Interventions to improve suboptimal prescribing in nursing homes: A narrative review.

Department of Medicine (Geriatrics), School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
The American journal of geriatric pharmacotherapy 06/2010; 8(3):183-200. DOI: 10.1016/j.amjopharm.2010.05.004
Source: PubMed

ABSTRACT Appropriate medication prescribing for nursing home residents remains a challenge.
The purpose of this study was to conduct a narrative review of the published literature describing randomized controlled trials that used interventions to improve suboptimal prescribing in nursing homes.
The PubMed, International Pharmaceutical Abstracts, and EMBASE databases were searched for articles published in the English language between January 1975 and December 2009, using the terms drug utilization, pharmaceutical services, aged, long-term care, nursing homes, prescribing, geriatrics, and randomized controlled trial. A manual search of the reference lists of identified articles and the authors' files, book chapters, and recent review articles was also conducted. Abstracts and posters from meetings were not included in the search. Studies were included if they: (1) had a randomized controlled design; (2) had a process measure outcome for quality of prescribing or a distal outcome measure for medication-related adverse patient events; and (3) involved nursing home residents.
Eighteen studies met the inclusion criteria for this review. Seven of those studies described educational approaches using various interventions (eg, outreach visits) and measured suboptimal prescribing in different manners (eg, adherence to guidelines). Two studies described computerized decision-support systems to measure the intervention's impact on adverse drug events (ADEs) and appropriate drug orders. Five studies described clinical pharmacist activities, most commonly involving a medication review, and used various measures of suboptimal prescribing, including a measure of medication appropriateness and the total number of medications prescribed. Two studies each described multidisciplinary and multifaceted approaches that included heterogeneous interventions and measures of prescribing. Most (15/18; 83.3%) of these studies reported statistically significant improvements in >or=1 aspect of suboptimal prescribing. Only 3 of the studies reported significant improvements in distal health outcomes, and only 3 measured ADEs or adverse drug reactions. CONCLUSIONs: Mixed results were reported for a variety of approaches used to improve suboptimal prescribing. However, the heterogeneity of the study interventions and the various measures of suboptimal prescribing used in these studies does not allow for an authoritative conclusion based on the currently available literature.

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    Annales Pharmaceutiques Françaises 07/2014; DOI:10.1016/j.pharma.2014.05.001
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    ABSTRACT: Medication is an essential part of health care and enables the prevention and treatment of many conditions. However, medication errors and drug-related problems (DRP) are frequent and cause suffering for patients and substantial costs for society. eMedication, defined as information technology (IT) in the medication management process, has the potential to increase quality, efficiency and safety but can also cause new problems and risks. In this thesis, we have studied the employment of IT in different steps of the medication management process with a focus on the user's perspective. Sweden is one of the leading countries when it comes to ePrescribing, i.e. prescriptions transferred and stored electronically. We found that ePrescribing is well accepted and appreciated by pharmacists (Study I) and patients (Study II), but that there was a need for improvement in several aspects. When the pharmacy market in Sweden was re-regulated, four new dispensing systems were developed and implemented. Soon after the implementation, we found weaknesses related to reliability, functionality, and usability, which could affect patient safety (Study III). In the last decade, several county councils in Sweden have implemented shared medication lists within the respective region. We found that physicians perceived that a regionally shared medication list generally was more complete but often not accurate (Study IV). Electronic expert support (EES) is a decision support system which analyses patients´ electronically-stored prescriptions in order to detect potential DRP, i.e. drug-drug interactions, therapy duplication, high dose, and inappropriate drugs for geriatric or pediatric patients. We found that EES detected potential DRP in most patients with multi-dose drug dispensing in Sweden (Study V), and that the majority of alerts were regarded as clinically relevant (Study VI). For an improved eMedication, we need a holistic approach that combines technology, users, and organization in implementation and evaluation. The thesis suggests a need for improved sharing of information and support for decision making, coordination, and education, as well as clarification of responsibilities among involved actors in order to employ appropriate IT. We suggest collaborative strategic work and that the relevant authorities establish guidelines and requirements for IT in the medication management process.
    10/2014, Degree: Doctoral dissertation, Supervisor: Göran Petersson

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