The effects of public reporting on physical restraints and antipsychotic use in nursing home residents with severe cognitive impairment

Objectives: To assess whether reductions in physical restraint use associated with quality reporting may have had the unintended consequence of increasing antipsychotic use in nursing home (NH) residents with severe cognitive impairment.

Design: Retrospective analysis of NH clinical assessment data from 1999 to 2008 comparing NHs subject to public reporting of physical restraints with nonreporting NHs.

Setting: Medicare- and Medicaid-certified NHs in the United States.

Participants: Observations (N = 3.9 million) on 809,645 residents with severe cognitive impairment in 4,258 NHs in six states.

Intervention: Public reporting of physical restraint use rates.

Measurements: Use of physical restraints and antipsychotic medications.

Results: Physical restraint use declined significantly from 1999 to 2008 in NH residents with severe cognitive impairment. The decline was larger in NHs that were subject to reporting of restraints than in those that were not (-8.3 vs -3.3 percentage points, P < .001). Correspondingly, antipsychotic use in the same residents increased more in NHs that were subject to public reporting (4.5 vs 2.9 percentage points, P < .001). Approximately 36% of the increase in antipsychotic use may be attributable to public reporting of physical restraints.

Conclusion: This analysis suggests that public reporting of physical restraint use had the unintended consequence of increasing use of antipsychotics in NH residents with severe cognitive impairment.