Introduction
Aging of the population in developed countries has been attributed to decreased birth rates and increased life expectancies, among other causes.1-2 These demographic changes are manifested in cultural, economic, social and health phenomena, and lead to an increase in the use of health resources. Psychosocial impairment, a health status of functional dependence, and multiple chronic medical conditions are some of the factors characteristic of this group of older persons, some of whom are institutionalized in nursing homes.3-5
In view of the expansion of the therapeutic arsenal devoted to caring for older persons, and in light of the fact that the number of persons residing in a nursing home is now double the number living at home, these factors lead to a greater risk for adverse effects, drug interactions and medication errors.6-9
Some publications report profiles of overuse of specific drugs or therapeutic subgroups, and others center on specific drugs for chronic diseases or their inappropriate use.10-12
Against this background we examined the need to reduce the inappropriate use of drugs, to optimize the efficiency of pharmaceutical care, and to foment strategies intended to facilitate the rational use drugs and improve the quality of prescribing practices based on safety and efficacy criteria. Evidence available from pharmacological evaluations in nursing homes has rarely been analyzed, and few reports of research done in Spanish nursing homes have been published.13-14
The present study was designed to measure the efficacy, after one year, of a program to improve appropriate prescribing practices for drugs and medical care supplies in a group of residential nursing homes.
Material and Methods
We analyzed pharmaceutical prescriptions at 107 residential nursing homes in the Barcelonés Norte y Maresme health region during the period from January 2001 to December 2002. The total population served by these two regions of the public health care system is 708 118 inhabitants, 14.7% of whom are older than 65 years according to the latest census.15 The unit of study was the nursing home, regardless of whether it was a public or private center, and regardless of whether the services it provided were also offered by other centers. An initial situation analysis was done to characterize the preintervention reference scenario. Each center was assigned to the intervention or control group according to strategic criteria based on opportunity costs with reference to medical prescriptions for drugs and medical supplies written between January and December 2001. The prioritization factors were: a) total cost of drugs at each center and interannual increase; b) whether the organism that managed the center monitored costs, or c) whether unfavorable results for qualitative or efficiency indicators were obtained. During the monitoring period we recorded prescriptions dispensed from January to December 2002.
We used a multicenter, controlled, quasi-experimental, before-after design to study of all outpatient prescriptions written by each prescribing physician that were charged to the Catalonian Health Service (CHS). We excluded from the study prescriptions for which the prescribing physician was not identified or which were not recorded by the pharmaceutical tracking system, and nursing homes that opened or were incorporated into the public health system during the study period.
The actions carried out in the intervention group were as follows: a) a letter describing the program and its aims, and requesting permission to include the center in the study; enclosed was a questionnaire requesting general information about the center and about the number and type of residents it served; b) a face-to-face meeting, lasting about 2 hours, with the medical directors and managers of each center, and with the director of the primary care center whose staff were responsible for writing prescriptions for the patients served by the nursing home; during the meeting detailed information was provided on the results of the situation analysis and the monitoring process; c) bimonthly distribution of printed material that contained general and specific information about the quantitative and qualitative indicators to be used during the study; to obtain informative feedback, a list was also provided of the prescribing targets for each therapeutic subgroups of drugs, and d) monitoring with 2 to 4 follow-up interviews during the second year (2002). All interviews at each center were led by one of the authors, and the purpose of the interviews was to highlight the positive results obtained or offer specific recommendations, reached by consensus with the medical staff, to correct shortcomings. The first interview was held at each center during the first trimester of the year. None of the nursing homes selected declined to participate in the program.
Overall figures for costs (retail price in euros) were obtained for each nursing home and each main therapeutic subgroup. The system of quantitative indicators proposed consisted of total cost of all packages prescribed, total cost per nursing home resident, proportion of total costs per center represented by the cost of urinary or fecal incontinence products (UIP), and percentage of total cost of IUP represented by nighttime pads or diapers. In addition, prescriptions for the following therapeutic subgroups were tracked:16 drugs for peptic ulcer and GORD (A02), antihypertensives (C07, C03, C02), antidepressants (N06A), antiasthmatics (R03), antibacterials (J01, J03), and nonsteriod anti-inflammatory drugs (NSAID) and analgesics (M01, M02).
As general qualitative indicators we used the percentage of packages with high intrinsic pharmacological value (HIPV), defined as drugs or associations whose clinical efficacy has been demonstrated in clinical trials or whose use is justified because of their immediate effect; and the percentage of generic pharmaceutical specialties (GPS). The qualitative indicators choice of drug or relative drug use were chosen by consensus among the authors on the basis of published information,17 which provided an approximate estimate of foreseeable consumption. These indicators were recorded for each center as the number of packages of each active pharmaceutical principle in different therapeutic subgroups: a) percentage of first-line antiasthmatics (short-acting inhalers [short-acting beta adrenergic receptor antagonists: orciprenaline, terbutaline, salbutamol, procaterol, and reproterol], inhaled corticosteroids [fluticasone, budesonide, and beclomethasone], and ipatropium bromide) compared to second-line antiasthmatics (long-acting inhaled beta adrenergic receptor antagonists [salmeterol, formoterol], cromoglycate, and nedocromil), and drugs used only exceptionally (oral and parenteral presentations, leukotriene antagonists, and others); b) percentage of total NSAID use represented by sodium diclofenac, ibuprofen, and naproxen; c) percentage of systemic antibiotics (J01) represented by penicillins (J01C-J01K) and macrolides (J01F), and d) percentage of total systemic NSAID (M01) represented by rofecoxib and celecoxib.
For the statistical analysis the source of information consisted of text records provided by the prescription tracking system. The data matrix was built and the analyses were done with a specially-written program for Microsoft Access. Descriptive, univariate analysis was used for individual indicators, and nonparametric bivariate analysis with nonparametric tests of significance and Student´s t test for paired data were used for multiple comparisons. Statistical significance was set at P<.05.
Results
The costs generated by medical prescriptions charged to the CHS for residents of public and private nursing homes represented 10% of the total cost of prescription drugs in the Barcelonés Norte y Maresme health region. The number of packages prescribed during the study period at the 107 participating centers was 522 805 in 2001 and 554 299 in 2002, and these prescriptions generated costs of 7.7 million euros in 2001, and 8.4 million euros in 2002, for an interannual increase of 6.0% and 9.4%.
Table 1 summarizes the characteristics of participating centers during the study period, i.e., number of residents, number of packages dispensed, total cost generated for all medications, and UIP only in the intervention and control groups, and results for other general quantitative indicators. The centers in the intervention group represented 19.6% of all centers. The interannual increase (from the reference period to the monitoring period) in the number of packages dispensed was--2.0%, and the increase in total cost of all medications was 0.7%.
These results show that total costs were contained in the intervention group as compared to the control group. In this connection we note that use of UIP was not the same in both groups, with an increase from the reference period to the monitoring period of 4.5% in the former and 8.5% in the latter (P=.000). This item accounted for 35.1% of the total cost of medications and medical supplies in all nursing homes during the reference period, and for 33.0% during the monitoring period.
Table 2 shows the results for quantitative variables for the main therapeutic subgroups. These groups accounted for 23.2% of the total pharmaceutical cost, and for 24.5% of all packages dispensed during the reference period; the corresponding figures for the monitoring period were 22.5% and 24.7%. During the preintervention phase the subgroup that accounted for the greatest proportion of total costs (6.5%) was drugs for peptic ulcer (A02B). In the intervention group, the cost reduction (-8.6%) and lower number of packages dispensed (4.0%) in comparison to the control group were findings of note.
The changes in total costs and number of packages dispensed for different therapeutic subgroups differed between the intervention and control groups. Especially significant was the difference in drugs prescribed to treat peptic ulcer (intervention group: total cost -18.6%, number of packages 3.8%) and NSAID (intervention: total cost 34.6%, number of packages 16.0%). The differences for antibacterials, antiasthmatics, and antihypertensives were smaller although also noteworthy. Total cost for all packages dispensed for all therapeutic subgroups decreased by 4.8% in the intervention group, and remained unchanged in the control group (0.1%) during the study. These differences were appreciable for antiasthmatics and NSAID, and contributed to the improvements in efficiency.
The findings for qualitative indicators, i.e., choice of drug and relative drug use, differed notably (Table 3). The percentage of prescriptions for HIPV drugs and GPS was above the standard/target values of 86% and 10%, respectively, in both the intervention and control groups. In the former, the use of GPS increased from 7.9% to 13.1% during the study. The results for choice of first-line antiasthmatics, recommended NSAID and use of coxibs showed slightly more improvement in the quality of prescribing practices in the intervention group as compared to the control group.
Discussion
Few studies have been published thus far in Spain on the use of medications at residential nursing homes.13-14,18 Moreover, the different methods used to measure prescribing practices, and the frequent changes in consumption patterns in response to supply and the introduction of novel products on the market, make it difficult to compare studies and therefore limit the external validity of the results. However, these unknowns do not invalidate the knowledge obtainable from studies of institutionalized patients, given that similarities can be assumed in clinical practice styles and organizational models such that these factors would not be expected to influence the results.
In earlier studies, interventions that combined informative feedback with printed material, periodic reminders and methods based on personalized interviews were found to be effective in improving prescribing quality.19-20 In Spain several intervention strategies have been proposed to influence the use of generic drugs or improve specific situations.21-24 The present study was based on available knowledge and on prior situation analysis, in a scenario involving a large number of centers, a large geographic area, differences in the numbers of residents at each center, differences in the types of care they provide, and wide variations in prescription practices. We attempted to use the most effective strategies on the basis of available resources; this was a useful practical exercise in clinical management since, on the basis of available scientific evidence and in situations of daily clinical practice, our aim was to favor the choice of the most cost-effective medications.
The quantitative results show that UIP and utilization of different therapeutic subgroups account for more than 55% of total pharmaceutical costs. This finding is similar to the results of other published studies.13-14,25-27 In the intervention group, total costs for drugs and medical supplies were contained in comparison to the control group. This effect was a result of the efficiency of specific actions, which led to improvements in the utilization of UIP and better compliance with the targets for nighttime UIP consumption, improvements in the selection of cheaper products (with omeprazole being a case in point), and an increase in the percentage use of GPS. The volume of prescriptions is such that the quantitative impact of small contributions is potentially considerable. In this connection the potential savings as a result of the program (in a simulated scenario based on total costs in excess of 524 thousand euros) are sufficient to justify the resources used and the possible effect of blinding on the results for the control group.
The percentages of HIPV drugs and GPS surpassed the proposed target figures, and of particular note was the 65.8% interannual increase in the intervention group (for a final relative increase of 13.1%). This indicator, together with the ratio of nighttime-to-total UIP consumption, were the two that received the greatest attention during the follow-up interviews. We note that that these improvements reflect considerable efforts in organizing care for the residents and in adapting to changes made by the health care teams at the nursing homes.
The indicators of relative drug use provide information on the relative proportions of use of different groups of drugs indicated for the same diagnosis. Our results for the use of first-line antiasthmatics and recommended NSAID reflect notable improvements in the quality of prescribing practices in the intervention group. These qualitative results showed a strong association with the qualitative results for different therapeutic subgroups, a result that further supports the consistency of the methods used here28 and of the approach used for information management.
Possible limitations of the study involve factors of design, process and methodology which may have influenced comparisons between the intervention and control groups during the monitoring period. As possible sources of selection or classification bias, we note the nonrandom assignment of centers to the two groups, moving by nursing home residents to a different center, and possible changes in their health status or morbidity. A further factor to be taken into account is that the contractual conditions under which services were purchased from public and private health care service institutions responsible for managing some of the nursing homes may have differed, and this, in turn, might have influenced the results. Other potential sources of error are miscounts of prescriptions not attributed to a specific prescribing physician, and possible administrative errors in delivering prescription forms to individual physicians.
It is worth noting that in follow-up interviews, every effort was made to use simple language that was comprehensible to health professionals, on the basis of available information. This made it impossible to estimate more accurately certain quantitative or qualitative indicators such as the daily defined dose.29 However, the volume of prescriptions, the evidence of regression upon the mean, and the design used for the study, suggest that our results are usable and comparable to those from other models. Additional studies should aim to confirm the consistency of the present findings.
Future research should promote actions designed to improve how the program is implemented, and to increase our knowledge of the diseases commonly seen in nursing home residents. An important aim should be to extend the intervention in a way that ensures greater homogeneity in prescribing practices at different centers, makes results from institutions responsible for operating the centers mandatory, and favors mechanisms of coordination with primary care services and pharmacists. An additional goal should be to develop a catalog of centers that allows the results of the intervention to be adjusted on the basis of confounding variables (differences between institutions, types of center and numbers of residents). More robust information management systems designed to classify patients on the basis of consumption of resources30 should also be developed to further improve the models.
In conclusion, the preliminary results of the program, which should be interpreted with caution, show that the intervention was effective in improving the efficiency of prescribing practices at selected nursing homes. The methods used here were shown to increase the rational use of medications and improve the quality of prescription practices. Further follow-up on the results of the program over time will allow us to monitor trends and design scenarios that will make it possible to further optimize the distribution of resources.
Acknowledgments
We thank the clinical and administrative staff at the nursing homes in the intervention group, without whose cooperation and organizational support the study would not have been possible. Thanks are also due to the administrative staff of the Barcelonés Norte y Maresme Health Region for their support, confidence in the process and comments on the methods.
Participating Centres
Residencia Matacás (Sant Adrià de Besós), Residencia Sant Roc de Canet (Canet de Mar), Residencia ICASS Mataró (Mataró), Residencia ICASS Santa Coloma (Santa Coloma de Gramanet), Residencia Hotel Impala (Arenys de Mar), Residencia Bell Resguard (El Masnou), Llar Residencia Itaca-Arenys (Arenys de Mar), Residencia El Mirador (Mataró), Residencia Geriátrica Titus (Arenys de Mar), Residencia Obra de Maria (Arenys de Munt), Residencia Llegat Roca i Pi (Badalona), Residencia Miramar (Canet de Mar), Residencia Meran (Badalona), Residencia Caldetes (Caldes d'Estrac), Residencia Loval (Llavaneres), Residencia Hermanos Aymar-Puig (Alella), Residencia Geriátrica Laia (Mataró), Residencia Bellavista (Caldes d'Estrac), Llar Doménech i Muntaner (Badalona), Residencia Floridadorada (Caldes d'Estrac) and Residencia Les Hortènsies (Alella).
