A multidisciplinary, multistep intervention reduced potentially inappropriate medication use in elderly nursing home patients without compromising their health and well-being, a study has shown.
The proportion of patients who successfully discontinued at least one potentially inappropriate medication (PIM) was greater among those assigned to the Multidisciplinary Multistep Medication Review (3MR) intervention compared with those who received usual care, the cluster randomized trial found.
“[O]ur study provides timely and practical guidance on how to operationalize deprescribing in nursing home residents,” the researchers write.
Hans Wouters, PhD, from the Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, Oostersingel, the Netherlands, and colleagues report their findings in an article published online October 10 in the Annals of Internal Medicine.
The growing prevalence of polypharmacy in older adults is associated with an increased risk for inappropriate prescribing, which in turn has been linked to multiple adverse events, including falls, cognitive decline, and hospitalizations, the authors explain.
The 3MR consists of four components: an assessment of the patient’s perspective and a comprehensive medical and medication review, pharmacist identification of “potential overprescribing and underprescribing and other suboptimal prescribing conditions,” a meeting between the treating physician and the pharmacist to review the medications and develop a revised plan, and implementation of medication changes on the basis of the plan.
Pharmacists used an automated prompt system that included the Screening Tool to Alert Doctors to Right Treatment (START), Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP), and the Beers criteria.
The researchers randomly assigned 426 nursing home residents from 59 facilities to the intervention (n = 233) or to usual care (n = 193), which comprised medication safety monitoring and occasional, nonstandardized medication reviews for individual residents when clinically indicated.
Primary and secondary outcomes were collected at baseline and at 4 months. The primary outcome was the proportion of patients who stopped at least one PIM at 4 months without relapse symptoms or withdrawal effects. At 4 months, at least one PIM was successfully discontinued in 91 (39.1%) intervention group patients compared with 57 (29.5%) control group patients (relative risk adjusted for covariates, 1.37; 95% confidence interval, 1.02 – 1.75).
The 10% improvement in the intervention group was less than the 20% the researchers had anticipated in the power analysis. “[T]his could have been due to a lower response in the intervention group or improved prescribing in the control group,” they write.
The secondary pharmacologic outcomes were the number of patients in whom an underprescribed medication was initiated or adjusted or who had a possibly hazardous drug replaced by a safer option. Secondary clinical outcomes included measures of neuropsychiatric symptoms, cognitive function, and quality of life.
No between-group differences were observed for the secondary pharmacologic or clinical outcomes, “although our study might have been underpowered to detect effects on these outcomes,” according to the authors. “Overall, our findings suggest that successful discontinuation of inappropriate medication use did not occur at the expense of further deterioration of nursing home residents’ well-being.”
The findings have implications for future research and clinical practice. “First, we used several criteria to support the decision-making process during the medication reviews. Evidence-based deprescribing guidelines that are currently being developed could be useful but were not available when we developed the 3MR,” the authors write.
Other considerations include the fact that the 3MR was only completed once for patients during the study period. “This population often experiences a gradual and progressive functional decline and has a limited life expectancy. Longitudinal research may provide information about how often systematic medication reviews, such as the 3MR, should be done or how medication prescribing should be adjusted as treatment goals shift from curative or preventive treatment to palliative or comforting care,” the researchers explain.
In addition, multidomain interventions that couple medication reviews with other interventions, such as those targeting physical and psychosocial well-being, as well as those that involve patients and families in the decision-making process around medication use, might influence clinical outcomes, the authors note.
A more effective intervention in this population might focus on deprescribing medications that were once beneficial but are no longer appropriate because of patients’ ages or conditions, Holly M. Holmes, MD, from the University of Texas Health Science Center McGovern Medical School in Houston, and Greg A. Sachs, MD, from Indiana University School of Medicine and Regenstrief Institute in Indianapolis, write in an accompanying editorial.
“Such an intervention might have a larger effect on reduction in medication use, quality of life, cost, and other secondary outcomes, particularly because use of burdensome medications is high among nursing home residents with dementia,” they write, noting that the recently developed Screening Tool of Older Persons Prescriptions in Frail Adults With Limited Life Expectancy (STOPPFrail) criteria address these medications.
The STOPPFrail criteria “have items focusing on use of medications that could be inappropriate in any setting (such as theophylline) and medications that are less likely to be beneficial in a population with advanced disease (such as statins in patients with limited life expectancy),” the editorial authors write. “The STOPP and START…criteria have also been adapted to the nursing home setting, with a focus on criteria identifiable in administrative databases, including 22 indicators of PIMs to stop (17 of which are part of the Beers criteria) and 2 medications to start.”
Dr Holmes and Dr Sachs stress that the 3MR intervention, as implemented in the study, may not be generalizable to all nursing home settings. “The pharmacist and specialist physician presence in Dutch nursing homes may not translate to other health care systems. It is unclear how the patient’s perspective and the patient questionnaire influenced the recommendations to deprescribe,” they write. “Other than use of the STOPP/START and Beers criteria, the results do not reveal details about the pharmacists’ thinking processes. Further, patients were excluded if they or their family had a difficult relationship with the staff, which highlights the need for high levels of cooperation.”
Despite its limitations, the current study holds important messages for clinicians caring for frail elderly patients in nursing home settings. “Medication reconciliation can be a complex process requiring substantial expertise, but improvements in medication use can be facilitated by working closely with the multidisciplinary team, particularly the consultant pharmacist,” according to the editorial authors. “Focusing on a specific set of criteria, such as the nursing home–adapted STOPP criteria, or a specific class of drugs, such as antipsychotics or benzodiazepines, might be the best first approach.”
The Netherlands Organization for Health Research and Development provided funding support for the study. The study authors and Dr Holmes have disclosed no relevant financial relationships. Dr Sachs reports personal fees from CVS Caremark outside the submitted work.
Ann Intern Med. Published online October 9, 2017. Abstract, Editorial extract
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