Yesterday was the third anniversary of the Nov. 30, 2011 U.S. Senate Committee on Aging’s hearing “Overprescribed: The Human and Taxpayers’ Cost of Antipsychotics in Nursing Homes.” The statements of the Senators at the hearing and the testimony of the witnesses universally condemned the barbaric yet all too common practice of chemically restraining nursing home residents by administering unnecessary, dangerous, and deadly antipsychotics.
Senator Blumenthal summed up the hearing’s sentiments:
Over use of antipsychotics . . . is a form of elder abuse, plain and simple. It’s a form of abuse of people who often have no idea what is happening, and even their families may not have a clear or informed idea about how these drugs are prescribed and applied. And it occurs not just in occasional or isolated case[s], but as a routine pattern and practice, as some of the statistics show.
Sitting in the hot seat at the hearing was Dr. Patrick Conway, Director and Chief Medical Officer for the Center for Medicare Services (CMS) who had the overdue task of explaining the rising misuse of chemical restraints in the nursing homes his agency was tasked with monitoring. Dr. Conway testified about CMS’s seven-part plan to “eliminating inappropriate use of antipsychotics. On this third anniversary of the Senate hearing, it seems like a good time to evaluate CMS’s performance.
1) Survey and Certification. Grade – F
Dr. Conway first spoke of CMS’s role as an enforcement agency and its commitment to cracking down on inappropriate drugging by its “armies of quality assurance.” While CMS did tinker with its guidelines for unnecessary medications and dementia care, enforcement requires action. Since the Senate hearing, enforcement of the federal standards to prevent inappropriate drugging – informed consent, chemical restraints, unnecessary use – has barely budged. Nursing homes who chemically restrain residents are no more likely to suffer penalties today than they were on Nov. 30, 2011. No progress has been made in enforcement despite Dr. Conway’s promises.
2) Training and Education. Grade – C+
The centerpiece of CMS’s subsequent campaign to end the misuse of antipsychotics in nursing homes has been education. Federal surveyors were trained and CMS sent a copy of its fine dementia care guide (Hand-in-Hand) to every nursing home in the country. But since an initial burst of activity, the CMS education efforts have largely been delegated to state coalitions where effectiveness has varied widely.
3) Regulations. Grade – F
Dr. Conway touted proposed new rules that would better insulate nursing home pharmacists from financial incentives to drug residents. The proposed rules were excellent and generated overwhelming support. CMS’s reaction was to kill the proposed rules. If there were a grade lower than an F, CMS would get it here.
4) Research. Grade – F
Dr. Conway stated CMS was funding research into nursing home prescribing practices that would presumably drive some change in inappropriate drugging. We have not seen the results of the research and even if it was completed, have not observed any impact on nursing home practices.
5) Quality Measure. Grade – C
CMS’s promise to place nursing home antipsychotic usage rates on its Nursing Home Compare website has been accomplished. But the “rates” are misleading. Rather than post the actual percentage of residents in the facility who receive an antipsychotic, the quality measure rates have exceptions and exclusions that conceal a lot of antipsychotic usage.
6) State Partnerships. Grade – B
CMS has consistently promoted state efforts to address inappropriate antipsychotic use and has periodically identified and spread best practices in dementia care.
7) Collaboration. Grade – C
Collaborations among nursing home care providers, resident advocates, and states were seen by CMS as the best way to reduce inappropriate use and it has encouraged those collaborations. The chief result has been the setting of antipsychotic reduction goals – 15% by the end of 2012 (that was not met until the end of 2013) and an additional 15% reduction by the end of 2016. The problem with such low numerical goals is they inherently accept and ignore a high level of drug misuse and attendant suffering. The goals were also set without the input of residents or resident advocates, whose views were not solicited and ultimately ignored.
Overall, we give CMS a D grade in its effort to eliminate the inappropriate use of antipsychotics in nursing homes. The main reason why is at least 299,000 nursing home residents in this country receive an antipsychotic – the vast majority of whom would be far better off with comfort-focused dementia care instead. CMS has worked on this issue, set some goals, and reduced the overall use of antipsychotics. But it has treated the issue as a mere training or education problem instead of the urgent crisis of outright elder abuse that it is. The bottom line is that CMS continues to tolerate widespread use of chemical restraints in our nursing homes and touts its campaign’s slow and insufficient progress.