New Antipsychotic Prescribing Continued into Skilled Nursing Facilities Following a Heart Failure Hospitalization: a Retrospective Cohort Study

Abstract

Background: Multimorbidity and polypharmacy are common among individuals hospitalized for heart failure (HF). Initiating high-risk medications such as antipsychotics may increase the risk of poor clinical outcomes, especially if these medications are continued unnecessarily into skilled nursing facilities (SNFs) after hospital discharge.

Objective: Examine how often older adults hospitalized with HF were initiated on antipsychotics and characteristics associated with antipsychotic continuation into SNFs after hospital discharge.

Design: Retrospective cohort.

Participants: Veterans without prior outpatient antipsychotic use, who were hospitalized with HF between October 1, 2010, and September 30, 2015, and were subsequently discharged to a SNF.

Main measures: Demographics, clinical conditions, prior healthcare utilization, and antipsychotic use data were ascertained from Veterans Administration records, Minimum Data Set assessments, and Medicare claims. The outcome of interest was continuation of antipsychotics into SNFs after hospital discharge.

Key results: Among 18,008 Veterans, antipsychotics were newly prescribed for 1931 (10.7%) Veterans during the index hospitalization. Among new antipsychotic users, 415 (21.5%) continued antipsychotics in skilled nursing facilities after discharge. Dementia (adjusted OR (aOR) 1.48, 95% CI 1.11-1.98), psychosis (aOR 1.62, 95% CI 1.11-2.38), proportion of inpatient days with antipsychotic use (aOR 1.08, 95% CI 1.07-1.09, per 10% increase), inpatient use of only typical (aOR 0.47, 95% CI 0.30-0.72) or parenteral antipsychotics (aOR 0.39, 95% CI 0.20-0.78), and the day of hospital admission that antipsychotics were started (day 0-4 aOR 0.36, 95% CI 0.23-0.56; day 5-7 aOR 0.54, 95% CI 0.35-0.84 (reference: day > 7 of hospital admission)) were significant predictors of continuing antipsychotics into SNFs after hospital discharge.

Conclusions: Antipsychotics are initiated fairly often during HF admissions and are commonly continued into SNFs after discharge. Hospital providers should review antipsychotic indications and doses throughout admission and communicate a clear plan to SNFs if antipsychotics are continued after discharge.

Keywords: antipsychotic agents; heart failure; hospitalization; nursing homes; older adults.

Figure 1

Flow diagram of Veterans hospitalized for heart failure and discharged to a skilled nursing facility by antipsychotic exposure, 2010–2015. Abbreviations: HF, heart failure; SNF, skilled nursing facility; MDS, minimum data set; ADL, activities of daily living.