Understanding stubborn antipsychotic prescribing in nursing homes: An environmental scan of National Partnership stakeholders

Context: Since CMS debuted the National Partnership to Improve Dementia Care in Nursing Homes (NHs), antipsychotic (AP) prescribing in NHs has decreased. Reductions have stalled in recent years however, and more than one in six NH residents continues to be prescribed AP medication despite poor safety and efficacy data. Environmental scans of QI stakeholders can help explain gaps between what is desired at the policy level and what happens in practice.

Objective: Apply an environmental scan of Partnership stakeholders to clarify why AP prescribing for dementia symptoms continues in NHs despite reduction efforts and consistent data showing concerning risk and, at best, modest effectiveness.

Setting/population: Between 2017 and 2022, we identified and engaged stakeholders in the decision to prescribe or not prescribe antipsychotics to NH residents. Stakeholders included the residents themselves, as well as their families, caregivers, clinicians, pharmacists, and the facilities in which they dwell. Other stakeholders included policy makers, advocacy groups, specialty associations, guideline creators, regional and federal legislators, the media, research scientists, communities, hospitals, and the pharmaceutical industry.

Study design/analysis: Where possible, stakeholders were assessed with structured qualitative interviews. When this was not possible, informal but purposive interviews were performed. Literature review supplemented gaps in stakeholder interviews. All assessments examined the variance between desired AP prescribing and practice reality. Condensed summaries of stakeholder perspectives were created through a structured five-pass horizontal process of immersion and crystallization. A coding team constructed prospective summations that best represented the distilled perspectives of stakeholder groups. Differences were resolved through negotiated consensus.

Results: Condensed perspectives of the 16 stakeholders engaged in this environmental scan, collated to emphasize at least one barrier to care and one opportunity to improve care.

Conclusion: An environmental scan of all Partnership stakeholders reveals improvement opportunities undetectable to single stakeholder assessments. These results suggest the success of the Partnership could be augmented by inclusion of all stakeholder perspectives, incorporation of contextual factors, and an explicit mechanism for continual adaptation.