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High-Risk Medication Use by Nursing Home Residents Before and After Hospitalization

Stevenson, David G. PhD*; Dusetzina, Stacie B. PhD; James O’Malley, A. PhD; Mitchell, Susan L. MD, MPH§; Zarowitz, Barbara J. PharmD, FCCP, BCPS, CGP, FASCP; Chernew, Michael E. PhD; Newhouse, Joseph P. PhD¶,#,**,††; Huskamp, Haiden A. PhD

doi: 10.1097/MLR.0000000000000214
Original Articles

Background: Two prominent challenges in nursing home care are ensuring appropriate medication use and achieving high-quality care as residents transition from the hospital to the nursing home. Research about prescribing practices at this important clinical juncture is limited.

Objective: To analyze the use of high-risk medications by nursing home residents before and after being hospitalized. We define high-risk medications using the Beers criteria for potentially inappropriate medication use.

Research Design, Subjects, Measures: Using a dataset with Medicare claims for inpatient and skilled nursing facility stays and pharmacy claims for all medications dispensed in the nursing home setting, we examine high-risk medication use for hospitalized nursing home residents before and after being hospitalized. Our study population includes 52,559 dual-eligible nursing home residents aged 65 and older who are hospitalized and then readmitted to the same nursing home in 2008. Our primary outcome of interest is the use of high-risk medications in the 30 days before hospitalization and the 30 days following readmission to the same nursing home.

Results: Around 1 in 5 (21%) hospitalized nursing home residents used at least 1 high-risk medication the day before hospitalization. Among individuals with high-risk medication use at hospitalization, the proportion using these medications dropped to 45% after nursing home readmission but increased thereafter, to 59% by the end of the 30-day period.

Conclusion: We found moderate levels of high-risk medication use by hospitalized nursing home residents before and after their hospital stays, constituting an important clinical and policy challenge.

*Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN

Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, Department of Health Policy and Management, Gillings School of Global Public, University of North Carolina at Chapel Hill, Chapel Hill, NC

The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH

§Hebrew Senior Life, Institute for Aging Research, Boston, MA

Omnicare Inc., Livonia, MI

Department of Health Care Policy, Harvard Medical School

#Department of Health Policy and Management, Harvard School of Public Health, Boston

**Harvard Kennedy School, Cambridge

††National Bureau of Economic Research, Cambridge, MA

The National Institute on Aging (R01 AG034085) provided financial support for the work. D.G.S. was supported by NIH-NIA K01 AG038481. S.L.M. was supported by NIH-NIA K24AG033640. S.B.D. is supported by the NIH Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) K12 Program and the North Carolina Translational and Clinical Sciences Institute (UL1TR001111).

J.P.N. is a director of and holds equity in Aetna, which sells Part D plans. B.J.Z. is an employee of Omnicare Inc., and holds Omnicare Inc., stock. She participates in research projects funded by grants from Amgen, Sanofi-Aventis, Mylan, AbbVie, Astellas, and Optimer. The remaining authors declare no conflict of interest.

Reprints: David G. Stevenson, PhD, Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Avenue, Suite 1200, Nashville, TN 37203-8684. E-mail:

© 2014 by Lippincott Williams & Wilkins.