Objective To examine the relationship between antihypertensive drug deintensification and recurrent falls in long‐term care. Data Sources/Settings Department of Veterans Affairs (VA) inpatient, outpatient, and purchased care data, Minimum Data Set assessments from VA nursing homes (NHs), and Medicare claims from fiscal years 2010 – 2015. Study Design We identified NH residents with evidence of overaggressive antihypertensive treatment, defined as systolic blood pressure (SBP) 80–120 and an index fall. Recurrent fall, hospitalization, and mortality within 30 days were compared between veterans whose antihypertensive medications were deintensified versus those whose antihypertensive medications were not using propensity score methods (PSM). Principal Findings Among 2,212 NH residents with possibly overaggressive antihypertensive treatment, 11 percent experienced antihypertensive drug deintensification. Lower blood pressure, >1 antihypertensive drug, no congestive heart failure, fracture from index fall, and older age were associated with higher likelihood of deintensification. Antihypertensive deintensification was associated with statistically significant (p‐value < .01) lower risk of recurrent fall among residents with SBP 80–100 (marginal effect = −11.4 percent; PSM = −13.6 percent) and higher risk of death among residents with SBP 101–120 (marginal effect = 2.1 percent, p‐value = .07; with PSM = 4.3 percent, p‐value = .04). Conclusions Results provide some needed evidence and guidelines for deintensifying antihypertensive medication among frail older residents; since hypertension is prevalent among 54 percent of NH residents, the potential impact of new evidence is great.

Since 2010, the Veterans Health Administration has initiated a home-based Caring for Older Adults and Caregivers at Home (COACH) program to provide clinical support to dementia patients and family caregivers. But its impact on health care utilization and costs is unknown. We compared 354 COACH care recipients with a propensity score weighted comparison group of 9,857 community-dwelling Veterans during fiscal years 2010-2015. In 1-year follow-up, COACH program was associated with a lower rate of long-term nursing home placement (average treatment effect on the treated [ATT] –3%; p = .01). The program increased utilization of emergency services (ATT 6%; p = .01), hospitals (ATT 10%; p < .001), and personal care services (ATT 31%; p < .001). Health care costs were also significantly increased. Improved access to services may have enabled COACH Veterans to stay at home longer. As one of Veterans Health Administration’s top priorities to expand caregiver assistance programs, COACH seems to be a promising model for a nationwide implementation.

OBJECTIVES To describe patterns of antihypertensive medication treatment in hypertensive nursing home (NH) residents with and without dementia and determine the association between antihypertensive treatment and outcomes important to individuals with dementia. DESIGN Observational cohort study. SETTING All US NHs. PARTICIPANTS Long‐term NH residents treated for hypertension in the second quarter of 2013, with and without moderate or severe cognitive impairment, as defined by the NH Minimum Data Set (MDS) Cognitive Function Scale. MEASUREMENTS The primary exposure was intensity of antihypertensive treatment, as defined as number of first‐line antihypertensive medications in Medicare Part D dispensing data. The outcome measures were hospitalization, hospitalization for cardiovascular diseases using Medicare Hierarchical Condition Categories, decline in physical function using the MDS Activities of Daily Living (ADLs) scale, and death during a 180‐day follow‐up period. RESULTS Of 255 670 NH residents treated for hypertension, 117 732 (46.0%) had moderate or severe cognitive impairment. At baseline, 54.4%, 34.3%, and 11.4% received one, two, and three or more antihypertensive medications, respectively. Moderate or severe cognitive impairment (odds ratio [OR] = 0.80 vs no or mild impairment; P < .0001), worse physical function (OR = 0.64 worst vs best tertile; P < .0001), and hospice or less than a 6‐month life expectancy (OR = 0.80; P < .0001) were associated with receipt of fewer antihypertensive medications. Increased intensity of antihypertensive treatment was associated with small increases in hospitalization (difference per additional medication = 0.24%; 95% confidence interval = 0.03%‐0.45%) and cardiovascular hospitalization (difference per additional medication = 0.30%; 95% confidence interval = 0.21%‐0.39%) and a small decrease in ADL decline (difference per additional medication = −0.46%; 95% confidence interval = −0.67% to −0.25%). There was no significant difference in mortality (difference per additional medication = −0.05%; 95% confidence interval = −0.23% to 0.13%). CONCLUSION Long‐term NH residents with hypertension do not experience significant benefits from more intensive antihypertensive treatment. Antihypertensive medications are reasonable targets for deintensification in residents in whom this is consistent with goals of care. J Am Geriatr Soc 67:2058–2064, 2019

Heterogeneity in physician practice within nursing homes (NHs) may explain variations in quality. However, data on physician practice organization in NHs are hard to obtain. We characterized NH physician practice using two claims-based measures: (a) concentration of NH care among physicians (measured by Herfindahl–Hirschman index of visits); and (b) physician NH practice specialization (measured by the proportion of a physician’s visits to NHs). We examined the relationship between the measures and NH administrator perceptions of physician practice reported in the Shaping Long-Term Care in America (SLTCA) Survey. All 2011 Part B claims from 13,718 physicians who treated Medicare fee-for-service patients in 2,095 NHs in the SLTCA survey were analyzed. The median Herfindahl–Hirschman index was 0.44 (interquartile range [IQR] 0.28-0.70), and the median specialization was 38.1% (IQR 19.9% to 60.9%). NHs with higher physician specialization reported more frequent physician participation in care coordination activities. Claims-based measures could inform the study of NH physician practice.

Purpose: Hypertension occurs in >50% of US nursing home (NH) residents, but it is unclear which antihypertensive classes offer the best balance of benefits and risks in this population. The objectives of this study were to describe the patterns of antihypertensive medication treatment in this population, focusing on thiazide diuretics, and to determine the association between thiazide diuretics (DIURs) and outcomes important to NH patients. Methods: This observational cohort study was conducted in long-term NH residents treated for hypertension in the second quarter (Q2) of 2013, from all US NHs. The primary exposure was the frequency of use of antihypertensive treatment class (DIURs, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers [ARBs], calcium channel blockers, and b-blockers) according to Medicare Part D dispensing data. Because DIURrelated urinary symptoms were a focus, residents receiving nonthiazide diuretics were excluded. We ascertained continued medication use by class from Q2 to Q4 of 2013, and ascertained 6-month incontinence and hospitalization using data from Medicare claims and the Minimum Data Set. Findings: Of 152,902 NH residents treated for hypertension, 52.2% were treated with b-blockers (22% as a single agent), 39.7% with calcium channel blockers (14% as a single agent), 38.8% with angiotensin-converting enzyme inhibitors (14% as a single agent), 14.2% with DIURs (2% as a single

Background: Treatment of hypertension in individuals with dementia has benefit-harm tradeoffs. The objectives of this study were to describe patterns of antihypertensive treatment in U.S. nursing home (NH) residents and determine the association between intensity of antihypertensive treatment and outcomes important for persons with dementia. Methods: Medicare claims and Minimum Data Set (MDS) assessments were used to capture information on dementia, hypertension, comorbid conditions, cognitive function, activities of daily living (ADLs), and hospitalizations in Medicare-enrolled long-term care residents in 2013. Intensity of hypertension treatment was defined as number of antihypertensive drugs received on the date of an index MDS according to Medicare part D claims. Outcomes ascertained were hospitalizations, ADL decline, and mortality within 180 days of the index MDS. Results: A total of 262,285 residents had both hypertension and dementia. Residents were 85.7 years old on average and 77% female. At baseline, 30%, 40%, and 30% were receiving 0, 1, and 2+ antihypertensive medications, respectively. In multivariable logistic regression models, increased intensity of antihypertensive treatment was associated with increased hospitalization among residents with dementia (OR 1.03 per added medication; 95%CI 1.01-1.04), but decreased hospitalization among residents without dementia (OR .98 per added medication; 95%CI .97-1.00; p-value for interaction < .0001). In residents with and without dementia, increased intensity of antihypertensive treatment was associated with increased hospitalization for cardiovascular diseases, but small decreases in ADL decline and mortality. Conclusion: Study findings suggest that long-term NH residents with hypertension and dementia may not experience benefit from more intensive blood pressure control.

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