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Risk of Hospitalization and Use of First- Versus Second-Generation Antipsychotics Among Nursing Home Residents
Rajender R. Aparasu, M.Pharm., Ph.D.; Satabdi Chatterjee, M.S., Ph.D.; Hua Chen, M.D., Ph.D.
Psychiatric Services 2014; doi: 10.1176/appi.ps.201300093
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Dr. Aparasu is with the Department of Pharmaceutical Health Outcomes and Policy, Texas Medical Center, and Dr. Chatterjee and Dr. Chen are with the College of Pharmacy, both at the University of Houston, Houston, Texas (e-mail: rraparasu@uh.edu).

Copyright © 2014 by the American Psychiatric Association


Objective  The study compared the risk of all-cause hospitalization associated with use of first- versus second-generation antipsychotics among elderly nursing home residents who were eligible for both Medicare and Medicaid.

Methods  A retrospective cohort study design was used to compare the risk of all-cause hospitalization among dual-eligible nursing home residents (≥65 years) during the 180 days after a new prescription for a first-generation (N=3,611) or a second-generation (N=46,293) antipsychotic. Propensity scores created from Medicare and Medicaid Analytic eXtract data were used to identify a matched cohort of equal numbers of users of each antipsychotic class (N=3,609). The Cox proportional model and the extended Cox hazard model were used to evaluate the risk of all-cause hospitalization in the matched cohort.

Results  The unadjusted rates of all-cause hospitalization were 21.3% and 30.5% among users of first- and second-generation antipsychotics, respectively. The Cox proportional model revealed a significant difference between the two classes in risk of all-cause hospitalization (hazard ratio [HR]=1.33, p<.001). There was no difference in hospitalization risk among users of first- versus second-generation antipsychotics within the first 20 days of use; however, the odds of hospitalization among users of first-generation antipsychotics increased by 58% after 20 days of use (HR=1.58, p<.001).

Conclusions  The study findings suggest that use of first- versus second-generation antipsychotics lasting more than 20 days is associated with a differential risk of all-cause hospitalization, possibly due to differential safety profiles of the two classes. Consequently, there is a need to monitor the use of antipsychotics by elderly patients, especially after a period of initial use.

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Figure 1 Guidelines for selection of participants in a study of all-cause hospitalizations following initiation of first- or second-generation antipsychotics

Figure 2 Distribution of propensity scores before matching among nursing home residents who were prescribed first-generation (N=3,609) or second-generation (N=46,287) antipsychoticsa

a Mean±SD propensity score=.88±.05, median propensity score=.88, for first-generation antipsychotics; mean±SD propensity score=.93±.06, median propensity score=.93, for second-generation antipsychotics. The curved line indicates normal distribution.

Figure 3 Distribution of propensity scores after matching among nursing home residents who were prescribed first-generation (N=3,609) or second-generation (N=3,609) antipsychoticsa

a Mean±SD propensity score=.88±.05, median propensity score=.88, first-generation antipsychotics; mean±SD=.88±.05, median=.88, second-generation antipsychotics. The curved line indicates normal distribution.

Figure 4 Kaplan-Meier survival curves indicating association between risk of all-cause hospitalization and use of first- or second-generation antipsychoticsa

a Log-rank p<.001

Anchor for Jump
Table 1Baseline characteristics of unmatched and matched cohorts of elderly nursing home residents using second-generation or first-generation antipsychoticsa
Table Footer Note

a Baseline characteristics pertain to the six-month period before index use of an antipsychotic. The matched cohort was created by matching the users of first- and second-generation antipsychotics by propensity score.



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