JAMDA Online
Original Study
Potentially Inappropriate Drug Prescribing and Associated Factors in Nursing Homes

A part of this work was presented as a poster at the 9th P2T “Physiologie, Pharmacologie et Thérapeutique” Congress (Poitiers, April 22, 2014, France; Cool C, Lebaudy C, Rolland Y, et al. Potentially inappropriate drug prescribing and associated factors in nursing homes. Fundamental and Clinical Pharmacology 2014;28(Suppl 1):60).
https://doi.org/10.1016/j.jamda.2014.08.003Get rights and content

Abstract

Importance

Polymedication is frequent in nursing home (NH) residents. This increases the risk of potentially inappropriate drug prescribing (PIDP), which can lead to adverse drug events, such as falls and hospitalization.

Objective

To identify PIDP in NH residents and to investigate subject-related and NH structural and organizational factors associated with PIDP.

Design

Cross-sectional study.

Setting

A total of 175 NHs in Midi-Pyrénées region, South-Western France.

Participants

A total of 974 subjects randomly selected from the 6275 NH residents participating in the IQUARE study.

Exposure

Patients with PIDP.

Main Outcomes and Measures

PIDP was the main outcome measure. It was defined using a specific indicator, based on the Summary of Product Characteristics, on the Laroche list, and on residents' clinical data. PIDP was defined as the presence of at least 1 of the following criteria: (1) drug with an unfavorable benefit-to-risk ratio; (2) drug with questionable efficacy according to the Laroche list; (3) absolute contraindication; (4) significant drug-drug interaction. Associated factors were identified by using multivariable logistic regression models.

Results

Among the 974 residents included, 71% had PIDP. PIDP was more frequent in patients without dementia, with several comorbidities and taking multiple medications. In the multivariable analysis, age (odds ratio [OR] 1.02; 95% confidence interval [CI] 1.01–1.03) and Charlson Comorbidity Index (CCI; P = .003, CCI = 1 versus 0: OR1/0 1.22; 95% CI 0.85–1.74, CCI ≥ 2 versus 0: OR2/0 1.72; 95% CI 1.23–2.41) were associated with an increased likelihood of PIDP. By contrast, dementia was associated with a lower likelihood of PIDP (OR 0.70; 95% CI 0.53–0.94). Among NH structural and organizational characteristics, the access to psychiatric advice and/or to hospitalization in a psychiatric unit (OR 1.36; 95% CI 1.02–1.82) and the presence of a reevaluation of drug prescriptions (OR 1.45; 95% CI 1.07–1.96) were associated with an increased likelihood of PIDP.

Conclusions and Relevance

Our work suggests that some NH characteristics are associated with an increased likelihood of PIDP. Gaining a better understanding of the factors influencing PIDP, especially structural and organizational NH factors, can help to determine the interventions that should be implemented.

Section snippets

Data Source

The IQUARE study (Impact d'une demarche QUAlité sur l’évolution des pratiques et le déclin fonctionnel des Résidents en EHPAD) is a multicentric individually tailored controlled trial performed in NHs in the Midi-Pyrénées area, South-Western, France (trial registration number: NCT01703689). IQUARE's research protocol has been fully described elsewhere25 and several analyses related to specific drug use have been previously published.26, 27, 28 IQUARE followed the principles of the Declaration

Characteristics of the Study Population (Residents) and NHs

From the 1000 residents randomly selected, 26 were excluded because of end of life. Resident characteristics and NH characteristics (aggregated at the resident level) according to PIDP are presented respectively in Table 1, Table 2.

Outcome Measures

Table 3 presents the prevalence of PIDP and other potential DRPs. Among the 974 residents included, 70.6% (n = 688) had PIDP: 65.3% (n = 656) of residents had at least 1 drug with an unfavorable benefit-to-risk ratio (21.6% according to the Laroche list,22 and 58.2%

Discussion

This study showed that the likelihood of PIDP was not related to NH characteristics, except for access to psychiatric advice and/or to hospitalization in a psychiatric unit. Prescribing drugs with an unfavorable benefit-to-risk ratio was less frequent in patients living in an NH with a special care unit.

To the best of our knowledge, few studies have investigated structural and organizational characteristics of NHs on the quality of drug prescribing, irrespective of the individual

Conclusion

This study provides the first multilevel findings of prescribing drugs with an unfavorable benefit-to-risk ratio among NH residents in France. Structural and organizational factors in NHs would be easier to change than individual characteristics of residents. Gaining a better understanding of the factors influencing PIDP can help to determine the interventions that should be implemented.

Acknowledgments

We thank all the people who rendered this research possible, particularly coordinating physicians, coordinating nurses, and directors of participating nursing homes. We also thank the helpful participation of Flavie Boyé, PharmD, Fiona Chautant, PharmD, Laurie Boccanfuso, PharmD, and Audrey Bigot, who conducted the Drug Utilization Review. The contributors received no financial compensation. We acknowledge Paul McCambridge for editing the final version of the manuscript.

References (56)

  • D. O'Mahony et al.

    STOPP & START criteria: A new approach to detecting potentially inappropriate prescribing in old age

    Eur Geriatr Med

    (2010)
  • P. De Souto Barreto et al.

    A multicentric individually-tailored controlled trial of education and professional support to nursing home staff: Research protocol and baseline data of the IQUARE study

    J Nutr Health Aging

    (2013)
  • P. De Souto Barreto et al.

    Indicators of benzodiazepine use in nursing home residents in France: A cross-sectional study

    J Am Med Dir Assoc

    (2013)
  • P. De Souto Barreto et al.

    Potential underuse of analgesics for recognized pain in nursing home residents with dementia: A cross-sectional study

    Pain

    (2013)
  • P. De Souto Barreto et al.

    Prevalence and associations of the use of proton-pump inhibitors in nursing homes: A cross-sectional study

    J Am Med Dir Assoc

    (2013)
  • Y. Rolland et al.

    Descriptive study of nursing home residents from the REHPA network

    J Nutr Health Aging

    (2009)
  • P.O. Lang et al.

    Interdisciplinary geriatric and psychiatric care reduces potentially inappropriate prescribing in the hospital: Interventional study in 150 acutely ill elderly patients with mental and somatic comorbid conditions

    J Am Med Dir Assoc

    (2012)
  • P. Lester et al.

    Antipsychotic drug use since the FDA black box warning: Survey of nursing home policies

    J Am Med Dir Assoc

    (2011)
  • A. Gallini et al.

    Trends in use of antipsychotics in elderly patients with dementia: Impact of national safety warnings

    Eur Neuropsychopharmacol

    (2014)
  • C.D. Van der Maarel-Wierink et al.

    Risk factors for aspiration pneumonia in frail older people: A systematic literature review

    J Am Med Dir Assoc

    (2011)
  • D.M. Fick et al.

    Updating the Beers criteria for potentially inappropriate medication use in older adults: Results of a US consensus panel of experts

    Arch Intern Med

    (2003)
  • S. Hartikainen et al.

    Medication as a risk factor for falls: Critical systematic review

    J Gerontol A Biol Sci Med Sci

    (2007)
  • D. Garfinkel et al.

    Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: Addressing polypharmacy

    Arch Intern Med

    (2010)
  • D. O'Mahony et al.

    Inappropriate prescribing in the older population: Need for new criteria

    Age Ageing

    (2008)
  • R.R. Aparasu et al.

    Inappropriate prescribing for the elderly: Beers criteria-based review

    Ann Pharmacother

    (2000)
  • J. Dhall et al.

    Use of potentially inappropriate drugs in nursing homes

    Pharmacotherapy

    (2002)
  • D.T. Lau et al.

    Potentially inappropriate medication prescriptions among elderly nursing home residents: Their scope and associated resident and facility characteristics

    Health Serv Res

    (2004)
  • B. Briesacher et al.

    Evaluation of nationally mandated drug use reviews to improve patient safety in nursing homes: A natural experiment

    J Am Geriatr Soc

    (2005)
  • Cited by (0)

    The authors declare no conflicts of interest.

    The IQUARE study was funded by the Regional Agency of Health from Midi-Pyrénées region (Agence Régionale de Santé – Midi-Pyrénées). The first author of this study (CC) was funded by the Ministry of Health as part of her pharmacy residency in “Innovation Pharmaceutique et Recherche” (IPR).

    View full text