October 09, 2017
By Will Boggs MD
NEW YORK (Reuters Health) - Multidisciplinary multistep medication review is effective in discontinuing inappropriate medication use in frail nursing home residents, according to results from a cluster randomized controlled trial in the Netherlands.
"We found an effect on reducing medication use, thus overtreatment, but not on initiating medication, thus undertreatment,” Dr. Hans Wouters from University of Groningen and University Medical Center Groningen, in the Netherlands, told Reuters Health by email. “In the group of nursing home residents, medication reviews seem therefore especially helpful for overtreatment.”
Earlier studies have shown that as many as 40% of nursing home residents receive one or more inappropriate drugs, and this inappropriate prescribing has been associated with adverse events and hospitalizations. Unfortunately, studies targeting discontinuation of inappropriate medications have yielded mixed results.
Dr. Wouters’s team randomly assigned 16 elder care physicians and 33 wards (including 233 nursing home residents) an intervention involving a single, multidisciplinary, multistep medication review (3MR) by the treating physician in collaboration with hospital pharmacists or pharmacists appointed to conduct medication reviews in nursing homes. The control group, which continued usual care, included 16 elder care physicians and 26 wards (with 193 nursing home residents).
During a mean follow-up of 144 days, at least one inappropriate medication was successfully discontinued in a greater proportion of nursing home residents from the intervention group (39.1%) than the control group (29.5%), according to the October 10 Annals of Internal Medicine report.
The intervention and control groups did not differ in initiation of at least one underprescribed medication, dose adjustments, switches to safer drugs, or mean Drug Burden Index (DBI).
Secondary clinical outcomes - falls, number of outpatient clinic visits, visits by elder care physicians, consultations by other healthcare professionals, cognitive function, neuropsychiatric symptoms, and quality of life - did not differ between the intervention and control groups.
“With our trial we could show how to improve the quality of medication use,” Dr. Wouters said. “We hope our study will inspire colleagues around the world to adopt this model in their setting.”
“In discontinuing inappropriate medication, we have steered vulnerable older patients away from potential hazard,” he said. “We would therefore advocate that medication reviews can be conducted even if they come at costs (as long as the costs are tolerable of course).”
Dr. Holly M. Holmes from University of Texas Health Science Center McGovern Medical Center, Houston, Texas, who coauthored an accompanying editorial, told Reuters Health by email, "The patients in this study and many patients in nursing homes are quite frail and have limited remaining life expectancy, and it's important to start reducing medications that may be burdensome without providing benefit. Medications that are not traditionally on lists of high risk drugs to avoid in older people, such as preventative drugs, may be of less and less benefit in such patients and should be carefully reviewed for de-prescribing.”
“I think it's also important to realize that although there weren't large differences in outcome between the intervention and control group and secondary outcomes weren't achieved, we should not be ignoring the continued use of harmful medications, and we need to make every effort to improve and reduce these exposures to harmful medications in patients living in nursing homes,” she said.
Dr. Holmes added, “A second title that my coauthor and I considered was ‘Get to Know Your Consultant Pharmacist.’ I think that's the biggest message. Pharmacists are a valuable and often underutilized team member.”
Dr. Gunhild Nyborg from University of Oslo, in Norway, who recently reviewed potentially inappropriate medication use in nursing homes, told Reuters Health by email, "This study is an important contribution in our efforts to prevent adverse side effects from medication use in this population.”
“The study was likely underpowered to show effects on secondary outcomes,” she said. “However, other studies have shown that potentially inappropriate medication (PIM) use increases the risk of adverse drug events.”
“As doctors, we have learned to treat medical conditions with pharmacological substances, but we know too little about what happens when we combine many drugs, especially in the very old, frail, often multi-morbid nursing home residents,” Dr. Nyborg said. “Drug trials are almost always performed in younger, healthier individuals. There is some evidence that we may be approaching a ‘tipping point,’ where de-prescribing in itself may improve quality of life in this population.”
“Some studies have calculated relatively large savings after de-prescribing due just to the decreased spending on drugs, and these are savings that directly benefit the nursing homes,” she added. “Thus, from what we know today, measures targeting de-prescribing in this population are likely cost-effective, but more research is needed.”
SOURCES: http://bit.ly/2g6cYyb and http://bit.ly/2ybpHGJ
Ann Intern Med 2017.
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