More than half of Medicare enrollees with advanced dementia continue to take cholinesterase inhibitors or memantine after being admitted to hospice, even though current guidelines generally recommend discontinuation of these medications in this patient population, according to a research letter in JAMA Internal Medicine.
Lauren J. Hunt, Ph.D., R.N., of the University of California, San Francisco, and colleagues analyzed data from all Medicare claims data from July 2014 through June 2018, when hospice agencies were required to report medications filled for patients to the Centers for Medicare & Medicaid Services (CMS). They examined all hospice enrollees with a terminal diagnosis of dementia who had a 30-day or longer prescription for donepezil, rivastigmine, galantamine, or memantine filled in the three months before admission and who were in hospice care for at least 30 days.
Overall, 138,029 enrollees took cholinesterase inhibitors or memantine at baseline. Of those, 57.3% continued these medications after hospice admission. The researchers defined continued use as any new fill of these medications after admission covered either by the hospice agency or by Medicare Part D. Patients who had Medicaid dual eligibility, lived at an assisted living facility, or lived in the Southeast had increased odds of continuing these medications, as did patients who were enrolled in a large (5,000+ residents) or for-profit hospice agency. More than 80% of fills were covered by Medicare Part D.
“While continued use might be therapeutic and aligned with the goals of some patients, this proportion is much higher than is likely clinically appropriate,” the researchers wrote, adding that many of the predictors of continued use that they identified, such as dual eligibility or hospice ownership, are not known to be related to medical need or benefit. “Study findings reinforce CMS’ concerns that inappropriate cost shifting from the hospice benefit to Medicare Part D may be occurring and point to the need for better enforcement of existing regulations.”
For related information, see the Psychiatric News article “To Improve Safety in Older Patients, Consider Deprescribing.”
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