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Measuring what changed

For facility ownership and management

You cannot know whether any of this worked without a baseline, and you cannot take credit for outcomes the evidence does not support. Both errors are common and the second is worse.

What is worth measuring

  • Medications with no recorded indication. The most defensible measure there is, because a drug treating nothing has only risk. It is also the one where the baseline is usually shocking — 65.3% of proton pump inhibitor prescriptions in one US skilled-nursing study had no appropriate diagnostic code.
  • Psychotropic prescriptions with a recorded target symptom. Not the number of psychotropics — the proportion where somebody wrote down what it was for. This is the measure that makes every later evaluation possible.
  • Central nervous system polypharmacy. Three or more concurrent CNS-active medications for more than 30 days, per the Beers threshold. Counts antidepressants, antiseizure medications, antipsychotics, benzodiazepines, Z-drugs, opioids and skeletal muscle relaxants — which means it catches the gabapentinoid substitution that a class-by-class count misses.
  • Anticholinergic burden, with the scale named. The scales disagree with each other, so a score without its scale is not comparable to anything.
  • Restraint episodes documented as events, with a root cause and a review.
  • Whether the plan travels. Ask three staff on different shifts what settles a specific resident. That is a real measure and it takes ten minutes.

What not to promise

What the evidence does and does not show

Sedating medications impair gait, balance and reaction time, and their labels say so. That part is not in doubt. What has not been shown is that a deprescribing program reduces fall rates — the trials that tested it were small, short, and mostly measured a medication count rather than a fracture. Those are two different questions, and absence of evidence from underpowered trials is not evidence that the drugs do not cause falls. What the evidence actually shows about deprescribing and falls.

Nor a mortality benefit — the 2024 update of the largest meta-analysis, covering 259 studies, found none in randomized studies. Nor a reduction in hospitalizations or emergency visits: the 118-trial, 417,412-patient synthesis found relative risks of 0.95 for hospitalizations and 1.02 for emergency department admissions, neither significant. Nor an improvement in quality of life, which showed a standardized mean difference of 0.09 (95% CI −0.04 to 0.23) in the same analysis.

We publish no savings claims and no financial projections for your facility. Where we cite cost or staffing figures they come from published research describing what care already costs, and they are not a forecast of what you would save. The published figures, with their populations and currency years.

How a target becomes a hazard

This is worth stating as an operating principle rather than a caution.

A measure creates pressure toward the measured number, and the pressure lands on whoever is closest to it. The antipsychotic quality measure is the clearest example available. CMS reported the share of long-stay nursing home residents on an antipsychotic falling from 23.9% in the fourth quarter of 2011 to 14.2% in the second quarter of 2025 — and in January 2023 announced audits of schizophrenia coding, on the concern that “some nursing homes have erroneously coded residents as having schizophrenia, which can mask the facilities’ true rate of antipsychotic medication use.” Its pilot found “an absence of comprehensive psychiatric evaluations and behavior documentation.”

The measure was respecified effective January 1, 2026 so that the diagnosis exclusions now require corroborating claims data rather than an assessment item alone. Figures produced under the old and new specifications are not comparable and should not be plotted on one line.

The clinical version of the same hazard: the withdrawal evidence says most residents can come off an antipsychotic safely, and that a specific identifiable minority — those who responded to it for psychosis, aggression or agitation, and those with more severe baseline symptoms — are likelier to relapse. A program pursuing a percentage rather than the individual will find that minority the hard way, and their relapse will not appear in the measure.

CMS itself states that clinical indications exist and that it “does not expect that the national prevalence of antipsychotic medication use will decrease to zero.”

Measure the process, not only the outcome

Given that the outcome measures this field can honestly promise are modest, the more useful internal measures are process ones: did the review happen on schedule, did it happen on every trigger, was a target symptom recorded, was the family told before rather than after, does the plan travel across shifts. Those are all things you control, all things that predict whether the clinical work is possible, and none of them require a claim the evidence will not support.

Back to the facility track.

References

  1. Patterson Burdsall D, Flores HC, Krueger J, et al. Use of proton pump inhibitors with lack of diagnostic indications in 22 Midwestern US skilled nursing facilities. Journal of the American Medical Directors Association. 2013;14(6):429–432. PMID 23583000 · DOI 10.1016/j.jamda.2013.01.021.
  2. By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7):2052–2081. PMID 37139824 · DOI 10.1111/jgs.18372.
  3. Jung H, Liu SH, Hume AL, et al. The Prevalence of Central Nervous System-Active Polypharmacy in US Nursing Homes. Journal of the American Medical Directors Association. 2026;27(6):106178. PMID 41895707 · DOI 10.1016/j.jamda.2026.106178.
  4. Salahudeen MS, Duffull SB, Nishtala PS. Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review. BMC Geriatrics. 2015;15:31. PMID 25879993 · DOI 10.1186/s12877-015-0029-9.
  5. Lee J, Negm A, Peters R, Wong EKC, Holbrook A. Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: a systematic review and meta-analysis. BMJ Open. 2021;11(2):e035978. PMID 33568364 · DOI 10.1136/bmjopen-2019-035978.
  6. Persaud N, Workentin A, Rizvi A, et al. Interventions to Address Potentially Inappropriate Prescribing for Older Primary Care Patients: A Systematic Review and Meta-Analysis. JAMA Network Open. 2025;8(6):e2517965. PMID 40577011 · DOI 10.1001/jamanetworkopen.2025.17965.
  7. Quek HW, Page A, Lee K, et al. The effect of deprescribing interventions on mortality and health outcomes in older people: An updated systematic review and meta-analysis. British Journal of Clinical Pharmacology. 2024;90(10):2409–2482. PMID 39164070 · DOI 10.1111/bcp.16200.
  8. Centers for Medicare & Medicaid Services. National Partnership to Improve Dementia Care in Nursing Homes: Antipsychotic Medication Use Data Report. cms.gov. 2026. https://www.cms.gov/files/document/data-report-national-partnership-improve-dementia-care-nursing-homes-antipsychotic-medication-use.pdf.
  9. Centers for Medicare & Medicaid Services. Adjusting Quality Measure Ratings Based on Erroneous Schizophrenia Coding, and Posting Citations Under Dispute. Memorandum QSO-23-05-NH, January 18, 2023. cms.gov. 2023. https://www.cms.gov/files/document/qso-23-05-nh-adjusting-quality-measure-ratings-based-erroneous-schizophrenia-coding-and-posting.pdf.
  10. Van Leeuwen E, Petrovic M, van Driel ML, et al. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database of Systematic Reviews. 2018;3(3):CD007726. PMID 29605970 · DOI 10.1002/14651858.CD007726.pub3.

Bibliographic records on this page were retrieved from PubMed. Every reference links to its DOI or PubMed record.

Written and medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, founder and medical director of DWARAA. Last reviewed . This page is educational. DWARAA does not prescribe, deprescribe, diagnose or treat.