We appreciate the opportunity to respond to the feedback by Xiong and Raj on our recent publication.1 They asked if high antipsychotic use in some NHs might be due to an institutional willingness to accept challenging patients who are taking antipsychotics for unclear reasons before admission. Certainly, a referral bias may exist, since 53% of the patients prescribed antipsychotics in our study received them within the first week of admission. However, when we excluded early initiators in our adjusted analyses, our results remained robust: residents entering NHs with the highest prescribing rates were more likely to initiate antipsychotic medication therapy after the first week of admission compared with patients entering homes with the lowest prescribing rates (risk ratio, 1.48; 95% confidence interval, 1.26-1.73). This suggests that the effect of NH prescribing culture on antipsychotic use is independent of referral bias.
Chen Y, Briesacher BA, Field TS, Tjia J, Lau DT, Gurwitz JH. Variations in Antipsychotic Prescribing in Nursing Homes: Can This Be Reflective of Referral Patterns?—Reply. Arch Intern Med. 2010;170(10):917-918. doi:10.1001/archinternmed.2010.144