Q. How does QIS address the use of psychoactive medications?

A. QIS has included investigations related to the use of antipsychotic medications since it was first implemented in 2007.

During Stage 1 of QIS, quality-of-care and quality-of-life indicators (QCLIs) measure use of benzodiazepines and antipsychotics.

These two QCLIs, which are contained in the Census Sample Record Review, include “Benzodiazepine Use” and “Antipsychotic Use without a Supporting Diagnosis.” The latter is consistent with the recently announced American Health Care Association Quality Initiative goal to safely reduce the off-label use of

The first QCLI, QP066, calculates the rate of Census Sample residents who are receiving benzodiazepines. This QCLI is a screen to identify facilities that have a high rate of sedative/hypnotic use so that further review in the second stage is targeted on facilities with high use rates. If the rate of benzodiazepine use exceeds the Stage 1 threshold, then benzodiazepine use is more fully reviewed using the Stage 2 psychoactive medications pathway.

The second QCLI, QP063, is not based on all census sample residents, but instead selects only those who are receiving one or more antipsychotic medications (the denominator). For those residents in the census sample who are receiving an antipsychotic medication, the QCLI calculates the proportion of residents who do not have a documented diagnosis reflecting psychoses based on a specific list of diagnoses (schizophrenia, psychotic mood disorder, acute psychotic episodes). Thus, the focus of this QCLI is to identify the rate of off-label use of antipsychotics.

If the threshold is exceeded, then antipsychotic use is more thoroughly investigated using the Critical Element Pathway in Stage 2 for Psychoactive Medications.

The Critical Element Pathway investigation for Psychoactive Medications is comprised of resident observations, resident/family interviews, and staff interviews. These investigations yield an evaluation of the Critical Elements: Assessment, Care Planning, Care Plan Implementation, Care Plan Revision, and Provision of Care and Services related to psychoactive medication use. In addition to application of the F-Tag determinations relating to the critical elements (F272, F279, F282, and F280), the determination of whether staff provided care to prevent adverse effects and use only necessary antipsychotic, anti-anxiety, and/or hypnotic drugs is made for F329.

Physician care is addressed through F385 and F386 as well as F501 because of the critical role of physicians in use of psychoactive medications. Pharmacy review is also included in this CE pathway, F428. The inclusion of all these F-Tags acknowledges that this is a multidisciplinary issue.

Andy Kramer, MD, is a long term care researcher and professor of medicine who was instrumental in the design and development of the Quality Indicator Survey (QIS).