At­ten­tion, please

Re­ports spot­light qual­ity, pa­tient-safety con­cerns at nurs­ing homes

Modern Healthcare - - The Week In Healthcare - Mau­reen McKinney

New stud­ies and gov­ern­ment au­dits are call­ing at­ten­tion to qual­ity and safety de­fi­cien­cies in U.S. nurs­ing homes, such as over­pre­scrib­ing of an­tipsy­chotic drugs and in­ad­e­quate in­fec­tion con­trol.

In a scathing May 9 re­port, HHS’ in­spec­tor gen­eral’s of­fice found that about half of atyp­i­cal an­tipsy­chotic drugs pre­scribed in nurs­ing homes were given to pa­tients with no med­i­cal in­di­ca­tion for them. The re­port cited a num­ber of trou­bling rea­sons for the overuse, in­clud­ing po­ten­tial kick­backs from drug com­pa­nies.

Four­teen per­cent of the more than 2 mil­lion nurs­ing-home res­i­dents over the age of 65 re­ceived at least one an­tipsy­chotic drug dur­ing the first six months of 2007. And of those claims, 83% were for off-la­bel uses, or for con­di­tions other than schizophre­nia or bipo­lar dis­or­der, the in­spec­tor gen­eral said in the re­port. The bill for er­ro­neous Medi­care claims for such drugs to­taled $116 mil­lion.

Also, 22% of the atyp­i­cal an­tipsy­chotic drugs ad­min­is­tered, amount­ing to $63 mil­lion, were deemed un­nec­es­sary by CMS stan­dards.

In the re­port, the in­spec­tor gen­eral ex­pressed worry that an­tipsy­chotics are be­ing pre­scribed to pa­tients with de­men­tia, in spite of warn­ings from the Food and Drug Ad­min­is­tra­tion that atyp­i­cal an­tipsy­chotics such as Sero­quel and Ris­perdal can in­crease the risk of death for those pa­tients. Pa­tient ad­vo­cates also warn that such drugs are of­ten used in nurs­ing homes to calm agi­tated res­i­dents rather than treat men­tal health is­sues.

Dr. David Gif­ford, se­nior vice pres­i­dent for qual­ity and reg­u­la­tory af­fairs for the Amer­i­can Health Care As­so­ci­a­tion, a large in­dus­try group rep­re­sent­ing nurs­ing homes, said the re­port high­lighted an is­sue—be­hav­ioral prob­lems in the el­derly and the use of an­tipsy­chotic drugs to man­age them—that is a source of concern for nurs­ing homes and pa­tients’ fam­ily mem­bers.

But Gif­ford ar­gued that off-la­bel use does not mean in­ap­pro­pri­ate use. “Doc­tors pre­scribe drugs for off-la­bel use all the time and I think that is the big­gest mis­un­der­stand­ing,” he said.

He did ac­knowl­edge that the per­cent­age of nurs­ing-home res­i­dents be­ing treated with such drugs “is prob­a­bly too high.”

“Can we do bet­ter?” Gif­ford said. “Yes, but peo­ple are do­ing a rea­son­able job. Tak­ing care of the el­derly is a team ef­fort, and the so­lu­tion needs to come from nurs­ing homes, hos­pi­tals, physi­cians and fam­ily mem­bers.”

Overuse of an­tipsy­chotic drugs is not nurs­ing homes’ only concern. De­spite the more than 380,000 deaths and up to $2 bil­lion in ad­di­tional costs at­trib­uted to in­fec­tions among nurs­ing-homes res­i­dents each year, a study pub­lished in the May is­sue of the Amer­i­can Jour­nal of In­fec­tion Con­trol found that roughly 15% of nurs­ing homes are cited an­nu­ally by CMS sur­vey­ors for de­fi­cien­cies in in­fec­tion con­trol.

In­spec­tions, which take place over the course of one week each year, re­quire cer­tain in­fec­tion-con­trol stan­dards be met to avoid a ci­ta­tion, known as an F-Tag 441.

Re­searchers found a strong cor­re­la­tion be­tween fa­cil­i­ties’ in­fec­tion-con­trol ci­ta­tions and their reg­is­tered-nurse staffing lev­els, said Ni­cholas Cas­tle, pro­fes­sor in the depart­ment of health pol­icy and man­age­ment at the Univer­sity of Pitts­burgh Grad­u­ate School of Pub­lic Health, and the study’s lead au­thor.

“RNs may have more train­ing in in­fec­tion con­trol, so this wasn’t sur­pris­ing,” Cas­tle said. “Many nurs­ing homes are un­der­staffed with re­spect to RNs, but more train­ing of other em­ploy­ees might be of use too.”

The goal of the study was to raise the is­sue with­out de­mo­niz­ing re­source-strapped nurs­ing homes, added Cas­tle, who also has an­other study about nurs­ing-home hand hy­giene cur­rently un­der re­view.

“The take­away is that a lot of the great work in in­fec­tion con­trol has been done in hos­pi­tals, but in our health­care sys­tem, folks bounce back from hos­pi­tals to nurs­ing homes again and again,” he said. “Nurs­ing homes are lag­ging be­hind hos­pi­tals in this area, and we need to do more anal­y­sis to see what the bar­ri­ers are and what can be done to help them con­trol in­fec­tions in the fu­ture.”

The Gov­ern­ment Accountability Of­fice also re­cently tar­geted nurs­ing-home over­sight. In a May 9 re­port, the GAO urged the CMS to beef up the over­sight process for state com­plaint in­ves­ti­ga­tions. Specif­i­cally, the re­port rec­om­mended the agency clar­ify its per­for­mance stan­dards and make im­prove­ments to its com­plaints data­base.

Lyn Bent­ley, di­rec­tor of reg­u­la­tory af­fairs for the Amer­i­can Health Care As­so­ci­a­tion, said the group wel­comed the re­port be­cause it high­lighted in­con­sis­ten­cies among states in the way they iden­tify and sub­stan­ti­ate data re­lated to com­plaints.

For pa­tients and fam­ily mem­bers who are con­sid­er­ing nurs­ing-home care in mul­ti­ple states, the way com­plaints are in­putted and sub­stan­ti­ated could have a sig­nif­i­cant im­pact on which fa­cil­ity they choose, she said.

“It’s good that this is­sue has been iden­ti­fied and CMS has said they’ll make an ef­fort to im­prove the process,” Bent­ley added.

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