Quality of prescribing in UK care homes : using local data to recommend optimal prescribing strategies

Abstract

Background: Inappropriate prescribing (IP) for older people is a public health concern worldwide because of its implications for increased healthcare costs and adverse drug events (ADE). Care home residents are particularly prone to IP due to intrinsic (frailty) and extrinsic (governance and management of homes) factors. My PhD focussed on prescribing for this vulnerable population. Methods: I conducted two systematic reviews which were aimed at: 1) establishing an IP-ADE link; and 2) interpreting interventions employed to reduce IP. Additionally, I evaluated the effectiveness of a multidisciplinary intervention in reducing IP in two nursing homes (combined sample size of 143 residents) managed by one general practice. In this multidisciplinary intervention, feedback from both a pharmacist medication review and an audit using STOPP (Screening Tool of Older Person's Prescriptions) which identified potentially inappropriate medication (PIM) and START (Screening Tool to Alert doctors to Right Treatment) which identified potential prescribing omission (PPO) were utilised by two general practitioners (GPs) to make appropriate changes to prescriptions. I compared the pre and post-intervention scores for PIMs and PPOs. Finally, I provided recommendations to improve overall prescribing quality in UK care homes. Main findings: The findings include: 1) Evidence for a correlation between IP and ADE was weak; 2) Interventions involving academic detailing, pharmacist medication review and multidisciplinary team meetings were more successful; 3) After the 13 months study, residents in the post-intervention group were significantly less likely to have been prescribed a PIM (RR 0.52, 95% CI 0.41-0.67) or a PPO (RR 0.58, 95% CI 0.48-0.69) as compared to residents in the pre-group. Factors influencing the number of PIMs and PPOs were number of medications and number of comorbidities respectively; 4) Recommendations for improving prescribing quality were broadly categorised into five areas: future research; legislation and directives; education and training; integrated healthcare services; and information technology. Conclusion: The multidisciplinary pharmacist-GP-researcher intervention is an effective and practical approach to reducing IP for nursing home residents.