The role of qualification and quality management in the prescription of antipsychotics and potentially inappropriate medication (PIM) in nursing home residents in Germany: results of the HIOPP-3-iTBX study.

BACKGROUND: Nursing home residents (NHR) show high rates of polypharmacy. The HIOPP-3-iTBX study is the first cRCT on medication optimization in nursing homes (NH) in Germany. The intervention did not result in a reduction of PIM and/or antipsychotics. This analysis looks at structure quality in the HIOPP-3-iTBX study participants. AIMS: Evaluation of structure quality as part of a cluster-randomized controlled intervention study. METHODS: Structure quality in multiprofessional teams from n = 44 NH (n = 44 NH directors, n = 91 family doctors (FD), and n = 52 pharmacies with n = 62 pharmacists) was assessed using self-designed questionnaires at baseline. Main aspects of the questionnaires related to the qualification of participants, quality management, the medication process and size of the facilities. All completed questionnaires were included. number of PIM/antipsychotics was drawn from the baseline medication analysis in 692 NHR. Data were analyzed by descriptive statistics and mixed model logistic regression. RESULTS: The presence of a nurse with one of the additional qualifications pain nurse or Zertifiziertes Curriculum (Zercur) Geriatrie in the participating NH was associated with a lower risk for the prescription of PIM/antipsychotics. No association between any characteristic in the other participants at baseline was observed. CONCLUSIONS AND DISCUSSION: The results support the known role of nursing qualification in the quality and safety of care. Further studies need to look more closely at how use is made of the additional qualifications within the multiprofessional teams. Perspectively, the results can contribute to the development of quality standards in NH in Germany.

Drug Safety for Nursing-Home Residents-Findings of a Pragmatic, Cluster-Randomized, Controlled Intervention Trialin 44 Nursing Homes.

BACKGROUND: The safety of drug use by nursing-home residents can be impaired by polypharmacy, potentially inappropriate medications (PIM), and neuroleptics, as well as by a lack of adequate interprofessional coordination in the nursing home. The goal of the HIOPP-3-iTBX Trial was to improve drug safety in nursing-home residents, including a reduction of PIM and/or neu - roleptic use, by means of a complex interprofessional intervention. METHODS: This cluster-randomized, controlled trial was performed in nursing homes in Germany. Residents over age 65 were included in the trial. The intervention was carried out over six months and consisted of four elements: a drug review by trained pharmacists, educational sessions for general practitioners and nurses, a drug safety toolbox, and change management seminars for members of the three participating professions. The nursing homes in the control group continued to provide usual care. The primary endpoint was the prescription of at least one PIM and/or at least two neuroleptic drugs simultaneously. The secondary endpoints were the incidence of falls and hospitalizations, quality of life, and health-care costs. This trial is registered in the German Clinical Trials Registry (DRKS00013588). RESULTS: 44 nursing homes with 862 residents were randomized, 23 of them (with 452 residents) to the intervention group and 21 (with 410 residents) to the control group. 41% of all nursing-home residents initially took at least one PIM and/or at least two neuroleptic drugs simultaneously. Follow-up data (including, among other things, the current drug regimen) were obtained for 773 residents. The intention-to-treat analysis continued to show no difference between the intervention group and the control group with respect to the primary endpoint. CONCLUSION: This trial of an intervention to improve drug safety in nursing homes led neither to reduced prescribing of PIM and/or neuroleptic drugs, nor to any improvement in the overall health status of the nursing-home residents.

Polypharmacy-an Upward Trend with Unpredictable Effects.

BACKGROUND: Guideline-oriented treatments can lead to polypharmacy, i.e., the simultaneous long-term use of multiple drugs. Polypharmacy mainly affects elderly patients. The goal of this review is to survey the current scientific evidence about polypharmacy, focusing on clinical endpoints, and to point out implications for medical practice and research. METHODS: This selective literature review is based on pertinent publications that were retrieved by a selective search in PubMed employing the terms "polypharmacy AND general practice." Selected references were considered as well. RESULTS: In Germany, polypharmacy currently affects approximately 42% of persons over age 65, with an ongoing upward trend. 20-25% of these patients receive potentially inappropriate drugs. Approximately 86% of the daily doses of drugs taken by persons over age 65 are prescribed by general practitioners. There is inconsistent evidence on the question whether polypharmacy affects clinical endpoints such as mortality. It cannot be determined with certainty whether polypharmacy itself, or the underlying multimorbidity, is the reason for worse clinical outcomes. Lists, instruments, and guidelines such as PRISCUS (a list of potentially inappropriate drugs for elderly patients), FORTA (Fit fOR The Aged), MAI (the Medication Appropriateness Index), and the Hausärztliche Leitlinie Multimedikation (a German-language guideline on polypharmacy for general practitioners) can help physicians take care of patients who are taking multiple drugs. It has not yet been proven, however, that their use has any effect on clinical outcomes. CONCLUSION: The decision whether to keep giving a drug or to discontinue it must always be made individually on the basis of current treatment goals; drug lists and a pertinent general practitioners' guideline can be useful aids in decision-making. Efforts to pay more attention to multimorbidity and polypharmacy in future studies and guidelines are deserving of support.