Racial disparity in schizophrenia diagnoses in nursing homes

The share of U.S. nursing home residents who are registered as having schizophrenia has skyrocketed over the past decade. As The New York Times reported last month, the change is in part due to a wave of questionable diagnoses.

A 2012 government effort to reduce the unnecessary use of antipsychotic drugs in nursing homes included an exemption for residents with schizophrenia. Since then, diagnoses have increased by 70 percent. Experts say some facilities are using the schizophrenia loophole to continue sedating dementia patients instead of providing the intensive and more expensive care that regulators are trying to promote.

The impact of this has been more severe on black residents, according to a new study published in the Journal of the American Geriatrics Society. Since the new rules came into effect, black Americans with dementia are 1.7 times more likely than their white nursing home neighbors to be diagnosed with schizophrenia, said researcher Shekinah A. Fashaw-Walters in Public Health at the University of Minnesota and senior author.

Black nursing home residents are already more likely to live in facilities that score lower on many quality measures, she said, and now face higher health risks of being wrongly diagnosed as schizophrenic to justify prescriptions for antipsychotics. For residents with Alzheimer’s disease and other forms of dementia, antipsychotic drugs increase the risk of infections and falls, and double the risk of death, studies show.

“I wanted to look at this increase in schizophrenia by race to see if this policy had a differential effect,” she said.

The results are consistent with previous research on diagnoses of schizophrenia. Among all age groups, clinicians are already more likely to misdiagnose a patient as schizophrenic – and more likely to prescribe antipsychotics – if they are black, said Stephen Strakowski, associate dean of research at the Dell Medical School at the University of Texas at Austin.

“When clinicians talk to a black or white patient who appears otherwise similar in terms of symptoms, they put too much emphasis on psychotic symptoms, delusions, and hallucinations, compared to other symptoms in black patients than they are. they do with white patients, ”he said.

“So it wouldn’t be a terrible surprise if if you encourage the diagnosis now, the difference will be magnified. “

Experts have long been concerned about drugs in nursing homes. The National Partnership for Improved Dementia Care began in 2012 after years of research that showed antipsychotic drugs were widely used in nursing homes despite warnings from the Food and Drug Administration of the potential harms.

The partnership includes federal and state agencies, nursing homes, advocacy groups and caregivers. It supports the care of patients with dementia without medication. This approach often requires substantial staffing and additional training, while antipsychotic medications can make it easier for nurses and caregivers to deal with difficult-to-care residents and cost less.

The partnership called on state inspectors to take a closer look at prescribing practices and issue citations for unnecessary drug use. Prescription rates are counted in official statistics the government uses to help rate facilities, a five-star system that serves as a consumer guide to families choosing a nursing home.

On the surface, the partnership has had a significant impact, boasting a dramatic reduction in the share of residents receiving antipsychotic medication. But the Times report found that more than half of the officially reported reduction in drug use was due to the increase in schizophrenia diagnoses due to the loophole in the new rules.

Responding to the Times report last month, Catherine Howden, spokesperson for the Centers for Medicare and Medicaid Services, said: “It is unacceptable for a facility to inappropriately classify a resident’s diagnosis to improve its performance metrics . We will continue to identify facilities that do so and hold them accountable. “

Nursing homes have increasingly become a provider of last resort for the country’s most vulnerable citizens, and part of the increase in the prevalence of schizophrenia diagnoses could be due to the movement of schizophrenic patients into homes. nursing care from other institutions.

But many experts say the schizophrenia exception is a major factor. The exemption was created because antipsychotic drugs are still considered the best treatment for many people with the disease. But schizophrenia is almost always diagnosed at a young age, and the increase in older residents since the rule took effect is difficult to explain otherwise. When government investigators looked at the medical claims history of nursing home residents diagnosed with schizophrenia in 2018, they found that one in three had no history of treatment for the disorder.

It would not be the first time that the incentives have had unintended consequences on the behavior of retirement homes. Other researchers have found that one of the reasons the drug rate soared in the first place was in reaction to an earlier government crackdown on the use of physical restraint.

Research has repeatedly shown that black Americans tend to receive less, and often worse, care than white Americans for a range of health conditions. Professor Fashaw-Walters says more attention is needed on how this plays out for older African Americans and other people of color. Too often, she said, policies are seen as “color blind” when in fact they could contribute to inequality.

“There’s such an increased risk with antipsychotics for all kinds of side effects, whether it’s falls or death,” she said. “This national partnership could be involved in some of these negative outcomes. This is the kind of scary part I think about the most.

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