Polypharmacy and the 5-Star Rating: How Too Many Medications Can Lower Nursing Home Quality Scores

Introduction

Polypharmacy has been defined in several different ways, but it typically means five or more medications daily. Polypharmacy is prevalent in nursing homes, with some studies finding that 60-90% of nursing home residents receive five or more medications. This is not only dangerous to residents – it can also negatively impact a facility’s CMS 5-Star Quality Measures rating. The more medications a resident receives, the more likely the resident is to experience adverse drug events and detrimental drug interactions. Polypharmacy is also linked to increased falls, hospitalizations, emergency department visits, and mobility issues, all of which are part of the Quality Measures rating.

The Case

A 90-year-old male with advanced dementia has been a long-term resident of Sparkling Shores Nursing Home for four years. He recently became more combative with care and at meals. His physician has prescribed several new medications over the last two months to treat these combative behaviors, including quetiapine, lorazepam, divalproex, and trazodone. His medication list included nine total medications that the resident received on a routine basis. The resident had four falls in the previous two weeks, and the last fall resulted in a femur fracture, which required hospitalization and surgical repair.

Understanding Polypharmacy in Nursing Homes

Common Causes

Many residents in nursing homes have several chronic medical conditions, such as congestive heart failure, diabetes, and dementia, which require medications that lead to increased prevalence of polypharmacy in these facilities. Often, nursing home residents are prescribed a drug that causes a bothersome side effect, which prompts providers to prescribe additional medication to treat the side effects. This phenomenon is called a “prescribing cascade.” There are also typically many different provider types that take care of nursing home residents due to the presence of multiple medical conditions requiring specialized care. Often, there is a lack of coordination among providers during medication reviews, which could limit the number of medications a resident is prescribed.

Scope of the Problem

As previously stated, polypharmacy is relatively common in nursing homes, but what is more startling is that up to 70% of nursing home residents may receive more than nine medications daily. This rate has been increasing since the 1990s. The most common types of drugs prescribed are pain medications such as acetaminophen, opioids, or NSAIDs, as well as cardiovascular medicines like aspirin or those used to treat high blood pressure. Gastrointestinal medications for reflux, constipation, or diarrhea are also frequently prescribed in long-term care facilities, as well as antipsychotics like haloperidol.

CMS 5-Star Quality Measures: The Connection

The Centers for Medicare & Medicaid Services (CMS) developed the 5-Star Quality Rating System to help consumers, families, and caregivers more easily compare nursing homes. Ratings range from 1 star (much below average) to 5 stars (much above average). CMS evaluates facilities in three core areas: health inspections, staffing, and quality measures. Quality measures are most affected by polypharmacy, including falls with significant injury, hospital admissions, functional decline, use of antipsychotic medications, and weight loss.

Root Causes of Polypharmacy within Nursing Homes

Polypharmacy is common in nursing homes for several reasons. Many long-term care facilities have gaps in medication reconciliation and the medication review process. In some facilities, especially those located in rural areas, there may be limited pharmacist engagement. Additionally, many nursing homes have communication challenges between consultants, prescribers, and nursing staff, which can exacerbate polypharmacy. The culture or system of many nursing homes supports an over-reliance on pharmacologic interventions for dementia related behaviors or other challenges, which contribute to polypharmacy.

Strategies to Reduce Polypharmacy and Improve Ratings

There are several strategies that a facility can implement to reduce polypharmacy and subsequently improve resident care and quality measures. It is essential to implement structured medication reviews, preferably led by a pharmacist, to discuss medication necessity, dose, and duplication. Deprescribing protocols can also help guide efforts to reduce polypharmacy. These protocols include evidence-based frameworks such as the Beers Criteria and the STOPP/START tools. Facility staff should be trained to focus on non-pharmacologic behavior management interventions for dementia, pain, and sleep. It is essential to form an interdisciplinary team that includes nurses, therapists, and social workers to discuss polypharmacy and the importance of deprescribing. Facilities should use data analytics to identify high-risk residents and medication trends affecting quality metrics.

The Case Follow-up

The 90-year-old male resident returns from the hospital after surgical repair for a femoral fracture with an additional medication added to his regimen - oxycodone. His physician meets with the interdisciplinary team to discuss a plan to move forward and address his combative behavior, reduce his risk of falls, and attempt to deprescribe some of his medications. The consulting pharmacist recommends reducing the resident’s quetiapine dose with the goal of discontinuation and reducing the resident’s lorazepam dose until discontinuation. Over the next four months, the resident’s physician reduces the resident’s medication list from 10 medications to four, and he has no further falls.

Conclusion

Polypharmacy not only negatively impacts resident health but also quality measures. Facilities must develop interventions to address the causes of polypharmacy. Deprescribing initiatives should be integrated into quality improvement efforts to ensure they become embedded in facility culture. Leadership should drive efforts to reduce polypharmacy to improve resident care and quality measures.