Date of Award

January 2025

Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)

Department

School of Public Health

First Advisor

Mayur M. Desai

Abstract

Background: In 2012, the Centers for Medicare & Medicaid Services (CMS) implemented initiatives to reduce unnecessary antipsychotic medication use in elderly nursing home residents to ensure quality of care. While antipsychotic use among long-stay nursing home residents has decreased nationwide, Massachusetts still exceeds the national average and ranks 6th in the U.S. This study aims to evaluate and identify both facility-level characteristics and resident-level correlates of antipsychotic use without an indicated diagnosis among long-stay residents in Massachusetts nursing homes. Methods: The study examined 30,857 long-stay residents across 345 nursing facilities in CY2023, using data from the Minimum Data Set (MDS), CMS Provider Information, and Massachusetts Department of Public Health (MDPH) Nursing Home Performance Reports. Antipsychotic use without associated diagnoses excludes residents with a diagnosis of schizophrenia, Huntington’s disease, or Tourette Syndrome. Facility-level characteristics include facility quality score, CMS overall star ratings, and level of staffing. Resident-level factors include age, sex, race/ethnicity, polypharmacy, mental and cognitive conditions, and Activities of Daily Living (ADLs) score. Results: Antipsychotics rate without an indicated diagnoses varied greatly across facilities (0% to 71.4%; mean=21.2%). The ecological study of facilities shows positive correlations between rate of antipsychotic use and increasing percentages of male patients and patients with cognitive impairment, along with a negative correlation with percentage of African American patients and average age, ADL score, and CMS star ratings. The individual-level study found increased risks of receiving antipsychotic medications for residents who are male, experience polypharmacy, and other mental and cognitive conditions, along with decreased odds of receiving antipsychotic medications for older residents, African Americans, and residents who live in facilities that met CMS minimum staffing requirement. Conclusion: Younger, and male residents with cognitive impairment face the highest likelihood of potential off-label antipsychotic use. Polypharmacy, other mental health conditions, and facility quality and staffing level can also play important roles in antipsychotic medication use. Future research and policy efforts should focus on addressing these disparities, ensuring appropriate prescribing practices, and minimizing unnecessary medication use.

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This is an Open Access Thesis.

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