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Table 3 Facility characteristics associated with APM use

From: Variation in use of antipsychotic medications in nursing homes in the United States: A systematic review

Factors increasing use Probable Etiologies References
   Expert panel inferences Article Explanations  
Physical Facility Characteristics
Physical Location Located in metropolitan area - Possible greater share of for-profit facilities
- Different organizational culture in urban locations
- More crowded NH may result in less medication screens
-Less staff per resident
-No explanation given Stevenson, 2010
Not located in the West or Midwest
Located in the central South or Northeast
- Different state laws and regulation regarding NHs
-Regional variation in training/org. cultures/hiring patterns/staffing levels and mix may all affect quality of care
-Difference in provider practice pattern
- Approaches may differ regionally
- Facilities in the East used a psychiatrist more often than those in the West
- Note: Briesacher, 2005 et al. found lower APM rates in southern U.S.
Briesacher, 2005, Briesacher, 2013,
Chen, 2010, Hughes, 2000 & Stevenson, 2010
Facility Size Smaller facility size -Economies of scale. As a result, larger facilities may be able to have more specialization and devote greater resources to quality care/improvement -Larger facilities may be able to provide more comprehensive services due to economies of scale and may be more able to implement change processes Chen, 2010, Hughes, 2000 & Kamble, 2009
Business Type For-profit status - Maximize profit and minimize cost
- APMs may substitute for staff, education or training
- For profits minimize expenditure which leads to low quality of staffing
- Non-teaching environment can be slower to adopt clinical guidelines
-APMs may be used to maximize profits and minimize the need for hands-on care
-APMs may be used in for-profit facilities as chemical restraints
Castle, 2009, Hughes, 2000, Lester, 2011, Miller, 2006 & Lucas, 2014
Presence of Acuity Services Alzheimer’s disease special care unit or other special care units -The proportion of patients with Alzheimer’s disease or dementia may be larger than in other NHs
-Dementia- related behavioral symptoms may occur more often
- A result of the impact of case-mix that is not completely captured in the aggregate diagnostic and behavioral variables included as controls Hughes, 2000
Staffing Characteristics
Staff Ratios Lower RN Staffing - Lower staff to patient ratios means less time spent with patients resulting in increased APM use - Greater use of APMs has been consistently associated with lower staff to patient ratios Hughes, 2000, Lucas, 2014, Miller, 2006, & Svarstad, 2001
Lower nurse aid staffing - Nurse aides spend more time with the patients, which results in less need for pharmacological treatment - Nurse aides may have more patient time, resulting in less APM use Hughes, 2000
Higher LPN staffing - Less time spent with the patients
-Different level of training could play a role
- LPNs do not spend as much time with the patient Lucas, 2014
BH Expertise Increasing number of mental health professionals and physicians - Physicians typically spend very little time with nursing home patients
- NHs with more mental health professionals may accept more patients with BH issues
- Consultant psychiatry is often identified with higher APM use
- Lucas et al. found however that the presence of mental health staff did not affect APM use
Bonner, 2015, Hughes, 2000 & Lucas, 2014
Facilities served by the highest-ranked psychiatric consultant group - High ranked psychiatric consultant groups make take on NHs with more BH problem patients, resulting in higher APM use - Characteristics of psychiatric consultant groups can influence prescribing Tija, 2014
Less SS support Minimal involvement of social services - Social services may caution against the use of antipsychotic medications or involve the family - Social services influence decision making regarding antipsychotic medication use. Bonner, 2015
Occupancy characteristics
Resident Mix Greater Facility share of Medicaid residents -Lower funding results in less quality of care and increased use of APMs - Medicaid provides less funding than private insurance resulting in fewer overall funds, possibly resulting in higher APM use
-Lower Medicaid reimbursement is associated with increased APM use
Castle, 2009, Hughes, 2000, Lucas, 2014 & Stevenson, 2010
Lower Medicare census No explanation No explanation given Stevenson, 2010
Increased racial diversity -Less funds are associated with lower quality of care in NHs - Less funds, less resources, aligning with the idea of two tiers of USA NH care Bonner, 2015 & Miller, 2006
Occupancy rate Low occupancy rate - Maybe NHs with high APM use become less favorable for the elder population and their families - Less funds are available and APMs may be used as a cheaper alternative for staff Hughes, 2000
Market Characteristics
Competition Minimal or no presence of competition - Competition may force NHs to improve quality of care to maintain occupancy - The presence of competition has shown to increase the quality of care in NHs Castle, 2009
Chain membership Independent Ownership (not part of a chain) - May have less resources, standardization, and accountability, which may lower quality of care - Chain membership may result in a higher degree of corporate standardization and oversight Castle, 2009
Quality Characteristics
Reporting deficiencies NH subject to reporting of physical restraints - Facilities used chemical restraints instead of physical restraints in place of addressing root causes of the overuse - The result of subjecting NHs to report physical restraint use was an increase of antipsychotic use as a substitution Konetzka, 2014
Deficiency citations Facilities with a higher number of deficiency citations - Facilities ranked in the highest quartile for deficiencies most likely provide lower quality of care, which could result in the use of APMs as chemical restraints -Multitasking incentive problem. The efforts to improve quality are spread to multiple areas of concern Lucas, 2014 & Bowblis, 2012
  1. BH behavioral health, LPN licensed practical nurse, MD doctor of medicine, NH nursing home, RN registered nurse