Charlotte Verrue

Pharmacists' Interventions for Optimization of Medication Use in Nursing Homes : A Systematic Review

The elderly use more medications than younger adults. In addition, the prevalence of inappropriate prescribing is high in nursing homes. The aim of this review was to collect and interpret the results of clinical studies of interventions involving pharmacists aimed at improving the quality of prescribing in nursing homes, and to identify the key elements for a successful intervention. To this end, we searched MEDLINE, International Pharmaceutical Abstracts and EMBASE from January 1987 to May 2008. Studies were selected that (i) involved a pharmacist; (ii) took place in the nursing home setting; (iii) involved residents aged ≥65 years; (iv) included residents with a range of diseases (not targeted at a specific pathology); (v) were controlled trials (randomized or not). The search strategy retrieved eight controlled studies that fitted the inclusion criteria. A meta-analysis was not possible because of the difference in outcomes chosen in the publications. We found mixed evidence for the effectiveness of various interventions by pharmacists on pharmacotherapy in the nursing home setting. Pharmacists can have different roles in the nursing home such as performing regular medication reviews, being an active member of a multidisciplinary team and/or educating physicians, nurses and other nursing home staff about medication use. Our review shows that the available evidence is mixed concerning the effectiveness of interventions by pharmacists on pharmacotherapy in the nursing home setting. At the same time, greater pharmacist involvement has been shown in published studies to increase physicians’ and nurses’ knowledge and awareness about medication. Evidence is scarce, however, and there is a need for large, well conducted randomized controlled trials in the nursing home setting. Attention should be paid to the choice of outcome measures and to multidisciplinary collaboration when assessing the effects of pharmacists’ interventions on medication use in nursing homes.

Tablet‐splitting: a common yet not so innocent practice

AIM  This paper is a report of a study conducted to quantify (i) the mean deviation from theoretical weight and (ii) the mean weight loss, after tablet-splitting with three different, commonly used splitting methods. BACKGROUND  Tablet-splitting is a widespread practice among all sectors of health care for different reasons: it increases dose flexibility, makes tablet parts easier to swallow and allows cost savings for both patients and healthcare providers. However, the tablet parts obtained are often not equal in size, and a substantial amount of tablet can be lost during splitting. METHOD Five volunteers were asked to mimic the situation in nursing homes and to split eight tablets of different sizes and shapes using three different routine methods: (i) with a splitting device (Pilomat® ), (ii) with scissors for unscored tablets or manual splitting for scored tablets and (iii) with a kitchen knife. Before and after splitting, tablets and tablet parts were weighed using an analytical balance. The data were collected in 2007. RESULTS For all tablets, method 1 gave a statistically significantly lower mean deviation from theoretical weight. The difference between method 2 and method 3 was not statistically significant. When pooling the different products, method 1 also induced significantly less weight loss than the two other methods. CONCLUSION  Large dose deviations or weight losses can occur while splitting tablets. This could have serious clinical consequences for medications with a narrow therapeutic-toxic range. On the basis of the results in this report, we recommend use of a splitting device when splitting cannot be avoided.

Organization of the medication management process in Belgian nursing homes

BACKGROUND With the increase of the proportion of old (>80 years), frail people living in long-term care settings, concern about the quality of medication management processes in nursing homes is growing. OBJECTIVES To characterize the organization of medication management processes in Belgian nursing homes. METHOD This cross-sectional, observational study of a representative sample of 76 Belgian nursing homes was performed in November and December 2005. The results are based on structured interviews that were conducted with 76 facility directors and 112 head nurses, using 2 questionnaires. RESULTS A self-reporting medication error system was set up in 69.7% of the nursing homes. Almost all nursing homes had a therapeutic drug formulary, but its use was not compulsory. Medications were mainly delivered from a community pharmacy (82.9%). The role of the pharmacist was often restricted to mere delivery of medications. Medications were not always administered by nurses, but also by care aides (67%) or nursing students (12.5%). The practice of postscription (i.e., prescribing medication after it has been dispensed by the pharmacist) was also found to be quite common (69.9%). CONCLUSION This study provides a detailed description of the organization of medication management processes in Belgian nursing homes. Based on these results, problem areas can be identified and, consequently, targeted improvement actions can be investigated and implemented.

A pharmacist-conducted medication review in nursing home residents: impact on the appropriateness of prescribing

Abstract Medication use in nursing homes is often suboptimal. This study investigated the impact of a pharmacist-conducted medication review on the appropriateness of prescribing for Belgian nursing home residents. We conducted a 6-month controlled, non-randomized study in two nursing homes (one intervention and one control nursing home). Sixty-nine residents completed the study in the intervention group (92 residents were included). For the control group, that were 79 residents (100 residents were included). Primary outcome was the appropriateness of prescribing, assessed by a set of validated quality indicators. At baseline, this study detected three main problems associated with the appropriateness of medication use: (i) the Medication Appropriateness Index (MAI) could be improved (continuation of no longer indicated medication was the most common problem), (ii) potential overuse was present in about half of the group, and (iii) potential underuse was present in about 30% of the sample. Despite this, our pharmacist-conducted medication review only modestly improved the appropriateness of prescribing. This may be attributed to the low implementation rate of the pharmacist recommendations.

Geneesmiddelengebruik in rust- en verzorgingstehuizen in België: verslag van het PHEBE-onderzoek

SamenvattingIn een representatieve steekproef van Belgische rusthuizen werd eind 2005 een uitvoerige transversale gegevensinzameling uitgevoerd om het medicatiebeleid en de kwaliteit van het geneesmiddelengebruik te beschrijven. De onderzoekers gingen na of buitenlandse methoden om de kwaliteit te evalueren (de criteria van Beers, ACOVE en BEDNURS) toepasbaar waren in de Belgische context. Het medicatiebeleid bleek vooral op het vermijden van distributiefouten gericht.Het geneesmiddelengebruik was overwegend chronisch en lag hoog (gemiddeld zeven verschillende geneesmiddelen per patiënt), met hoge uitgaven (ook voor de patiënt) en per patiënt gemiddeld twee meldingen van mogelijke kwaliteitsproblemen.