Nursing homes: a case study of prescribing in older people. Carmel M. Hughes

Transcription

1 Nursing homes: a case study of prescribing in older people Carmel M. Hughes

2 Objectives of lecture To highlight issues with nursing home care, focussing on use of medicines To highlight influences on prescribing in this environment Legislation Pharmacy input Challenges for the future

3 Where do older people live? Age range (year) Own home Sheltered housing Care home or hospital % 11% 1% % 23% 5% % 19% 21% Age Concern Website statistics

4 Nursing home carebasic facts The waiting room for heaven Emerged from Victorian workhouses Dumping ground for the elderly Vulnerable population Average age is 80 Over 70% are women Tend to be more physically and mentally disabled than those living in their own homes Need help with a range of activities Receive more medication than age-matched patients who live in the community

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7 A catalogue of concern

8 From practice to research Community pharmacy practice Very high numbers of prescriptions for nursing home residents Very high numbers of prescriptions for psychotropic drugs Anti-psychotics, hypnotics, anxiolytics Large quantities; long duration of use UK publications-few US publications-many

9 Scandal and shame US nursing home scandals throughout the 1970s and 1980s Extensively documented by the media and scientific literature Elderly residents were dying as a result of the care they received in US nursing homes

10 A problem of care Nursing home care in the United States-Failure of Public Policy Unloving care-the nursing home tragedy Tender loving greed; how the incredibly lucrative nursing home industry is exploiting America s older people and defrauding us all

11 A problem for politics US Congress directed Institute of Medicine to investigate what was happening in US nursing homes

12 Improving the quality of care in nursing homes Unsafe and unsanitary conditions Abuse Neglect Malnutrition Medication errors Failure to provide prescribed drugs Excessive use of physical restraints Excessive use of chemical restraints i.e. anti-psychotics (20-50%), hypnotics, anxiolytics

13 Restraints Physical Tied into chairs or beds Chemical Use of antipsychotics, hypnotics and anxiolytics to sedate and subdue residents Understaffed facilities may make excessive use of anti-psychotic drugs to substitute for inadequate numbers of nursing staff IOM report 1986

14 American response-obra 87 Omnibus Budgetary Reconciliation Act 1987 (OBRA 87) Fully implemented in 1991 Sought to improve the quality of care in US nursing homes Regulations and standards Detailed inspections Enforcement procedures Hughes et al., BMJ 1999; 319:

15 OBRA 87 The resident has the right to be free from any psychoactive drug administered for purposes of discipline or convenience and not required to treat the resident s medical symptoms. Under this law, consultants pharmacists are required to monitor the use of these drugs and challenge their unjustified usage.

16 What do consultant pharmacists do? Check that: No resident s drug regimen contains drugs that are not medically necessary Excessive doses Excessive duration Without adequate indications If adverse events have arisen, dose should be reduced or drug stopped Needs to be documentation justifying the prescription of psychoactive medication

17 What do consultant pharmacists do? Drug reviews conducted on a monthly or quarterly basis Will also evaluate the appropriateness of and response to drug therapy Report irregularities to attending doctor or director of nursing Most US nursing homes have an attending doctor

18 Did OBRA make a difference? Improvements in many aspects of care Reduction in pressure sores, dehydration and use of physical restraints Reduction in hospitalisations Reduction in the use of psychoactive medications BUT. need an examination of the clinical consequences of changes in prescribing rather than viewing the change to be an end in itself Gurwitz and Avorn, 1995

19 The Minimum Data Set (MDS) Used to collect information on all nursing home residents 350 separate pieces of information Section U-drugs which resident is receiving MDS data stored on database

20 Impact of legislation Compare prescribing of drugs in US nursing homes to where there is no legislation If these drugs were prescribed less, would residents fall less? Compare prescribing and falls in the USA to places where OBRA had no standing MDS used to collect data in: Denmark, Iceland, Italy, Japan, Sweden Hughes et al., JAGS 2000; 48:

21 The residents Almost 70% of residents were female Over 40% >80 years old At least 25% had severe ADL impairment and moderate cognitive impairment At least one-third were receiving between 4-6 drugs per day, and in US, 30% were receiving between 7-10 drugs per day

22 Anti-anxiety/hypnotic drugs Country Denmark Iceland Italy Japan Sweden USA % of residents using antianxiety/hypnotic drugs Adjusted Odds ratio (95% CI) 3.24 ( ) 8.80 ( ) 2.18 ( ) 2.11 ( ) 2.92 ( ) 1.0 (referent)

23 Antipsychotic drugs Country Denmark Iceland Italy Japan Sweden USA % of residents using antipsychotic drugs Adjusted Odds ratio (95% CI) 1.07 ( ) 1.86 ( ) 1.47 ( ) 0.45 ( ) 1.74 ( ) 1.0 (referent)

24 Impact on falls Country Denmark Iceland Italy Japan Sweden USA % of residents falling Adjusted Odds ratio (95% CI) 1.73 ( ) 0.65 ( ) 0.84 ( ) 0.34 ( ) 1.26 ( ) 1.0 (referent)

25 Impact on falls? Rate of falls was less in some countries were prescribing was more widespread Environmental and medical factors Variation between homes in the USA in the prescribing of these drugs Is regulation enough?

26 Beyond regulation Regulation has been effective at reducing poor care but has been less effective at promoting good care in the nursing home setting Need better ways of monitoring drug use in nursing homes

27 Collaboration Pharmacists working with doctors to improve the quality of prescribing beyond the OBRA drugs Reduction in the use of inappropriate medication Tackles undertreatment of medical conditions Seeks to reduce adverse drug events Promotion of evidencebased practice Trial undertaken in N. Carolina and N. Ireland

28 Fleetwood N.I. Project- Design Cluster randomised controlled trial 12 months duration Focus on psychoactive drugs Anxiolytics, hypnotics, antipsychotics Primary outcomes Change in proportion of residents receiving inappropriate psychoactive drugs Secondary outcomes Change in the number of residents who fall Changes in direct healthcare costs over time Professional satisfaction Patterson et al., JAGS 2010; 58: 44-53

29 Fleetwood N.I. Project- Design cont d 11 matched pairs of nursing homes randomly assigned as intervention or usual care 15 residents per home recruited, total=334 9 prescribing support pharmacists delivered intervention to 11 homes Training provided on intervention and medicines for older people

30 Fleetwood N.I. Project - Intervention Monthly visits by prescribing support pharmacists to homes Algorithm to assess appropriateness of psychoactive drug prescriptions Liaison with GPs and other healthcare professionals Documentation on pharmaceutical care plan Outcomes assessed at 3, 6 and 12 months

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32 Northern Ireland baseline findings Residents Intervention Control Number of participants 173 (51.8%) 161 (48.2%) Mean age 82.5 years 82.7 years Women 125 (72.2%) 119 (73.9%) Nos. receiving 1-5 meds 6-10 meds 10+ meds 19 (11%) 60 (34.7%) 94 (54.35%) 21 (13.%) 66 (41%) 74 (46%) Psychoactive drugs 113 (65.6%) 108 (67%) Inappropriate psychoactive drugs 92 (81.4%) 79 (72%)

33 Use of health services Health service Mean no. of GP practices per nursing homes (SD) Mean no. of GPs per nursing home (SD) Mean number of GP visits per resident per year (SD) Mean no. of community pharmacies per nursing home (SD) N=334 residents across 22 nursing homes in NI 9.0 (6.1) 20.4 (14.3) 1.52 (2.11) 1.2 (0.7)

34 Number of interventions Pharmacists recorded interventions in 91.4% cases Total of 396 interventions Mean of 2.8 ± 3.3 interventions per resident Prescriber was contacted >90% of all interventions (n=376) Mean of 2.3 ± 3.5 recommendations per resident 72.4% of pharmacists recommendations accepted by the prescribers Patterson et al., J Appl Ther Res 2010; 7: 91-99

35 Types of interventions undertaken by pharmacists 25% 5% 3% 3% 8% 3% None Indication-Add/Monitor 37% Indication-unnecessary Efficacy-wrongdrug Efficacy-dose low Safety-ADR Safety-dosehigh Adherence 7% 9% Technical

36 Northern Ireland 12 months findings Drug category Intervention Control Inappropriate psychoactive 28/128 (22%) 72/125 (58%) Inappropriate hypnotic/anxiolytic 20/128 (16%) 52/125 (42%) Inappropriate antipsychotic 8/128 (6%) 20/125 (16%)

37 Impact of the intervention After one year the odds ratio of a resident receiving an inappropriate psychoactive drug in an intervention home = 0.26 (95% CI: 0.14, 0.49) compared to a resident in the control group of homes

38 Other outcomes No difference in the rate of falls between the two groups Nurses, GPs and pharmacists very satisified with the service Appears to be cost-effective

39 Cost-effective intervention Mean differences in costs and in proportion of residents receiving one or more Inappropriately prescribed psychoactive drugs

40 External validation of the work

41 What do we value? Schools are hot politics, old folks homes aren t Polly Toynbee, Guardian, Jan 12th 2007 Increasing prevalence of dementia in UK By 2025, >1 million will have dementia By 2050, 1.7 million will have dementia Number of people who require residential care is likely to double over the next 25 years

42 What do we need to think about? Too much Overtreatment e.g. antipsychotics Too little Undertreatment e.g. depression Too late End of life e.g. withdrawal of treatment

43 The critical question When is enough, enough? This will be the defining question for the next generation of practitioners Professor Kieran Sweeney