If you track the national nursing home antipsychotic rate, the number you are looking at after January 1, 2026 is not measuring the same thing as the number before it.
What changed
The long-stay antipsychotic quality measure was respecified effective January 1, 2026. Two changes matter.
- The numerator now draws on pharmacy claims as well as the resident assessment item.
- The diagnosis exclusions now require corroboration. Under the previous specification, a coded diagnosis of schizophrenia, Tourette syndrome or Huntington’s disease on the assessment excluded a resident from the measure. Under the current one, the exclusion requires both the assessment item and a matching diagnosis in claims and encounter data.
Why it changed
In January 2023 CMS announced audits of schizophrenia coding, stating that it “is concerned that some nursing homes have erroneously coded residents as having schizophrenia, which can mask the facilities’ true rate of antipsychotic medication use,” and that “when nursing home residents are given erroneous schizophrenia diagnoses, they are subject to poor care and unnecessary antipsychotic medications, both of which can be very dangerous.” Its pilot audit found “an absence of comprehensive psychiatric evaluations and behavior documentation,” with recorded behaviors “related to dementia, rather than schizophrenia.”
The practical consequence
Do not plot figures from the two specifications on one line. The internally consistent national series is the one CMS reports for the Partnership: 23.9% in the fourth quarter of 2011 falling to 14.2% in the second quarter of 2025, a relative decrease of 40.6%. Figures produced under the new specification are higher for a methodological reason and not because prescribing rose.
CMS states plainly, and it is worth quoting when a facility feels pressure from this number, that circumstances exist where clinical indications for antipsychotics are present and that it “does not expect that the national prevalence of antipsychotic medication use will decrease to zero.”
The larger point
A measure creates pressure toward the measured number, and the pressure lands on whoever is closest to it. The coding problem CMS describes is what that pressure produced last time. A measure that is harder to game is an improvement; it is not a substitute for reviewing each resident individually, and the withdrawal evidence is specific about who relapses when a program stops doing that.
Read more: Antipsychotics and mortality in dementia · Measuring what changed.
References
- 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.
- 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.
- 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 in this note 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.