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CMS to Collect Anticonvulsant Data on MDS Form

CMS to Collect Anticonvulsant Data on MDS Form

CMS will begin collecting data on usage of anticonvulsant medications in Section N of the MDS form effective October 1, 2024, reports McKnight’s Long-Term Care News.  Section N addresses “high-risk medications”.

The trigger for this change was a November 2022 report from the U.S. Office of Inspector General (OIG) indicating that while antipsychotic use in nursing homes declined slightly from 2011 to 2019, use of anticonvulsants increased. They attribute this change to CMS efforts to reduce antipsychotic usage.

A focus on psychotropic drugs

Both antipsychotics and anticonvulsants are considered psychotropic drugs—medications that affect the mind, emotions, and behavior. CMS lists psychotropic drugs as including, but not limited to: antipsychotic, antidepressant, antianxiety, and hypnotic drugs, notes the OIG report. With the uptick in anticonvulsant usage, “the use of psychotropic drugs shifted toward a different category,” concluded the OIG.

The requirement for reporting anticonvulsant use to the MDS came about because CMS agreed with two of three recommendations of the OIG report, said McKnight’s Long-Term Care News. CMS agreed to evaluate use of psychotropic drugs “to determine whether additional action is needed to ensure that use among residents is appropriate”. It also agreed with the OIG recommendation to “use data to identify nursing homes or nursing home characteristics that are associated with a higher use of psychotropic drugs,” while focusing oversight on any concerning trends.

A focus on trends stems from OIG findings that in 2019, higher use of psychotropic drugs was associated with two characteristics: lower RN staffing numbers and higher percentages of residents with low-income subsidies.

CMS policy: antipsychotics

In 2015, CMS began incorporating antipsychotic use into its Nursing Home Five-Star Quality Ratings calculations. From 2015 to 2019, “there was a 194% increase in the number of residents reported in the MDS as having schizophrenia but who lacked a corresponding schizophrenia diagnosis in their Medicare claims and encounters,” said the OIG report.

Thus, CMS announced on Jan. 18, 2023 that it would “conduct targeted, off-site audits to determine whether nursing homes are accurately assessing and coding individuals with a schizophrenia diagnosis.”

“Downstream effects” on anticonvulsants

Following release of the OIG report in November 2022, report team lead Andrea Staples told McKnight’s Long-Term Care News that the discovery of rising anticonvulsant use was “very concerning”.  She commented, “CMS guidance states that the ‘use of psychotropic medications, other than antipsychotics, should not increase when efforts to decrease antipsychotic medications are being implemented, unless the other types of psychotropic medications are clinically indicated.’”

It’s like squeezing bubbles in a balloon instead of letting the air out. Candon et al., writing in the Journal of the American Geriatrics Society, caution against “potential downstream effects that policy interventions that target specific drug classes may have on clinician’s prescribing behavior, including their use of other drug classes”.

They also point to limited evidence of effectiveness of anticonvulsants for treating BSPD among people living with dementia. (Learn more about anticonvulsants used for nursing home residents.)

Neurology-forward solution

Treating BPSD in dementia is “a clinical challenge with no easy solutions,” comment the editors of the Journal of the American Geriatrics Society. It is important to examine the evidence behind medication options, weighing risks and benefits, they add. “All drugs carry risk and must be prescribed appropriately,” noted the OIG report.

GuideStar Eldercare clinicians are working to apply ever-evolving research to the bedside, forging and validating clinical care models that reduce the use of psychotropic drugs. In a recently published study, we reported reducing antipsychotic usage by 68%. Accurate diagnosis and medication review are key to this process.

A neurology-forward approach recognizes dementias as neurodegenerative (rather than psychiatric) illnesses. Bedside neurology, combined with psychiatric and psychological assessment and polypharmacy review, allows for diagnosis-driven, multidisciplinary solutions to improve quality of living for nursing home residents.

Our team can enhance a facility’s ability to deliver positive outcomes and meet CMS guidance. For help preparing for the MDS Section N change, feel free to reach out.