Jl Westbury

A Comparison of Prescribing Criteria When Applied to Older Community-Based Patients

BackgroundStudies have compared prescribing criteria for older people in general terms, reporting the findings without true side-by-side comparisons of the frequency and type of potential drug-related problems (DRPs).ObjectiveThe aim of this study was to compare the frequency and type of DRPs identified by several prescribing criteria. Additionally, original pharmacist DRP findings were compared with DRPs identified using the prescribing criteria.MethodThree prescribing criteria were automated: Beers 2012 (Beers), Screening Tool of Older Person’s Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START), and Prescribing Indicators in Elderly Australians (PIEA). The criteria were applied to medication reviews of 570 ambulatory older Australian patients. DRPs identified by each set of criteria were recorded. Each DRP was assigned a descriptive term which highlighted mainly drug classes and/or diagnoses to provide a meaningful common language for comparison between recorded DRPs. Descriptive terms were used to compare the frequency and type of DRP identified by each set of criteria, as well as against original pharmacists’ findings.ResultsBeers identified 399 DRPs via 21 different descriptive terms, STOPP/START identified 1,032 DRPs via 42 terms, and PIEA identified 1,492 DRPs via 33 terms. The various types of DRPs identified by all of the three prescribing criteria were represented by 53 different terms. When constrained to the same 53 different terms, pharmacists identified 862 DRPs.ConclusionEach set of criteria displayed relevance through mutual agreement of known high-risk medication classes in older people. The number and scope of DRPs identified by pharmacists was best represented by STOPP/START. The application of STOPP/START may be further augmented with relevant criteria from PIEA and Beers.

Psycholeptic use in aged care homes in Tasmania, Australia

Background and objective:  Although non‐drug techniques are recommended to manage sleep disturbance, anxiety and challenging behaviours associated with dementia, several studies in Australia and overseas have noted a high use of psycholeptics (anxiolytics/hypnotics and antipsychotics) in aged care homes to treat these conditions. The aim of this study was to examine the current pattern of psycholeptic use in Tasmanian aged care homes and compare this data with other Australasian research.Summary Background and objective:  Although non-drug techniques are recommended to manage sleep disturbance, anxiety and challenging behaviours associated with dementia, several studies in Australia and overseas have noted a high use of psycholeptics (anxiolytics/hypnotics and antipsychotics) in aged care homes to treat these conditions. The aim of this study was to examine the current pattern of psycholeptic use in Tasmanian aged care homes and compare this data with other Australasian research. Methods:  Cross-sectional study of residents’ psycholeptic use from 40 aged care homes throughout Tasmania during November 2005–January 2007. Results:  Two thousand three hundred and eighty-nine residents were included in the study. Of the residents, over half were taking at least one psycholeptic medication regularly; over one-fifth of residents were taking antipsychotics (21%) and 43% were taking anxiolytics/hypnotics. Conclusion:  In comparison with other recent Australasian studies, the current level of benzodiazepine use in Tasmanian aged care homes is of major concern, at approximately three times that reported in Sydney and New Zealand. There is also substantial use of multiple psycholeptic agents. Interventions to reduce benzodiazepine use and improve psycholeptic utilization in Tasmania need to be developed urgently. The results demonstrate the value of regular auditing of prescribing to highlight problem areas in prescribing.

A Computer Simulation of Community Pharmacy Practice for Educational Use

Objective. To provide a computer-based learning method for pharmacy practice that is as effective as paper-based scenarios, but more engaging and less labor-intensive. Design. We developed a flexible and customizable computer simulation of community pharmacy. Using it, the students would be able to work through scenarios which encapsulate the entirety of a patient presentation. We compared the traditional paper-based teaching method to our computer-based approach using equivalent scenarios. The paper-based group had 2 tutors while the computer group had none. Both groups were given a prescenario and postscenario clinical knowledge quiz and survey. Assessment. Students in the computer-based group had generally greater improvements in their clinical knowledge score, and third-year students using the computer-based method also showed more improvements in history taking and counseling competencies. Third-year students also found the simulation fun and engaging. Conclusion. Our simulation of community pharmacy provided an educational experience as effective as the paper-based alternative, despite the lack of a human tutor.

Review of psychotropic medication in Tasmanian residential aged care facilities.

Aim:  To examine psychotropic medication review practices in residential aged care facilities.

The effect of knowledge and expectations on adherence to and persistence with antidepressants.

Purpose Adherence to and persistence with antidepressants are often suboptimal. However, little is known about how patient knowledge and outcome expectations may influence antidepressant adherence and persistence. Method Individuals who had been prescribed their first antidepressant to treat depression in the preceding 6 months were recruited to an online survey via Facebook. Knowledge, education received, and initial outcome expectations were analyzed for associations with persistence and adherence. Results Two hundred and twenty surveys were analyzed. A total of 117 participants had taken their antidepressant for at least 3 months; another 25 had never started or stopped after <3 months without consulting their doctor. Differences in expectations and various educational messages among persistent and nonpersistent participants were identified. Having received the instruction “don’t stop it without checking with your doctor” was a significant independent predictor of persistence (odds ratio [OR] =5.9, 95% confidence interval [CI] =1.4–24.5). At the time of the survey, 82.7% of participants were taking an antidepressant and 77.9% were adherent. Significant independent predictors of adherence were a greater age (OR =1.1, 95% CI =1.0–1.2), knowledge (OR =1.6, 95% CI =1.1–2.3), being informed of common side effects (OR =5.5, 95% CI =1.1–29.0), and having discussed ways to solve problems (OR =3.9, 95% CI =1.1–14.5). Conclusion Improving outcome expectations and particular educational messages may increase adherence and persistence. Greater knowledge may enhance adherence. Further investigation is warranted to determine whether a focus on these simple educational messages will improve outcomes in patients who commence an antidepressant.

Rethinking psychotropics in nursing homes

MJA 199 (2) · 22 July 2013 98 Rethinking psychotropics in nursing homes TO THE EDITOR: We thank Hilmer and Gnjidic for highlighting the excessive use of psychotropic medications in Australian nursing homes.1 We recently completed a national psychotropic audit of over 9000 nursing home medication reviews conducted during the 2011– 12 financial year. Our results were alarming: even after excluding residents with schizophrenia or bipolar disorder, more than a quarter of residents reviewed (27%) were taking antipsychotics. Concerningly, 41% of all residents reviewed were prescribed benzodiazepines. Such findings are not new. The problem of excessive psychotropic use in Australian nursing homes has been reported for nearly 20 years and has been the subject of both federal and state inquiries. As possible solutions, Hilmer and Gnjidic suggest economic evaluations and investment in staff and in research to develop better management strategies.1 Yet, qualitative research has determined that a major reason for high prescribing lies in an overestimation of the efficacy of psychotropic medications and limited awareness of their adverse effects.2 Consequently, awareness-raising and education of health practitioners and residents’ relatives is key. We would also like to emphasise that programs to reduce psychotropic use in Australian nursing homes have proven successful in controlled trials. Resident and staff education reduced benzodiazepine use by half in a South Australian nursing home.3 Likewise, through local audit, benchmarking and nurse education in 15 Tasmanian nursing homes, antipsychotic and benzodiazepine use was reduced significantly over a 6-month period.4 It is time to move beyond describing psychotropic usage patterns and evaluating solutions to implementing these successful intervention strategies on a wider scale.

An investigation into drug-related problems identifiable by commercial medication review software

BACKGROUND Accredited pharmacists conduct home medicines reviews (HMRs) to detect and resolve potential drug-related problems (DRPs). A commercial expert system, Medscope Review Mentor (MRM), has been developed to assist pharmacists in the detection and resolution of potential DRPs. AIMS This study compares types of DRPs identified with the commercial system which uses multiple classification ripple down rules (MCRDR) with the findings of pharmacists. METHOD HMR data from 570 reviews collected from accredited pharmacists was entered into MRM and the DRPs were identified. A list of themes describing the main concept of each DRP identified by MRM was developed to allow comparison with pharmacists. Theme types, frequencies, similarity and dissimilarity were explored. RESULTS The expert system was capable of detecting a wide range of potential DRPs: 2854 themes; compared to pharmacists: 1680 themes. The system identified the same problems as pharmacists in many patient cases. Ninety of 119 types of themes identifiable by pharmacists were also identifiable by software. MRM could identify the same problems in the same patients as pharmacists for 389 problems, resulting in a low overlap of similarity with an averaged Jaccard Index of 0.09. CONCLUSION MRM found significantly more potential DRPs than pharmacists. MRM identified a wide scope of DRPs approaching the range of DRPs that were identified by pharmacists. Differences may be associated with system consistency and perhaps human oversight or human selective prioritisation. DRPs identified by the system were still considered relevant even though the system identified a larger number of problems.

An Internet-Based Method for Extracting Nursing Home Resident Sedative Medication Data From Pharmacy Packing Systems: Descriptive Evaluation

Background Inappropriate use of sedating medication has been reported in nursing homes for several decades. The Reducing Use of Sedatives (RedUSe) project was designed to address this issue through a combination of audit, feedback, staff education, and medication review. The project significantly reduced sedative use in a controlled trial of 25 Tasmanian nursing homes. To expand the project to 150 nursing homes across Australia, an improved and scalable method of data collection was required. This paper describes and evaluates a method for remotely extracting, transforming, and validating electronic resident and medication data from community pharmacies supplying medications to nursing homes. Objective The aim of this study was to develop and evaluate an electronic method for extracting and enriching data on psychotropic medication use in nursing homes, on a national scale. Methods An application uploaded resident details and medication data from computerized medication packing systems in the pharmacies supplying participating nursing homes. The server converted medication codes used by the packing systems to Australian Medicines Terminology coding and subsequently to Anatomical Therapeutic Chemical (ATC) codes for grouping. Medications of interest, in this case antipsychotics and benzodiazepines, were automatically identified and quantified during the upload. This data was then validated on the Web by project staff and a “champion nurse” at the participating home. Results Of participating nursing homes, 94.6% (142/150) had resident and medication records uploaded. Facilitating an upload for one pharmacy took an average of 15 min. A total of 17,722 resident profiles were extracted, representing 95.6% (17,722/18,537) of the homes’ residents. For these, 546,535 medication records were extracted, of which, 28,053 were identified as antipsychotics or benzodiazepines. Of these, 8.17% (2291/28,053) were modified during validation and verification stages, and 4.75% (1398/29,451) were added. The champion nurse required a mean of 33 min website interaction to verify data, compared with 60 min for manual data entry. Conclusions The results show that the electronic data collection process is accurate: 95.25% (28,053/29,451) of sedative medications being taken by residents were identified and, of those, 91.83% (25,762/28,053) were correct without any manual intervention. The process worked effectively for nearly all homes. Although the pharmacy packing systems contain some invalid patient records, and data is sometimes incorrectly recorded, validation steps can overcome these problems and provide sufficiently accurate data for the purposes of reporting medication use in individual nursing homes.

Halting Antipsychotic Use in Long-Term care (HALT): a single-arm longitudinal study aiming to reduce inappropriate antipsychotic use in long-term care residents with behavioral and psychological symptoms of dementia

BACKGROUND Inappropriate use of antipsychotic medications to manage Behavioral and Psychological Symptoms of Dementia (BPSD) continues despite revised guidelines and evidence for the associated risks and side effects. The aim of the Halting Antipsychotic Use in Long-Term care (HALT) project is to identify residents of long-term care (LTC) facilities on antipsychotic medications, and undertake an intervention to deprescribe (or cease) these medicines and improve non-pharmacological behavior management. METHODS LTC facilities will be recruited across Sydney, Australia. Resident inclusion criteria will be aged over 60 years, on regular antipsychotic medication, and without a primary psychotic illness or very severe BPSD, as measured using the Neuropsychiatric Inventory (NPI). Data collection will take place one month and one week prior to commencement of deprescribing; and 3, 6 and 12 months later. During the period prior to deprescribing, training will be provided for care staff on how to reduce and manage BPSD using person-centered approaches, and general practitioners of participants will be provided academic detailing. The primary outcome measure will be reduction of regular antipsychotic medication without use of substitute psychotropic medications. Secondary outcome measures will be NPI total and domain scores, Cohen-Mansfield Agitation Inventory scores and adverse events, including falls and hospitalizations. CONCLUSION While previous studies have described strategies to minimize inappropriate use of antipsychotic medications in people with dementia living in long-term care, sustainability and a culture of prescribing for BPSD in aged care remain challenges. The HALT project aims to evaluate the feasibility of a multi-disciplinary approach for deprescribing antipsychotics in this population.

Expansion of the reducing use of sedatives (RedUSe) project to Australian nursing homes.

Psychotropic medications work on the brain to affect mental function and behaviour. For over 20 years, concern has been raised over the overuse of psychotropic medication, particularly antipsychotics and benzodiazepines (‘sedatives’) in nursing homes. The Reducing Use of Sedatives (RedUSe) project was developed as a multi-strategic, interdisciplinary initiative aimed to promote the quality use of sedative medication in this setting [1]. The key strategies of RedUSe, namely audit & feedback, education and medication review, were tested in a controlled 6-month trial of 25 nursing homes in 2008/2009. The intervention significantly reduced the rates of antipsychotic and benzodiazepine use and doubled the number of sedative dosage reductions. In addition, the rate of new sedative prescribing in intervention homes was reduced to a quarter of the rate observed in control homes[1]. In 2013, the Australian Government awarded substantial funding to expand RedUSe to 150 nursing homes around the country. This abstract describes how the RedUse project was evaluated and enhanced before national expansion.