The Diagnosis of Schizophrenia Among Nursing Home Residents With ADRD: Does Race Matter?

Published:October 26, 2021DOI:


      • What is the primary question addressed by this study? To examine racial differences in the change in the frequency of schizophrenia diagnosis among nursing home residents with ADRD following the public reporting of nursing home antipsychotic use, and sources of such racial differences.
      • What is the main finding of this study? The increase in the frequency of schizophrenia diagnosis during the study period was greater for Black residents with ADRD as compared with whites. Such racial differences were related to NHs’ racial composition, but racial differences in the growth of schizophrenia diagnosis persisted within a NH after accounting for NH factors.
      • What is the meaning of the finding? Efforts are needed to reexamine policies that may incentivize inaccurate diagnosis and exacerbate racial differences in nursing home care.



      To examine racial differences in the frequency of schizophrenia diagnosis codes used among nursing home (NH) residents with Alzheimer's Disease and Related Dementias (ADRD), pre and post the implementation of public reporting of antipsychotic use in NHs.


      The 2011–2017 Minimum Data Set and Medicare Master Beneficiary Summary File were linked. We identified long-stay NH residents (i.e., those who had quarterly or annual assessments) with ADRD aged 55 years and older (N = 7,734,348). Outcome variable was defined as the diagnosis of schizophrenia documented in the MDS assessments. Main variables of interest included individual race (black versus white), the percent of blacks in a NH and time trend. Multivariate regressions were estimated.


      The frequency of schizophrenia diagnosis codes among NH residents with ADRD steadily increased over the study period, and blacks experienced a greater increase than their white counterparts. For example, the overall likelihood of having schizophrenia diagnosis increased 1.9 percentage points (95% confidence interval [CI]: 0.019, 0.020, p < 0.01) from 2011 to 2017 among whites, while blacks had an addition 1.3 percentage points increase (95% CI: 0.011, 0.015, p < 0.01). The increase in the likelihood of having schizophrenia diagnosis code was higher in NHs with higher percent of blacks: the increase from 2011 to 2017 was 2.6 percentage point (95% CI: 0.023, 0.029, p < 0.01) higher in NHs with the highest percent of blacks, compared to NHs with lowest percent of blacks. Racial differences in the growth of schizophrenia diagnosis also existed within a NH after accounting for NH factors.


      Following the implementation of public reporting of antipsychotic use in NH, black residents experienced a greater increase in the likelihood of having schizophrenia diagnosis than white NH residents. NHs with a higher proportion of blacks had a greater increase in schizophrenia diagnosis, and blacks experienced an increased likelihood of schizophrenia diagnosis than whites within a NH. Further research is needed to determine a causal relationship between the federal policy mandating public reporting and disparities in schizophrenia diagnostic coding.

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