Medication use in rest and nursing homes in Belgium. - KCE

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36 Medication use in Nursing Homes KCE reports 47 appropriateness. 75 These 10 ratings can be combined to produce a weighted score per medication. The MAI is a time-consuming instrument, but is currently the most comprehensive instrument to measure appropriateness of prescribing in the elderly. In Norway, a comprehensive set of prescribing quality indicators was developed, based on data from the health care record and medication charts of institutionalized elderly. 76 More details on this list are given in the method section and the result section of this report. The ACOVE Project (Assessing Care Of the Vulnerable Elder) used systematic literature reviews, expert opinions and the guidance of expert groups and stakeholders in the US to develop a comprehensive set of quality-of-care indicators that are relevant to vulnerable elders. 77 About a third of the indicators refer to medication. As part of the ACOVE project, Knight & Avorn 78 developed quality indicators for appropriate medication use in vulnerable elders using a systematic literature review and expert panel considerations. On the basis of the literature review and the authors expertise, 16 potential quality indicators were proposed to the expert panel. 12 of them were judged to be valid. Elliott et al. 68 developed a set of indicators of prescribing quality for elderly in Australian hospitals. These indicators were based on a set of indicators developed previously in the UK and were piloted at nine Australian hospitals. The indicators were divided in 3 groups: 1) summarising general prescribing activity, 2) assessing prescribing based on prescription data only, and 3) assessing prescribing based on prescription and clinical data. 24 indicators were developed and applied on the prescriptions of 1,416 patients. Following pilot audits, 5 indicators were deleted, resulting in a final set of 19 indicators. The review of prescription by 2 pharmacists (n=66) showed also a good inter-rate reliability. The developed indicators provide a tool that can be used to assess, monitor, benchmark and improve prescribing for the age. Oborne et al. 79 aimed to modify previously developed indicators and algorithms from the hospital setting for use in nursing homes, and to apply these indicators in the nursing home setting. 13 indicators were successfully modified and applied on 934 residents in 22 nursing homes in the UK. These objective, evidence-based and simple to use prescribing appropriateness criteria provide an objective audit tool that can be of use in comparing prescribing between units and to enhance prescribing quality. A remark on outcomes The above described sets of quality of prescribing are all measures of the quality of process to achieve better outcome among patients. They are not direct measures of outcome such as mortality, morbidity, hospital admissions, or quality of life. Few studies on inappropriate prescribing look directly at health outcomes. Only preliminary attempts to link outcomes, measured by the Resident Assessment Instrument with drug utilization data, have been published. 80, 81 The measurement of quality of life may be difficult to measure with generic instruments, given the high prevalence of cognitive disabilities and disabilities of the senses. 2.3.4 Which institutional characteristics are important for the quality of prescribing? The organizational characteristics of nursing homes can substantially influence the quality of prescribing in nursing homes. This chapter will give an overview of the nursing home characteristics and their impact upon quality of prescribing (expressed by volume, expenditures and appropriateness of prescribing). Only studies explicitly exploring the relationship between institutional characteristics and quality of prescribing are listed. We examined the following characteristics: Size and type of the institution Case-mix of the institution Staffing within the institution
KCE reports 47 Medication use in Nursing Homes 37 General approach to management of care processes Approach to medication management 2.3.4.1 Size and type of the institution (public, private not-for-profit, private for profit) 2.3.4.2 Case-mix 2.3.4.3 Staffing There is some evidence that organizational factors can have a significant impact on both the quantity and quality of psychotropic drug use in nursing homes. However, the relationships are complex and poorly understood. A few studies found higher rates of drug use in larger facilities and for-profit facilities, but other studies found that facility size and ownership had no effect. 82-86 In the sample of Schmidt et al., 86 all nursing homes were non-profit and operated by public municipalities and there was no functional difference in financial status among the residents -all were covered by the Swedish universal health care insurance plan. Residents' clinical and demographic characteristics did not account for variations of drug use from one facility to another, suggesting that facility differences are not due simply to resident mix. Mylotte et al. 87 determined significant correlations between the antibiotic use and cost indicators, overall infection rate and case-mix index at the facility level, between 11 long-term care facilities (USA). There was no correlation between the CMI of the RUGs II system as a measure of functional status and infection rate. Nevertheless, there was a trend toward a significant correlation between mean facility CMI and mean facility incidence of antibiotic use (AUR antibiotic utilization ratio), and cost per RCD (resident care day). Shorr et al. 88 found more extensive antipsychotic drug use in those Tennessee homes with poorer third-shift staffing. Svarstad et al. 89 used a more refined measure of home staffing in their study of private- and public-pay residents in Wisconsin homes. As predicted, residents in homes with less adequate nurse staffing and resources were more likely to have an order for an antipsychotic or anxiolytic medication, more likely to receive such medications, and more likely to have inappropriate use, even after controlling for residents' clinical and demographic characteristics. The hypotheses suggest that home differences in drug use are due largely to organizational factors such as: resource availability and demand (low/high nurse staffing; low/high resident functioning); caregiver communication (presence/absence of intervention team meetings); facility size (small/large number of beds; reflecting a measure of institutional environment). Mullins et al. 90 examined nursing home personnel's perceptions of patient autonomy in their home. Findings indicated staff members' education and race had the greatest effect on their perceptions of personal autonomy. Somewhat surprisingly, staffing levels, turnover rates, and restraint usage did not affect their views of autonomy ( whether the resident would be allowed to make his or her own decisions or whether the nursing home staff would decide for the resident ). Schnelle et al. 38 compared nursing homes that report different staffing statistics on quality of care. Staff in the highest staffed homes (California), according to state cost reports, reported significantly lower resident care loads during onsite interviews across day and evening shifts (7.6 residents per nurse aide [NA]) compared to the remaining homes that reported between 9 to 10 residents per NA). The highest-staffed homes performed significantly better on 13 of 16 care processes implemented by NAs compared to lower-staffed homes. Castle et al. 91 examined the association between nurse aide (NA) plus licensed practical nurse (LPN) and registered nurse (RN) turnover and quality indicators in nursing homes. Indicators of care quality used are the rates of physical restraint use, catheter use, contractures, pressure ulcers, psychoactive drug use, and certification survey
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