Response to regulatory stringency: the case of antipsychotic medication use in nursing homes.

Department of Economics and Scripps Gerontology Center, Miami University, Oxford, OH 45056, USA.
Health Economics (Impact Factor: 2.14). 08/2012; 21(8):977-93. DOI: 10.1002/hec.1775
Source: PubMed

ABSTRACT This paper studies the impact of regulatory stringency, as measured by the statewide deficiency citation rate over the past year, on the quality of care provided in a national sample of nursing homes from 2000 to 2005. The quality measure used is the proportion of residents who are using antipsychotic medication. Although the changing case-mix of nursing home residents accounts for some of the increase in the use of antipsychotics, we find that the use of antipsychotics by nursing homes is responsive to state regulatory enforcement in a manner consistent with the multitasking incentive problem. Specifically, the effect of the regulations is dependent on the degree of complementarity between the regulatory deficiency and the use of antipsychotics.


Available from: Stephen Crystal, Dec 31, 2013
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives To describe the rationales that providers and family members cite for the use of antipsychotic medications in people with dementia living in nursing homes (NHs).DesignQualitative, descriptive study.SettingTwenty-six medium-sized and large facilities in five Centers for Medicare and Medicaid Services regions.ParticipantsIndividuals diagnosed with dementia who received an antipsychotic medication.MeasurementsData were collected from medical record abstraction and interviews with prescribers, administrators, direct care providers, and family members. Textual data from medical record abstraction and responses to open-ended interview questions were analyzed using directed content analysis techniques. A coding scheme was developed, and coded reasons for antipsychotic prescribing were summarized across all sources.ResultsMajor categories of reasons for use of antipsychotic medications in the 204 NH residents in the study sample were behavioral (n = 171), psychiatric (n = 159), emotional states (n = 105), and cognitive diagnoses or symptoms (n = 114). The most common behavioral reasons identified were verbal (n = 91) and physical (n = 85) aggression. For the psychiatric category, psychosis (n = 95) was most frequently described. Anger (n = 93) and sadness (n = 20) were the most common emotional states cited.Conclusion The rationale for use of antipsychotic drug therapy frequently relates to a wide variety of indications for which these drugs are not approved and for which evidence of efficacy is lacking. These findings have implications for clinical practice and policy.
    Journal of the American Geriatrics Society 01/2015; 63(2). DOI:10.1111/jgs.13230 · 4.22 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The paper by Kleijer and colleagues (2014) in this issue of International Psychogeriatrics describes factors that may influence antipsychotic drug (APD) prescribing rates in nursing homes in several countries. The authors conclude that the large variability is only partly explained by differences in resident characteristics, and that it is associated with certain facility characteristics such as bed size and urban/rural location. They also identify the likelihood that differences in physician prescribing patterns or facility prescribing culture may influence APD prescribing rates, as has been found in previous studies (Briesacher et al., 2005; Chen et al., 2010).
    International Psychogeriatrics 03/2014; 26(3):361-2. DOI:10.1017/S1041610213002597 · 1.89 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The high cost of the US health care system does not buy uniformly high quality of care. Concern about low quality has prompted two major types of public policy responses: regulation, a top-down approach, and report cards, a bottom-up approach. Each can result in either functional provider responses, which increase quality, or dysfunctional responses, which may lower quality. What do we know about the impacts of these two policy approaches to quality? To answer this question, we review the extant literature on regulation and report cards. We find evidence of both functional and dysfunctional effects. In addition, we identify the areas in which additional research would most likely be valuable. Expected final online publication date for the Annual Review of Public Health Volume 35 is March 18, 2014. Please see for revised estimates.
    Annual Review of Public Health 10/2013; DOI:10.1146/annurev-publhealth-082313-115826 · 6.63 Impact Factor