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

Published:October 26, 2021DOI:https://doi.org/10.1016/j.jagp.2021.10.008

      Highlights

      • 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.

      ABSTRACT

      Objective

      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.

      Methods

      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.

      Results

      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.

      Conclusion

      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.

      Key Words

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      References

        • Simmons SF
        • Bonnett KR
        • Hollingsworth E
        • et al.
        Reducing antipsychotic medication use in nursing homes: a qualitative study of nursing staff perceptions.
        Gerontologist. 2018; 58: e239-e250
        • Mitka M.
        CMS seeks to reduce antipsychotic use in nursing home residents with dementia.
        JAMA. 2012; 308: 119-121
        • Steinberg M
        • Lyketsos CG.
        Atypical antipsychotic use in patients with dementia: managing safety concerns.
        Am J Psychiatry. 2012; 169: 900-906
      1. U.S. Food & Drug Aministration. Information for healthcare professionals: conventional antipsychotics. Available at:http://wwwfdagov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm124830htm. 2008.

        • van Iersel MB
        • Zuidema SU
        • Koopmans RT
        • et al.
        Antipsychotics for behavioural and psychological problems in elderly people with dementia: a systematic review of adverse events.
        Drugs Aging. 2005; 22: 845-858
        • Kate NS
        • Pawar SS
        • Parkar SR
        • et al.
        Adverse drug reactions due to antipsychotics and sedative-hypnotics in the elderly.
        J Geriatir Mental Health. 2015; 2: 16-29
        • Gara MA
        • Minsky S
        • Silverstein SM
        • et al.
        A naturalistic study of racial disparities in diagnoses at an outpatient behavioral health clinic.
        Psychiatr Services (Washington, DC). 2019; 70: 130-134
      2. Centers for Medicare adn Medicaid Services. MDS 3.0 quality measures user's manual. Available at:http://wwwcmsgov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-User's-Manual-V80pdf.2013; Accessed May 18, 2018.

      3. Centers for Medicare and Medicaid Services. Update report on the National Partnership to improve dementia care in nursing homes. Available at:https://wwwcmsgov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/SC-Letter-16-28-Partnership-Update-Reportpdf. 2016.

        • Gurwitz JH
        • Bonner A
        • Berwick DM.
        Reducing excessive use of antipsychotic agents in nursing homes.
        JAMA. 2017; 318: 118-119
      4. The New York Times. Phony diagnoses hide high rates of drugging at nursing homes. 2021;Available at:https://www.nytimes.com/2021/09/11/health/nursing-homes-schizophrenia-antipsychotics.html Accessed September 12, 2021.

      5. Ogarek J, Neylon K, Gadbois E, et al. Effects of CMS’ measure of antipsychotic prescribing practices for nursing facilities on utilization of antipsychotic medications and changes in diagnostic patterns. 2019;Available at: https://www.nasmhpd.org/sites/default/files/TAC_Paper_2_508C.pdf Accessed June 8, 2021.

      6. Texas health and human services. Improving dementia care. Available at:https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/long-term-care/qmp/ltc-prescriber-strategies.pdf Accessed May 8, 2021.

        • Tamara Konetzka R
        • Yan K
        • Werner RM
        Two decades of nursing home compare: what have we learned?.
        Med Care Res Rev. 2021; 78: 295-310
        • Bresnahan M
        • Begg MD
        • Brown A
        • et al.
        Race and risk of schizophrenia in a US birth cohort: another example of health disparity?.
        Int J Epidemiol. 2007; 36: 751-758
        • Olbert CM
        • Nagendra A
        • Buck B.
        Meta-analysis of Black vs. White racial disparity in schizophrenia diagnosis in the United States: do structured assessments attenuate racial disparities?.
        J Abnorm Psychol. 2018; 127: 104-115
        • Strakowski SM
        • Lonczak HS
        • Sax KW
        • et al.
        The effects of race on diagnosis and disposition from a psychiatric emergency service.
        J Clin Psychiatry. 1995; 56: 101-107
        • Choi MR
        • Eun HJ
        • Yoo TP
        • et al.
        The effects of sociodemographic factors on psychiatric diagnosis.
        Psychiatr Invest. 2012; 9: 199-208
        • Gara MA
        • Vega WA
        • Arndt S
        • et al.
        Influence of patient race and ethnicity on clinical assessment in patients with affective disorders.
        Arch Gen Psychiatry. 2012; 69: 593-600
        • Cohen CI
        • Magai C.
        Racial differences in neuropsychiatric symptoms among dementia outpatients.
        Am J Geriatric Psychiatry. 1999; 7: 57-63
        • Sink KM
        • Covinsky KE
        • Newcomer R
        • et al.
        Ethnic differences in the prevalence and pattern of dementia-related behaviors.
        J Am Geriatr Soc. 2004; 52: 1277-1283
        • Coehlo DP
        • Hooker K
        • Bowman S.
        Institutional placement of persons with dementia: what predicts occurrence and timing?.
        J Fam Nurs. 2007; 13: 253-277
        • Luppa M
        • Luck T
        • Brahler E
        • et al.
        Prediction of institutionalisation in dementia. A systematic review.
        Dement Geriatr Cogn Disord. 2008; 26: 65-78
        • Porter CN
        • Miller MC
        • Lane M
        • et al.
        The influence of caregivers and behavioral and psychological symptoms on nursing home placement of persons with Alzheimer's disease: a matched case-control study.
        SAGE Open Med. 2016; 42050312116661877
        • Gitlin LN
        • Marx KA
        • Stanley IH
        • et al.
        Assessing neuropsychiatric symptoms in people with dementia: a systematic review of measures.
        Int Psychogeriatr. 2014; 26: 1805-1848
        • Mor V
        • Zinn J
        • Angelelli J
        • et al.
        Driven to tiers: socioeconomic and racial disparities in the quality of nursing home care.
        Milbank Q. 2004; 82: 227-256
        • Cai S
        • Mukamel DB
        • Temkin-Greener H
        Pressure ulcer prevalence among black and white nursing home residents in New York state: evidence of racial disparity?.
        Med Care. 2010; 48: 233-239
        • Cai S
        • Feng Z
        • Fennell ML
        • et al.
        Despite small improvement, black nursing home residents remain less likely than whites to receive flu vaccine.
        Health Aff (Millwood). 2011; 30: 1939-1946
        • Wooldridge J.
        Introductory Econometrics: A Modern Approach.
        South-Western Cengage Learning, Mason, OH2012
      7. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.
        Lancet (London, England). 2018; 392: 1789-1858
        • Mitka M.
        CMS seeks to reduce antipsychotic use in nursing home residents with dementia.
        JAMA. 2012; 308: 119-121
        • Desai AK
        • Grossberg GT.
        Recognition and Management of Behavioral Disturbances in Dementia.
        Prim Care Companion J Clin Psychiatr. 2001; 3: 93-109
        • Gitlin LN
        • Kales HC
        • Lyketsos CG
        Nonpharmacologic management of behavioral symptoms in dementia.
        JAMA. 2012; 308: 2020-2029
        • O'Brien JA
        • Caro JJ.
        Alzheimer's disease and other dementia in nursing homes: levels of management and cost.
        Int Psychogeriatr. 2001; 13: 347-358
        • Muramatsu RS
        • Goebert D.
        Psychiatric services: experience, perceptions, and needs of nursing facility multidisciplinary leaders.
        J Am Geriatr Soc. 2011; 59: 120-125
        • Grabowski DC
        • Aschbrenner KA
        • Rome VF
        • et al.
        Quality of mental health care for nursing home residents: a literature review.
        Med Care Res Rev. 2010; 67: 627-656
        • Cohen-Mansfield J
        • Thein K
        • Marx MS
        • et al.
        What are the barriers to performing nonpharmacological interventions for behavioral symptoms in the nursing home?.
        J Am Med Dir Assoc. 2012; 13: 400-405
        • Gaugler JE
        • Yu F
        • Davila HW
        • et al.
        Alzheimer's disease and nursing homes.
        Health Affairs. 2014; 33: 650-657
        • Carlson DL
        • Fleming KC
        • Smith GE
        • et al.
        Management of dementia-related behavioral disturbances: a nonpharmacologic approach.
        Mayo Clin Proc. 1995; 70: 1108-1115
        • Bradford A
        • Shrestha S
        • Snow AL
        • et al.
        Managing pain to prevent aggression in people with dementia: a nonpharmacologic intervention.
        Am J Alzheimers Dis Demen. 2012; 27: 41-47
      8. The American Geriatrics Society and American Association for Geriatric Psychiatry recommendations for policies in support of quality mental health care in U.S. nursing homes.
        J Am Geriatr Soc. 2003; 51: 1299-1304
        • Kincaid C
        • Peacock JR.
        The effect of a wall mural on decreasing four types of door-testing behaviors.
        J Appl Gerontol. 2003; 2003: 76-88
        • Fleming R
        • Purandare N.
        Long-term care for people with dementia: environmental design guidelines.
        Int Psychogeriatr. 2010; 22: 1084-1096
        • Gitlin LN
        • Winter L
        • Vause Earland T
        • et al.
        The Tailored Activity Program to reduce behavioral symptoms in individuals with dementia: feasibility, acceptability, and replication potential.
        Gerontologist. 2009; 49: 428-439
        • Allen-Burge R
        • Stevens AB
        • Burgio LD.
        Effective behavioral interventions for decreasing dementia-related challenging behavior in nursing homes.
        Int J Geriatr Psychiatry. 1999; 14 (discussion 228-232): 213-228