The effects of public reporting on physical restraints and antipsychotic use in nursing home residents with severe cognitive impairment

Abstract

Objectives: To assess whether reductions in physical restraint use associated with quality reporting may have had the unintended consequence of increasing antipsychotic use in nursing home (NH) residents with severe cognitive impairment.

Design: Retrospective analysis of NH clinical assessment data from 1999 to 2008 comparing NHs subject to public reporting of physical restraints with nonreporting NHs.

Setting: Medicare- and Medicaid-certified NHs in the United States.

Participants: Observations (N = 3.9 million) on 809,645 residents with severe cognitive impairment in 4,258 NHs in six states.

Intervention: Public reporting of physical restraint use rates.

Measurements: Use of physical restraints and antipsychotic medications.

Results: Physical restraint use declined significantly from 1999 to 2008 in NH residents with severe cognitive impairment. The decline was larger in NHs that were subject to reporting of restraints than in those that were not (-8.3 vs -3.3 percentage points, P < .001). Correspondingly, antipsychotic use in the same residents increased more in NHs that were subject to public reporting (4.5 vs 2.9 percentage points, P < .001). Approximately 36% of the increase in antipsychotic use may be attributable to public reporting of physical restraints.

Conclusion: This analysis suggests that public reporting of physical restraint use had the unintended consequence of increasing use of antipsychotics in NH residents with severe cognitive impairment.

Keywords: antipsychotics; nursing homes; public reporting; quality; restraints.

Figure 1.

(A) Physical restraint and (B) Antipsychotic use in nursing homes according to cognitive impairment, 1999–2008. Sample comprises 23,377,681 resident-level observations from 4,272 nursing homes in California, Florida, Illinois, New York, Ohio, and Texas that were subject to public reporting of physical restraints.

Figure 2.

Physical restraints and antipsychotic use in nursing home residents with severe cognitive impairment, 1999–2008. Sample comprises 3,889 ,781 resident-level observations from 4,258 nursing homes in California, Florida, Illinois, New York, Ohio, and Texas that were subject to public reporting of physical restraints.

Figure 3.

Trends in physical restraint and antipsychotic use in nursing home (NH) residents with severe cognitive impairment according to NH staffing level: 1999–2008. Sample comprises 3,889,781 resident-level observations from 4,258 NHs in California, Florida, Illinois, New York, Ohio, and Texas subject to public reporting of physical restraints. Staffing is classified as low if total nurse hours per resident-day is at or equal to the median of 3.19 and as high if greater than the median.