Evaluation of National Drug Use Reviews to
Improve Patient Safety in Nursing Homes
Becky Briesacher, PhD1
Rhona Limcangco, MPharm2
Linda Simoni-Wastila, PhD1,2
Jalpa Doshi, PhD3
Jerry Gurwitz, MD1
1University
of Massachusetts
2University of Maryland
3University of Pennsylvania
May 2004
Funded by Centers of Medicare and Medicaid Services (CMS)
Introduction
In July 1999, CMS expanded drug use review protocols of
nursing homes [NH] to include 41 inappropriate medications.
Largest effort to codify standards of safe medication use in
NHs since the 1987 OBRA to reduce antipsychotics.
State surveyors and consultant pharmacists must evaluate
medication records for:

use of inappropriate drugs,

adverse medication reactions, or

justification if exempted use.
For noncompliance, surveyors may cite facility as
deficient in care and jeopardize CMS certification status.
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Background and Study Objective
New drug criteria based on 1997 consensus list of risky
medications for older adults (Beers criteria);
 Criteria apply to all adults 65+ and some relate to specific diseases.
 Highest use of Beers drugs occurs in NHs. (23%-40%).
No agreement about best solutions to reduce use.
 Advocates for policy interventions believe unsafe medication use
will continue unabated without drug reviews.
 Critics argue prescribing habits will naturally decline as new
practice patterns omit “archaic and offensive” drugs.
To test if nationally-required drug use reviews reduce
exposure to inappropriate medications in NHs.
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Methods
Data
 1997-2000 Medicare Current Beneficiary Survey (MCBS), nationally
representative dataset of community-dwelling and institutionalized
Medicare beneficiaries
 Overlapping panel samples selected w/stratified probability design
(n=12,000)
 Data contain surveys of health status and medical care linked to
Medicare Part A and B claims.
 Our study linked a restricted file of MCBS LTC medications. LTC
medication file contains monthly chart abstracts of MARs.
Study sample
 Medicare beneficiaries in NHs [unweighted n=2,242] and
comparator group in Assisted Living Facilities (ALF)
[unweighted n=664].
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Methods
Criteria
 Study created measures for 38 of 41 CMS criteria
 (3 drugs omitted due to ill-defined disorders such as insomnia)
 Criteria categorized by consensus classification of
justifiable use (Zhan 2001):
 always avoid (e.g. Barbiturates such as Barbital)
 rarely appropriate (e.g., Valium), or
 some acceptable indications (e.g., Amitriptyline).
 Medical claims/health surveys examined for disease
criteria
 Diabetes, BPH, COPD, GERD/PUD, arrhythmia, or seizure/epilepsy.
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Methods
Analysis
 Study constructed quarterly observations of medication use
 Estimated prevalent use and new exposures
 new drug use is preceded by three months’ without any use
 Did not apply CMS protocols for exceptions
 (e.g., some criteria do not apply if medication given intermittently)
 Plotted exposure rates in relation to policy implementation
(11 quarters prior and 5 quarters post).
 Compared pre- and post-policy estimates between NHs and ALFs
 Statistical Approach: descriptive frequencies and multivariate
analysis controlling for demographics and health status
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Table 1. Population Characteristics, 1997 and 2000
1997
2000
Characteristics
NH
ALF
NH
ALF
Weighted total
n=2,026,000
n=496,000
n=1,860, 000
n=585, 000
Average age
80.3
73.6
80.5
74.6
Female (%)
67.7
67.1
69.3
68.0
White race (%)
88.1
95.5
86.3
94.9
Fair-Poor Health (%)
65.8
43.5
65.9
41.4
Select Conditions (%)
Dementia/Alzheimer’s
Diabetes
Chronic lung disease
BPH
GERD/PUD
Seizure/Epilepsy
Arrhythmia
44.6
27.1
24.0
3.2
3.8
23.8
7.1
34.4
16.8
17.8
4.1
2.6
13.5
5.3
42.3
29.6
30.1
5.6
2.6
31.1
8.0
32.0
20.9
15.5
3.4
1.0
17.1
4.2
7.6
7.2
8.9
7.9
Average Monthly
Rx Use
Unweighted unique n=928 (1997) n=843 (2000) NH; n=250 (1997) n=289 (2000) ALF
Source: MCBS, 1997-2000
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Figure 1.
National US estimates of inappropriate medication use always to be avoided or rarely appropriate by
institutional residence, 1997-2000
Fig 1
6
Nursing Home
Assisted Living
July 1999 CMS Policy Expansion
5
Percent Prevalence
4
3
2
1
0
Q1-1997
Q2
Q3
Q4
Q1-1998
Q2
Q3
Q4
Q1-1999
Q2
Q3
Q4
Q1-2000
Q2
Q3
Q4
Quarters
7
Figure 2.
National estimates of inappropriate medication use that may have some indications by institutional
residence, 1997-2000
Fig 2
Nursing Homes
Assisted Living
25
July 1999 CMS Policy Expansion
Percent Prevalence
20
15
10
5
0
Q1-1997
Q2
Q3
Q4
Q1-1998
Q2
Q3
Q4
Q1-1999
Q2
Q3
Q4
Q1-2000
Q2
Q3
Q4
Quarters
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Fig 3
Figure 3.
National US estimates of innapropriate medication use restricted with specific diagnoses,
by institutional residence, 1997-2000
Nursing Home
Assisted Living
20
July 1999 CMS Policy Expansion
Percent Prevalence
15
10
5
0
Q1-1997
Q2
Q3
Q4
Q1-1998
Q2
Q3
Q4
Q1-1999
Q2
Q3
Q4
Q1-2000
Q2
Q3
Q4
Quarters
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Results
Descriptive analysis found evidence of general trend toward
less Beers criteria prescribing in ALFs and NHs rather than
policy impact.
Pre-policy and Post-policy prevalence rates:
 NH 28.8% (95% CI: 27.3-30.3) to 25.6% (CI: 24.1-27.1, p<.05)
 ALF 22.4% (CI: 19.8-25.0) to 19.0% (CI: 16.7-21.3).
Prescriber disfavor did not include disease criteria.
Most prescribing in post-period is new use (16.4% in NH vs.
16.6% in ALFs)
Multivariate analysis detected no differences in post-policy
use of inappropriate drugs between NHs and ALFs.
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Caveats and Conclusion
•Cross-over effects possible
•Post-policy observation may have been too short
Study highlights unclear effectiveness of trying to improve
patient safety in NH through nationally mandated drug use
reviews.
Our study is the first to evaluate CMS policy on inappropriate
medications.
Study is among the first to use MCBS LTC drug files.
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