Quality gap in nursing home antipsychotic quality measure performance increases over pandemic, reversing past gains

Context: Since 2011, CMS has graded nursing home (NH) performance in antipsychotic (AP) prescribing quarterly, publishing findings as a quality measure (QM). While average AP prescribing has decreased since 2011, marked performance variation between the best- and the worst-performing NHs persists. The COVID-19 pandemic had a detrimental effect on all measured quality in NHs; the impact on equity in quality, however, is less understood.

Objective: Assess the performance trajectories of the best- and worst-performing NH deciles in AP QM scores, emphasizing the inflection point of the pandemic.

Dataset: NursingHomeCompare reports NH QM outcomes for every federally certified NH in the US from 2011-2022 (Quarterly average: 13,837).

Study Design/Analysis: Interrupted time series. Quarterly AP QM scores were sorted into deciles of performance and trended from quarter 2 of 2011 to quarter 1 of 2022. To measure the difference in changes in quality between the best- and worst-performing deciles, an OLS linear regression model was applied, incorporating a one-degree spline with a knot at quarter 2 of 2020 to model trends before and during the pandemic.

Results: All deciles of AP QM performance improved over the pre-pandemic period and relapsed over the pandemic period; however, the best- and worst-performing deciles were on different improvement trajectories over both intervals. The quality gap between the best- and worst-performing deciles narrowed over the pre-pandemic period as the worst-performing decile improved faster than the best-performing decile (improving 1.7% versus 0.9% annually, p<.0001). During the pandemic, the quality gap widened as best-performing decile relapsed less than the best-performing decile (worsening by 0.5% vs 1.8% annually, p<.0001).

Conclusions: The pandemic reversed advances in AP QM performance equity in addition to AP QM performance. The negative impacts of the pandemic on AP QM performance were disproportionately concentrated in already poor-performing deciles, while the best-performing deciles had greater resilience to pandemic stressors. Even as QMs improve, it is still important to monitor equity in performance across NHs. The gap in quality between the best-and worst-performing NHs remains wide, illustrating the need for ongoing improvement in NH quality performance equity. The stress test of the pandemic may offer opportunities to better understand the factors contributing to inequity in quality performance.