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Shireman TI, Coulibaly N, Zhang T, Zullo AR, Gerlach LB, Coe AB, Daiello LA, Lo D, Bynum JPW. Impact of federal antipsychotic use policy in nursing homes on new diagnoses for approved indications in dementia residents. J Am Geriatr Soc 2024. [PMID: 39177336 DOI: 10.1111/jgs.19129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 06/07/2024] [Accepted: 07/12/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND Federal policies targeting antipsychotic use among nursing home (NH) residents may have increased reporting of diagnoses for approved uses, including schizophrenia, Tourette's syndrome, and Huntington's Disease (called "exclusionary diagnoses" because they exclude residents from the antipsychotic quality metric). We assessed changes in new exclusionary diagnoses among long-stay NH admissions specifically with dementia following federal policies. METHODS Retrospective, quarterly, interrupted time-series analysis (2009-2018) of new long-stay NH residents with dementia and no exclusionary diagnoses reported before NH admission. The National Partnership and the addition of facility level antipsychotic use to the Five Star Quality Rating system were key time exposures. Outcome was quarterly facility level predicted percentage of exclusionary diagnoses within 2 years of admission stratified by NH characteristics. RESULTS For 264,095 long-stay admissions, mean percentage of new exclusionary diagnoses was 2.2% before the Partnership. After the Partnership, there was an unadjusted increase in the percentage over time (slope change, 0.044, p = 0.018), but the percentage never exceeded 2.9%. The Partnership contributed to a one-time decrease in diagnoses in NHs with an intermediate percentage of Black residents (-1.29%, p = 0.004). Before the Partnership, diagnoses were increasing among not-for-profit relative to for-profit NHs (0.044; p = 0.012), but after the Partnership, the pattern reversed. For-profit NHs saw an increase (+0.034, p = 0.002); not-for-profit NHs experienced a decrease (-0.014, p = 0.039). Quality Rating modifications had no significant effect. CONCLUSIONS Exclusionary diagnosis reporting among long-stay NH residents with dementia, the group most at risk from antipsychotics, did not increase in response to federal policies. Evaluation of reasons for the observed increase in exclusionary diagnoses among non-dementia NH residents is warranted along with continued attention to how to incentivize the appropriate use of medications in residents with dementia that is crucial for high-quality NH care.
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Affiliation(s)
- Theresa I Shireman
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Neto Coulibaly
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Tingting Zhang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Andrew R Zullo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Lauren B Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Antoinette B Coe
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Lori A Daiello
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Derrick Lo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Cai S, Qin Q, Veazie P, Temkin-Greener H. Telemedicine and Disparities in Mental Health Service Use Among Community-Dwelling Older Adults With Alzheimer Disease and Related Dementias. J Am Med Dir Assoc 2024; 25:105027. [PMID: 38768645 DOI: 10.1016/j.jamda.2024.105027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/05/2024] [Accepted: 04/08/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE To examine disparities in mental health (MH) service utilization, via in-person and telemedicine (ie, tele-MH), by individuals' race, ethnicity, and community socioeconomic status, among community-dwelling older adults with Alzheimer disease and related dementias (ADRD) before and after the expansion of the Centers for Medicare and Medicaid Services' (CMS's) telemedicine policy. DESIGN Observational study. SETTING AND PARTICIPANTS A total of 3,003,571 community-dwelling Medicare beneficiaries with ADRD between 2019 and 2021 were included in the study. METHODS Multiple national data were linked. The unit of analysis was individual-quarter. Three outcomes were defined: any MH visits (in-person or tele-MH), in-person MH visits, and tele-MH visits per quarter. Key independent variables included individual race and ethnicity, the socioeconomic status of the community, and an indicator for the implementation of the telemedicine policy. Regression analyses with individual random effects were used. RESULTS In general, Black and Hispanic older adults with ADRD and those in socioeconomically deprived communities were less likely to have MH visits than white adults and those from less-deprived communities. In-person and tele-MH visits varied throughout the pandemic and across subpopulations. For instance, at the beginning of the pandemic, white, Black, and Hispanic older adults experienced 5.05, 3.03, and 2.87 percentage point reductions in in-person MH visits, and 3.53, 1.26, and 0.32 percentage point increases in tele-MH visits (with P < .01 for racial/ethnic differences), respectively. During the pandemic, the increasing trend in in-person MH visits and the decreasing trend in tele-MH visits varied across different subgroups. Overall, racial and ethnic differences in any MH visits were reduced, but the gap in any MH visits between deprived and less-deprived communities doubled during the pandemic (P < .01). CONCLUSIONS AND IMPLICATIONS Telemedicine may have provided an opportunity to improve access to MH services among underserved populations. However, although some disparities in MH care were reduced, others widened, underscoring the importance of equitable health care access strategies to address the unique needs of different populations.
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Affiliation(s)
- Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Qiuyuan Qin
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Peter Veazie
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Armstrong MJ, Barnes LL. Under-Diagnosis of Dementia with Lewy Bodies in Individuals Racialized as Black: Hypotheses Regarding Potential Contributors. J Alzheimers Dis 2024; 97:1571-1580. [PMID: 38277299 PMCID: PMC10894581 DOI: 10.3233/jad-231177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 01/28/2024]
Abstract
Dementia with Lewy bodies (DLB) is one of the most common degenerative dementias after Alzheimer's disease (AD) dementia. DLB is under-diagnosed across populations but may be particularly missed in older Black adults. The object of this review was to examine key features of DLB and potential associations with race in order to hypothesize why DLB may be under-diagnosed in Black adults in the U.S. In terms of dementia, symptoms associated with high rates of co-pathology (e.g., AD, vascular disease) in older Black adults may obscure the clinical picture that might suggest Lewy body pathology. Research also suggests that clinicians may be predisposed to give AD dementia diagnoses to Black adults, potentially missing contributions of Lewy body pathology. Hallucinations in Black adults may be misattributed to AD or primary psychiatric disease rather than Lewy body pathology. Research on the prevalence of REM sleep behavior in diverse populations is lacking, but REM sleep behavior disorder could be under-diagnosed in Black adults due to sleep patterns or reporting by caregivers who are not bed partners. Recognition of parkinsonism could be reduced in Black adults due to clinician biases, cultural effects on self-report, and potentially underlying differences in the frequency of parkinsonism. These considerations are superimposed on structural and systemic contributions to health (e.g., socioeconomic status, education, structural racism) and individual-level social exposures (e.g., social interactions, discrimination). Improving DLB recognition in Black adults will require research to investigate reasons for diagnostic disparities and education to increase identification of core symptoms in this population.
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Affiliation(s)
- Melissa J. Armstrong
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
- 1Florida Alzheimer Disease Research Center, Gainesville, FL, USA
| | - Lisa L. Barnes
- Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, IL, USA
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Shireman TI, Fashaw-Walters S, Zhang T, Zullo AR, Gerlach LB, Coe AB, Daiello L, Lo D, Strominger J, Bynum JPW. Federal Nursing Home Policies on Antipsychotics had Similar Impacts by Race and Ethnicity for Residents With Dementia. J Am Med Dir Assoc 2023; 24:1283-1289.e4. [PMID: 37127131 PMCID: PMC10523862 DOI: 10.1016/j.jamda.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/15/2023] [Accepted: 03/20/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Federal initiatives have been successful in reducing antipsychotic exposure in nursing home residents with dementia. We assessed if these initiatives were implemented equally across racial and ethnic minority groups. DESIGN Retrospective, cross-sectional trends study. SETTING AND PARTICIPANTS National long-stay nursing home residents with dementia from 2011 to 2017. METHODS We examined trends in psychotropic drug class exposures from the Minimum Data Set assessments for non-Hispanic Black (NHB), Hispanic, and non-Hispanic White (NHW) residents using interrupted time-series analyses with age-sex standardized quarterly outcomes and time points to denote the National Partnership (2012) and Five Star Rating changes (2015). RESULTS Initially, antipsychotic (33.0%) and sedative (6.8%) exposure was highest for Hispanic residents; antidepressant (59.8%) and anxiolytic (23.4%) exposure was highest for NHW residents; NHB residents had the lowest use of each. Antipsychotic use dropped at the time of the Partnership (β = -0.8807, P = .0023) and the slope declined further after the Partnership (β = -0.6611, P < .0001) for NHW. In comparison to NHW, the level and slope changes for NHB and Hispanics were not significantly different. The Five Star Rating change did not impact the level of antipsychotic use (β = 0.027, P = .9467), but the slope changed to indicate a slowed rate of decline (β = 0.1317, P = .4075) for NHW. As to the other psychotropic drug classes, there were few significant differences between trends seen in the racial and ethnic subgroups. The following exceptions were noted: antidepressant use decreased at a faster rate for NHB residents post-Partnership (β = -0.1485, P = .0371), and after the Five Star Rating change, NHB residents (β = -0.0428, P = .0312) and Hispanic residents (β = -0.0834, P < .0001) saw antidepressant use decrease faster than NHW. Sedative use in slope post-Partnership period (β = -0.086, P = .0275) and post-Five Star Rating (β = -0.0775, P < .0001) declined faster among Hispanic residents. CONCLUSIONS AND IMPLICATIONS We found little evidence of clinically meaningful differences in changes to 4 classes of psychotropic medication use among racial and ethnic minority nursing home residents with dementia following 2 major federal initiatives.
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Affiliation(s)
- Theresa I Shireman
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Shekinah Fashaw-Walters
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Tingting Zhang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Lauren B Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Antoinette B Coe
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Lori Daiello
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Neurology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Derrick Lo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Julie P W Bynum
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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