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Research funding has been criticized as biased against novel initiatives and lacking diversity, which leads to further disparities. Patient and stakeholder engagement could support research that goes beyond traditional paradigms and increases diversity. However, best practices to engage stakeholders in research, including funding decisions, continue to be developed. We report on the implementation of stakeholder input in two federally funded initiatives, one that seeks to advance research reducing disparities, and the other seeks to advance deprescribing research. Overall, the review process includes stakeholders as decision makers and supports their efforts through group discussion and other activities. Reconciling stakeholder input that may differ from scientific peer review is a challenge within the decision for funding. Lessons learned include balancing stakeholder and scientific assessments and including guidance on stakeholder engagement to grant awardees. [ABSTRACT FROM AUTHOR]

This study examines the association between antipsychotic (AP) medication use and care transitions in the nursing home (NH) population. This cross-sectional study used data from a 5% random sample of Medicare beneficiaries between 2011 and 2015. Propensity score adjusted negative binomial regression was performed and conditional probabilities of having a first transition from the NH to specific locations were calculated. Among 150,284 eligible beneficiaries, the majority were female (67%), white (84%), and >75 years old (63%). Controlling for resident characteristics, the odds of having any transition was 5% lower among those with AP use [IRR (95% confidence interval (CI))=0.95(0.94–0.96)] relative to those with no AP use. Residents with AP use had higher proportions of transitions to hospital (22.7% vs. 19.5%, p < 0.01), emergency department (19.6% vs. 10.7%, p < 0.01), and different NH (1.5% vs. 0.4%, p < 0.01), and lower proportions of transition to non-healthcare locations compared to those without AP use. Findings demonstrate that residents with AP use had higher probabilities of transitions to more costly care settings such as the emergency department and hospital compared to those without AP use. Future longitudinal studies will help to inform clinical interventions aimed at improving the quality of care for this population. [ABSTRACT FROM AUTHOR]

Purpose: Psychotropic medications are used to manage behavioral symptoms of dementia in nursing homes despite limited efficacy and the risk of adverse effects, and may be considered an easier solution for the treatment of behavioral symptoms. However, non‐pharmacologic interventions are preferable but are most effective with consistent staffing. To address this, the Centers for Medicare and Medicaid Services implemented additional regulatory scrutiny through F‐tag for deficiencies of care, targeting inappropriate psychotropic medication use (F‐758 tag). The purpose of this study was to examine associations between nurse staffing levels and the occurrence of deficiency citations for inappropriate psychotropic medication use in residents with dementia symptoms. Design This was secondary data analysis of a cross‐sectional study using CASPER (Certification and Survey Provider Enhanced Reporting) and PBJ (Payroll‐Based Journal) data from 14,548 Medicare or Medicaid‐certified facilities surveyed between December 1, 2017 and December 31, 2018. Methods: Staffing measures included nursing hours per resident day and registered nurse skill‐mix. Generalized linear mixed models with facilities nested within states, were used to estimate the magnitude of the associations between the occurrence of inappropriate psychotropics use deficiency citations and nurse staffing levels. Covariates included facility location, size, ownership, the presence of dementia special care units, and the proportion of residents with dementia, depression, psychiatric disorders, mental behavioral symptoms, and residents with Medicare/Medicaid. Results: There were 1875 facilities with deficiency citations regarding inappropriate psychotropics use for residents with dementia. When controlling for covariates, facilities with greater hours per resident day for registered nurses (odds ratio [OR] = 0.54, 95% confidence interval [CI] = 0.44–0.67), certified nursing assistants (OR = 0.87, 95% CI = 0.77–0.99) and total nurse staff (OR = 0.87, 95% CI = 0.79–0.96) had significantly lower odds of inappropriate psychotropics use deficiency citations. Nursing homes with greater registered nurse skill‐mix had significantly lower odds of receiving the deficiency tags (OR = 0.10, 95% CI = 0.04–0.26). Conclusion: Citations for inappropriate psychotropic medication use among residents with dementia were less likely to occur in facilities with higher staffing levels for registered nurses, certified nursing assistants, total nurse staff, and greater registered nurse skill‐mix. Facilities need to be equipped with adequate nurse staffing levels to facilitate the use of non‐pharmacological interventions and reduce inappropriate psychotropic medication use. Clinical Relevance: Adequate nursing staffing is associated with fewer deficiencies related to the use of psychotropic medications to treat behavioral symptoms. Nursing home administrators and policymakers need to focus on assuring adequate nurse staffing levels to provide safe and high‐quality dementia care. [ABSTRACT FROM AUTHOR]

Objective: To examine the determinants of potentially inappropriate medication (PIM) use.Data Sources/study Setting: U.S. nationally representative data on (n = 16,588) noninstitutionalized older adults (age ≥65) with drug use from the 2006-2010 Medical Expenditure Panel Survey.Study Design: We operationalized the 2012 Beers Criteria to identify PIM use during the year, and we examined associations with individual-level characteristics hypothesized to be quality enabling or related to need complexity.Principal Findings: Almost one-third (30.9 percent) of older adults used a PIM. Multivariate results suggest that poor health status and high-PIM-risk conditions were associated with increased PIM use, while increasing age and educational attainment were associated with lower PIM use. Contrary to expectations, lack of a usual care source of care or supplemental insurance was associated with lower PIM use. Medication intensity appears to be in the pathway between both quality-enabling and need-complexity characteristics and PIM use.Conclusion: Our results suggest that physicians attempt to avoid PIM use in the oldest old but have inadequate focus on the high-PIM-risk conditions. Educational programs targeted to physician practice regarding high-PIM-risk conditions and patient literacy regarding medication use are potential responses. [ABSTRACT FROM AUTHOR]

Engagement in children's mental health treatment is strikingly low. This might be due to differences in perspectives about what it means to be engaged in treatment as well as the strategies that are most effective at engaging families, as little is known about how well consumers' perspectives map onto current models of engagement and the empirical literature. This qualitative study examined family perspectives of (1) aspirational and actual engagement in treatment, (2) barriers that impeded engagement, and (3) engagement strategies they recommended their providers and agencies use. Four focus groups were conducted with 20 caregivers (ages 24-75), and 11 youth and young adults (ages 15-23). All participants were currently or formerly enrolled in children's mental health services. Data were analyzed through consensual qualitative research methods. Findings revealed that youth and caregivers' definitions of engagement included both attitudinal and behavioral components. Numerous barriers impeded components of aspirational engagement, and agency- and provider-related barriers were most pervasive. Youth reported more attitudinal barriers, whereas caregivers reported more behavioral barriers. Participants described advocacy (e.g., taking direct action to influence treatment) as a key engagement component; however, such advocacy often involved treatment non-adherence that could be interpreted by providers as disengagement. Families recommended strategies to strengthen the therapeutic relationship and build trust that are empirically supported. However, families described many experiences in which providers did not use these empirically supported strategies. Families also described some theoretically supported engagement strategies as having a negative impact on engagement. In sum, the findings suggest that providers should take an empowering family-centered treatment approach where they seek to understand and build upon clients' engagement perspectives. [ABSTRACT FROM AUTHOR]

Objectives To examine disease-specific associations between antipsychotic dose and duration and all-cause mortality. Design Retrospective cohort study. Setting A 5% random sample of Medicare beneficiaries who had a Minimum Data Set 2.0 clinical assessment completed between 2007 and 2009. Participants Three mutually exclusive cohorts of new antipsychotic users with evidence of severe mental illness ( SMI, n = 5,621); dementia with behavioral symptoms (dementia + behavior) without SMI (n = 1,090); or delirium only without SMI or dementia + behavior (n = 2,100) were identified. Measurements Dose and duration of therapy with antipsychotics were assessed monthly with a 6-month look-back. Dose was measured as modified standardized daily dose ( mSDD), with a mSDD of 1 or less considered below or at recommended maximum geriatric dose. Duration was categorized as 30 or fewer, 31 to 60, 61 to 90, and 91 to 184 days for SMI and dementia + behavior and 7 or fewer, 8 to 30, 31 to 90, and 91 to 184 days for delirium. Complementary log-log models with mSDD and duration as time-dependent variables were used to estimate hazard ratios ( HRs) and 95% confidence intervals ( CIs) for mortality. Results In all three groups, new antipsychotic users with a mSDD of 1 or less had significantly lower mortality risk ( HRSMI = 0.77, 95% CI = 0.67-0.88; HRdementia+behavior = 0.52, 95% CI = 0.36-0.76; HRdelirium = 0.61, 95% CI = 0.44-0.85) than peers with a mSDD greater than 1. Individuals with longer duration of antipsychotic use (91-184 days for SMI and delirium) had significantly lower mortality than those with a short duration of use (≤30 days for SMI; ≤7 days for delirium). The interaction between dose and duration was statistically significant in the SMI cohort ( P < .001). Conclusion Lower mortality was observed with within-recommended dose ranges for dementia + behavior, SMI, and delirium and with long duration of antipsychotic use for the latter two disease groups. Prescribers should monitor antipsychotic dosage throughout the course of antipsychotic treatment and customize dose and duration regimens to an individual's indications. [ABSTRACT FROM AUTHOR]

Objectives To examine the influence of quality measures of psychopharmacological medication ( PPM) prescribing on all-cause mortality in a Medicare long-stay nursing home ( NH) population. Design Longitudinal. Setting 2007-09 Medicare data linked to Minimum Data Set 2.0 files. Participants Four new-user cohorts of residents initiating antipsychotic (n = 13,105), antidepressant (n = 14,251), anxiolytic and sedative-hypnotic (n = 10,789), and any PPM (n = 14,568) medication. Measurements Three measures of PPM prescribing quality were assessed monthly with a 6-month look-back: evidence of appropriate indication, dose (modified standardized daily dose ( mSDD); below (<1), at (1), and above (>1) recommended geriatric dose), and duration of therapy (DOT; ≤30, 31-60, 61-90, 91-180 days from medication initiation). Complementary log-log models with quality measures as time-dependent variables were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for mortality. Results Appropriate use of antidepressants, anxiolytics and sedative-hypnotics, and any PPMs, as evidenced by appropriate indications, was significantly associated with lower mortality risk (HRantidepressants = 0.81, 95% CI = 0.76-0.86; HRanxiolytics and sedative-hypnotics = 0.81, 0.75-0.88; HRPPM = 0.89, 0.83-0.95). Antipsychotic and anxiolytic and sedative-hypnotic users with a mSDD of less than 1 had lower mortality risk than those with a mSDD greater than 1, whereas a protective effect was observed in antidepressant users with a mSDD greater than 1. In all four cohorts, those with a DOT of 91 to 180 days had lower mortality than those with a DOT of 1 month or less; the lower risk of mortality was detected after antipsychotic use for 31 days or longer. Conclusion Optimal PPM prescribing quality, as measured by indication and duration, is associated with low mortality. The benefit related to drug dosage varied by therapeutic class. When prescribing PPMs to NH residents, providers should consider not only drug choice, but also dose and duration of prescribed regimens. [ABSTRACT FROM AUTHOR]