaid files included NH identifying number, period of stay, race, original county of residence, and date of birth.2' Each subject was matched with an ambulatory person enrolled in Medicaid throughout the study year. Matching was on the basis of race, sex, type of county of residence (urban, intermediate, rural), and age (within 5 years). The comparison group provided a benchmark for analysis of drug use among nursing home patients. It is not a control group because of the potentially greater morbidity among nursing home patients. The Tennessee Medicaid program reimburses for almost all legend drugs (available by prescription only). Profiles of drug use were compiled from pharmacy claims for patients 485
ANTIPSYCHOTIC DRUG USE IN NURSING HOMES
and the comparison group during the study year. The profiles recorded patient identifying number, prescribing physician number, and drug type and quantity.21 Drugs dispensed were classified by therapeutic category with a previously developed computerized system.22 Drugs classified as antipsychotic were so designated by the AMA Drug Evaluations. 23 The suggested daily dose for persons 65 years of age and older is 25 to 100 mg of chlorpromazine or its equivalent.9' 11, 12 To simplify comparison, quantities of antipsychotic drugs were converted into daily doses, using standard conversion factors23 and defining a "daily dose" as the equivalent of 100 mg of chlorpromazine. In subsequent references to amounts of antipsychotic drugs, the units are "daily doses." Those patients who received 365 or more daily doses during the study year were termed chronic recipients.
The physician population comprised all doctors who wrote one or more prescriptions under Medicaid for the continuous NH patients during the study year. The size of a physician's NH practice was defined as the number of continuous NH patients for whom the physician wrote Medicaid prescriptions during the year. The physician with the largest practice in each nursing home was termed the "dominant physician." Physician specialty, board certification status, year and school of graduation, and county of practice were identified by linking the Medicaid provider file, state licensure information, and the Board of Medical Specialties Certification Directory.24 Prescribing of antipsychotic drugs was measured with a physician prescribing index, defined as the ratio of daily doses of antipsychotic drugs prescribed for continuous NH patients (numerator) to size of NH practice (denominator). Differences in the average prescribing indices were statistically tested under the assumption that the underlying distributions of prescribing indices for antipsychotic drug prescribers were exponential. The observed distribution supported this assumption. The variance of contrasts of average prescribing indices was derived, and then estimated with maximum likelihood techniques. The contrast divided by its estimated standard deviation is asymptotically normally distributed.25 This procedure was appropriate, since sample sizes were large in all cases where it was applied. Facilities In Tennessee, almost all long-term nursing home patients are in intermediate care facilities. It is estimated that more than 75 per cent of such patients are Medicaid recipients* In this study, "nursing home" (NH) designates intermediate care facilities. The state NH licensure file and the records of the Medicaid program's 1976 annual NH inspection provided NH characteristics: number of beds, cost per patient day, staffing patterns, cited deficiencies, and fire code violations. We grouped selected inspection criteria into eight classifications: administrative arrangements, service arrangements (e.g. physical therapy), social services (e.g. occupational *Written communication, D. Johnson, Assistant Director, Division of Medicaid, 1978.
486
therapy), physician services, dietetic services, pharmacy services, record-keeping practices, and physical plant. Facility ratings were computed for each classification by dividing the number of deficiencies cited by the total number of inspection criteria. Use of antipsychotic drugs in facilities was measured with the NH antipsychotic drug usage index, the analog of the physician prescribing index. The t test was used to determine significance because the usage indices closely followed a Gaussian distribution. Antipsychotic drug use in each NH also was measured with the chronic recipient rate. The relation between characteristics of facilities and antipsychotic drug use was analyzed with multiple regression techniques. The dependent variable was the antipsychotic drug usage index of the NH (daily doses of antipsychotic drug per patient). The independent variables were number of beds, cost per patient day, staff per bed, and the deficiency ratings. Independent variables were entered singly into the regression equation (significance level of .05). The eight homes for which complete information could not be obtained and the 18 which had fewer than ten study patients were excluded from this analysis. To preserve confidentiality, the files of this study identified Medicaid beneficiaries, physicians, and facilities by identification number only.
Results Patients
During the study year, 5,902 persons 65 years of age and older resided continuously in NHs. All of these patients were matched with an ambulatory Medicaid-eligible person. The patients were typically female (76 per cent), white (86 per cent) and of urban background (41 per cent). Strikingly, 61 per cent of the continuous NH patients were 80 years of age and older. Of the 5,902 continuous NH patients, 5,739 (97 per cent) received 384,326 prescriptions, an average of 67 per person. For the ambulatory comparison group, 4,161 persons (71 per cent) received 123,025 prescriptions, an average of 30 per person. Figure 1 shows the number of persons receiving prescriptions in selected therapeutic categories. Among continuous NH patients, central nervous system (CNS) drugs were the most frequently prescribed medications (74 per cent of the patients). In contrast, only 36 per cent of the ambulatory comparison groups received CNS drugs. Figure 2 illustrates that antipsychotic drugs were the most frequently prescribed CNS medication for continuous NH patients, accounting for 43,526 prescriptions to 2,559 patients (43 per cent), whereas these drugs were infrequently prescribed for the ambulatory comparison group. Continuous NH patients often received prescriptions from multiple categories of CNS drugs during the study year: 34 per cent received drugs from two or more different categories, 9 per cent received drugs from three or more, and 1.6 per cent from four categories. The most frequent combination was an antipsychotic and sedative-hypnotic, most commonly thioridazine and flurazepam. The next most frequent combinaAJPH May 1980, Vol. 70, No. 5
RAY, ET AL.
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ANTIPSYCHOTICS
HYPNOTICS
MINOR TRANQUILIZERS
ANTIDEPRESSANTS
CATEGORIES OF CENTRAL NERVOUS SYSTEM DRUGS CENTRAL NERVOUS SYSTEM
CARDIOVASCULAR
DRUG
FIGURE 2-Number of Persons Receiving Drugs from Categories of Central Nervous System Drugs: 5,902 Continuous Nursing Home Patients and the Matched Ambulatory Comparisons, Tennessee Medicaid, July 1975 through June 1976
ANTIINFECTIVE
CATEGORIES
FIGURE 1-Number of Persons Receiving Drugs from Selected Categories: 5,902 Continuous Nursing Home Patients and the Matched Ambulatory Comparisons, Tennessee Medicaid, July 1975 through June 1976
age, 21 per cent were chronic recipients contrasted with only 4 per cent of those 90 years of age and older. Sex, race, and county of residence were not strongly associated with rates
of antipsychotic drug use.
tion was a minor tranquilizer and sedative-hypnotic drug, usually diazepam and chloral hydrate. The three most frequently prescribed antipsychotic drugs were thioridazine (1,442 persons), chlorpromazine (794 persons), and haloperidol (472 persons). Continuous NH patients received more than 700,000 daily doses of antipsychotic drugs during the study year. Table 1 shows the distribution of patients by quantity of drug received. There were 549 (9.3 per cent) continuous patients who were chronic recipients of antipsychotic drugs; one patient received more than 3,600 daily doses. The proportions of continuous NH patients given antipsychotic drugs decreased with increasing age (Figure 3, p < .001). The proportions of chronic recipients followed the same pattern (p < .001). Of those patients 65 to 69 years of
Physicians A total of 1,580 physicians wrote prescriptions for continuous NH patients during the study year. Of these, 666 (42 per cent) prescribed antipsychotic medications. Table 2 shows that some physicians prescribed large quantities of these drugs: 70 doctors each wrote prescriptions totaling 2,000 or more daily doses; 20 doctors prescribed 5,000 or Un
RECIPIENTS
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TABLE 1-Distribution of Continuous Nursing Home Patients by Daily Doses, Tennessee Medicaid, July 1975 through June 1976
(zL) Z:
Continuous Nursing Home Patients
QUa
Daily Doses*
No.
%
z 0L
0 1-29
3343 293 490 535 692 549 5902
56.6 5.0 8.3
30-89 90-180 180-364 2 365 TOTAL
9.1 11.7 9.3 100.0
*A "daily dose" is defined as the equivalent of 100 mg of chlorpromazine.
AJPH May 1980, Vol. 70, No. 5
40F
Zz
20k
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NO. OF PATIENTS
440
773
AGE GROUPS 1107 1374
85 -89
>90
1288
920
FIGURE 3-Per Cent of Continuous Nursing Home Patients Who Were Antipsychotic Drug Recipients and Chronic Recipients, by Age Group, Tennessee Medicaid, July 1975 through June 1976 487
ANTIPSYCHOTIC DRUG USE IN NURSING HOMES
TABLE 2-Distribution of Physicians Prescribing Antipsychotic Drugs to Continuous Nursing Home Patients by Quantity of Drug Prescribed (in daily doses) Tennessee Medicaid, July 1975 through June 1976 Physicians Daily Doses*
No.
%
0 1-100 100-499 500-1999 2000-4999 : 5000 TOTAL
914 236 222 138 50. 20 1580
57.8 14.9 14.1 8.7 3.2 1.3 100.0
*A "daily dose" is defined as the equivalent of 100 mg of chlorpromazine.
more daily doses. These 20 physicians (1.3 per cent) prescribed 37 per cent of the drug for 27 per cent of the patients. One physician prescribed 28,1 10 daily doses for 106 patients, another 27,170 daily doses for 111 patients. Table 3 presents selected characteristics of physicians in each of four NH practice-size categories. It reveals that 86 per cent of the physicians had practices containing fewer than 10 continuous NH patients. The 14 per cent of physicians whose practices included 10 or more patients prescribed 81 per cent of the antipsychotic medication. These physicians with large NH practices were more likely to be family practitioners (p < .001) and in rural practice (p < .001) than were their counterparts with smaller NH practices. One characteristic which did not change significantly with size of NH practice was proportion of recent medical school graduates. Average physician prescribing indices increased with increasing size of NH practice (Figure 4, p < .001). Physicians whose NH practices were limited to one or two continuous NH patients had an average index of 20 daily doses per patient treated, whereas those doctors whose practices includ-
ed 20 or more continuous patients prescribed an average of 4 times as much antipsychotic medication per patient. Figure 5 depicts average antipsychotic prescribing indices by board certification status. For physicians with small NH practices (9 or fewer continuous NH patients), two results are of principal interest. First, among board certified physicians, family practitioners had the largest average prescribing index (53 daily doses per patient seen), then internists (26 daily doses per patient), and surgeons (12 daily doses per patient). These differences were statistically significant (p < .05). Second, board certified surgeons had a smaller average prescribing index than those not certified (p < .001). For family practitioners with large NH practices (10 or more continuous NH patients), the difference between the average prescribing indices for board-certified and non-certified physicians (Figure 5) was not statistically significant. After controlling for board certification status, the family practitioners with large NH practices had a higher average prescribing index than did those with small NH practices (p < .01). There were too few internists or surgeons with large NH practices to permit analysis. Figure 6 shows the average prescribing indices for physicians in urban, intermediate, and rural counties. For small NH practices, average physician prescribing indices increased with increasing rurality of practice (p < .01). For physicians with large NH practices, there were no significant differences between average prescribing indices for the three locations of practice. For each location, physicians with large NH practices had a significantly higher average prescribing index than did those with small NH practices (p < .01). The relation between average prescribing index and year of graduation from medical school was characterized by an inverted U-shaped curve (Figure 7, p < .001, test for quadratic trend). Physicians graduating during the decade 1950 to 1959 had the highest average prescribing index. Similar patterns were observed when controlling for specialty and size of NH practice.
TABLE 3-Characteristics of Physicians Caring for Continuous Nursing Home Patients by Number of Patients Treated, Tennessee Medicaid, July 1975 through June 1976 No. of Continuous Patients Seen in Practice
No. of Physicians % Total Daily Doses*
Prescribed % Physicians in Family Practice % Physicians in Rural Location % Physicians Rural Family Practitioners % Physicians Graduating Since 1960
1-2
3-9
10-19
.20
949 4.3
406 14.6
113 13.5
112 67.6
26.8
56.9
74.3
81.3
13.0
28.3
50.4
42.9
8.8
21.4
45.1
37.5
25.5
21.4
24.8
21.4
*A "daily dose" is defined as the equivalent of 100 mg of chlorpromazine.
488
AJPH May 1980, Vol. 70, No. 5
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10-19 3-9 20+ 1-2 NO. CONTINUOUS NURSING HOME PATIENTS IN PHYSICIANS PRACTICE NO. OF PHYSICIANS
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FIGURE 4-Average Physician Antipsychotic Drug Prescribing Indices by Size of Physician's Practice (number of continuous nursing home patients treated), Tennessee Medicaid, July 1975 through June 1976. (A "daily dose" is defined as the equivalent of 100 mg of chlorpromazine.) 238 PHYSipschotic695g recive
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The continuous NH patients resided in 173 NHs during the study year. Antipsychotic drugs were given to patients in all of these facilities (Table 4). The average usage index rate varied widely among nursing homes, ranging from 1.2 to 375 daily doses per patient. The chronic recipient rate also varied widely, ranging from 0 to 46 per cent of patients in a home. As numbers of beds in NHs increased, there was an associated increase in the average number of daily doses of
facility characteristics were significantly associated with antipsychotic drug use. A similar analysis in which the chronic recipient rate was the dependent variable produced the same
SMALL PRACTICE
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PRACTICE
results.
Prescribing in a NH often was concentrated in the hands of one doctor, the dominant physician. In one-half the homes this physician prescribed for 76 per cent or more of the continuous patients. As the relationship between the NH and the dominant physician grew stronger (an increasing proportion of the home's continuous patients in his practice), the
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