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Name
Potentially Inappropriate Use of Antipsychotics in Long-Term Care
Short/Other Names

Percentage of Residents on Antipsychotics Without a Diagnosis of Psychosis

Description
This indicator looks at how many long-term care residents are taking antipsychotic drugs without a diagnosis of psychosis. These drugs are sometimes used to manage behaviours in residents who have dementia. Careful monitoring is required, as such use raises concerns about safety and quality of care.
Interpretation
Lower is better. It means that a lower percentage of long-term care residents received antipsychotic medication.
HSP Framework Dimension

Health System Outputs: Appropriate and effective

Areas of Need

Living With Illness, Disability or Reduced Function

Geographic Coverage

Newfoundland and Labrador, New Brunswick, Nova Scotia, Ontario, Manitoba, Saskatchewan, Alberta, British Columbia, Yukon

Reporting Level/Disaggregation

Province/Territory, Region, Facility, Corporation, Sector (residential and hospital-based continuing care)

Indicator Results

Accessing Indicator Results on Your Health System: In Depth

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<div role="button" class="expandableTitle" aria-controls="identifyingInfoRegion">Identifying Information</div>
Name
Potentially Inappropriate Use of Antipsychotics in Long-Term Care
Short/Other Names

Percentage of Residents on Antipsychotics Without a Diagnosis of Psychosis


<div role="button" class="expandableTitle" aria-controls="descAndCalRegion">Indicator Description and Calculation</div>
Description
This indicator looks at how many long-term care residents are taking antipsychotic drugs without a diagnosis of psychosis. These drugs are sometimes used to manage behaviours in residents who have dementia. Careful monitoring is required, as such use raises concerns about safety and quality of care.
Calculation: Description

This indicator examines the percentage of residents on antipsychotics without a diagnosis of psychosis. It is calculated by dividing the number of residents who received antipsychotic medication by the number of all residents with valid assessments (excluding those with schizophrenia, Huntington’s chorea, delusions and hallucinations, and end-of-life residents) within the applicable time period.

Unit of Analysis: Resident

Calculation: Geographic Assignment

Place of service

Calculation: Type of Measurement

Percentage or proportion

Calculation: Adjustment Applied

The following covariates are used in risk adjustment:
Individual Covariates: Motor agitation; moderate/impaired decision-making problem; long-term memory problem; Cognitive Performance Scale (CPS); combination Alzheimer's disease/other dementia; age younger than 65

Facility-Level Stratification: Case Mix Index (CMI)

Calculation: Method of Adjustment

Stratification, Direct Standardization, Indirect Standardization
Standard Population:
3,000 facilities in 6 U.S. states and 92 residential care facilities and continuing care hospitals in Ontario and Nova Scotia

Denominator

Description:
Residents with valid assessments

Inclusions:
1. Residents with valid assessments. To be considered valid, the target assessment must

a. Be the latest assessment in the quarter

b. Be carried out more than 92 days after the Admission Date

c. Not be an Admission Full Assessment
Exclusions:
1. Residents who are end-stage disease (J5c = 1) or receiving hospice care (P1ao = 1)

2. Residents who have a diagnosis of schizophrenia (I1ii = 1) or Huntington's chorea (I1x = 1), or those experiencing hallucinations (J1i = 1) or delusions (J1e = 1)

Numerator

Description:
Residents who received antipsychotic medication on their target assessment

Inclusions:
1. Residents with valid assessments. To be considered valid, the target assessment must

a. Be the latest assessment in the quarter

b. Be carried out more than 92 days after the Admission Date

c. Not be an Admission Full Assessment

2. Residents who received antipsychotic medication on one or more days in the week before their target assessment (O4a = 1, 2, 3, 4, 5, 6 or 7)
Exclusions:
1. Residents who are end-stage disease (J5c = 1) or receiving hospice care (P1ao = 1)

2. Residents who have a diagnosis of schizophrenia (I1ii = 1) or Huntington's chorea (I1x = 1), or those experiencing hallucinations (J1i = 1) or delusions (J1e = 1)


<div role="button" class="expandableTitle" aria-controls="backgroundRegion">Background, Interpretation and Benchmarks</div>
Rationale

CCRS quality indicators were developed by interRAI (www.interrai.org), an international research network, to provide organizations with measures of quality across key domains, including physical and cognitive function, safety and quality of life. Each indicator is adjusted for resident characteristics that are related to the outcome and independent of quality of care. The indicators can be used by quality leaders to drive continuous improvement efforts. They are also used to communicate with key stakeholders through report cards and accountability agreements.

Interpretation

Lower is better. It means that a lower percentage of long-term care residents received antipsychotic medication.

HSP Framework Dimension

Health System Outputs: Appropriate and effective

Areas of Need

Living With Illness, Disability or Reduced Function

Targets/Benchmarks

CIHI: None

Health Quality Ontario (external): 19% for long-term care

References

Canadian Institute for Health Information. CCRS Quality Indicators Risk Adjustment Methodology. 2013.

Canadian Institute for Health Information. When a Nursing Home Is Home: How Do Canadian Nursing Homes Measure Up on Quality? 2013.

Health Quality Ontario. Long-Term Care Benchmarking Resource Guide. 2013.

Health Quality Ontario. Results From Health Quality Ontario’s Benchmark Setting for Long-Term Care Indicators. 2017.

Health Quality Ontario. Health Quality Ontario Indicator Library. Accessed October 4, 2017.

Hirdes JP, Mitchell L, Maxwell CJ, White N. Beyond the "iron lungs of gerontology": Using evidence to shape the future of nursing homes in Canada. Canadian Journal on Aging. 2011.

Hirdes JP, Poss JW, Caldarelli H, et al. An evaluation of data quality in Canada's Continuing Care Reporting System (CCRS): Secondary analyses of Ontario data submitted between 1996 and 2011. BMC Medical Informatics and Decision Making. 2013.

Jones RN, Hirdes JP, Poss JW, et al. Adjustment of nursing home quality indicators. BMC Health Services Research. 2010.


<div role="button" class="expandableTitle" aria-controls="availabilityRegion">Availability of Data Sources and Results</div>
Data Sources

CCRS

Available Data Years

Type of Year:
Fiscal
First Available Year:
2010
Last Available Year:
2016

Geographic Coverage

Newfoundland and Labrador, New Brunswick, Nova Scotia, Ontario, Manitoba, Saskatchewan, Alberta, British Columbia, Yukon

Reporting Level/Disaggregation

Province/Territory, Region, Facility, Corporation, Sector (residential and hospital-based continuing care)


<div role="button" class="expandableTitle" aria-controls="resultRegion">Result Updates</div>
Update Frequency

Every year

Indicator Results

Web Tool:
Your Health System: In Depth
URL:
Accessing Indicator Results on Your Health System: In Depth

Updates

Residents who have been coded as experiencing delusions have been excluded from the calculation of the numerator and denominator for this indicator.


<div role="button" class="expandableTitle" aria-controls="qualityRegion">Quality Statement</div>
Caveats and Limitations

Users should be cautious when interpreting results from the Continuing Care Reporting System (CCRS) because the CCRS frame does not currently contain all facilities in all provinces and territories that make up the CCRS population of interest; thus the population covered by CCRS may not be representative of all continuing care facilities across Canada.

Coverage is incomplete in the following jurisdictions:

– Manitoba (includes all facilities in Winnipeg Regional Health Authority only)
– New Brunswick
– Nova Scotia

Indicators are risk-adjusted to control for potential confounding factors.

Trending Issues

Since 2003, the number of facilities and jurisdictions submitting to CCRS has been increasing. With the addition of new jurisdictions, it is possible that differences in care practices may affect indicator rates; however, changes to the underlying population would be controlled for using risk adjustment. There is also evidence to suggest that trending and use of data from the entire time series is not an issue and that data quality is consistent over time (Hirdes et al., 2013).

Comments

The CCRS quality indicators use 4 rolling quarters of data for calculations in order to have a sufficient number of assessments for risk adjustment. Since residents are assessed on a quarterly basis, each resident can contribute to the indicator up to 4 times.

Data for this indicator is also available in the Quick Stats tool, which includes results in both the residential and hospital-based continuing care sectors: https://www.cihi.ca/sites/default/files/document/ccrs-quick-stats-2016-2017-en.xlsx.

Indicator results are also available on

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