Combining Quality Improvement and Geriatrics Training: The Nursing Home Polypharmacy Outcomes Project

Abstract

To examine sustained effects of an educational intervention, we repeated a successful quality improvement (QI) project on medication safety and cost-effectiveness. In October 2007 and August 2008, facility leadership and geriatrics faculty identified all patients receiving ≥9 medications (polypharmacy cohort) in a 170-bed teaching nursing home and taught Geriatric Medicine fellows (n=12 in 2007, 11 in 2008) to: 1) systematically collect medication data; 2) generate medication recommendations (stop, taper, or continue) based on expert criteria (Beers Criteria) or drug-drug interaction programs; 3) discuss recommendations with patients’ attending physicians; and 4) implement approved recommendations. Over the two projects, the polypharmacy cohorts demonstrated decreased potentially inappropriate medications (odds ratio (OR) 0.78, 95% confidence interval (95%CI)0.69–0.88, p<0.001), contraindicated medications (OR=0.63, 95%CI=0.47–0.85, p=0.002) and medication costs (OR=0.97, 95%CI=0.96–0.99, p<0.001). Our findings suggest that programs planning educational QI projects for trainees may benefit from a multi-year approach to maximize both clinical and educational benefits.

Polypharmacy Management in the Older Adults: A Scoping Review of Available Interventions

“…However, some interventions were provided at community or hospital pharmacies, by pharmacists alone, in the form of pharmaceutical care, or in cooperation with a physician, e.g., under an umbrella of collaborative physician-pharmacist medication therapy management (MTM) program (Mansur et al, 2012;Patterson et al, 2012;Doan et al, 2013;Cooper et al, 2015;Jódar-Sánchez et al, 2015;Wilson et al, 2015;Cadogan et al, 2016;Chau et al, 2016;Jokanovic et al, 2017;Komagamine and Hagane, 2017;Malet-Larrea et al, 2017;McNicholl et al, 2017;McNicholl et al, 2017;Tommelein et al, 2017;Lin et al, 2018). Specialists who are perfectly prepared to take care of polypharmacy in the older adults are geriatricians, thus relevant interventions could be included in the geriatric consultation (Eyigor and Kutsal, 2012;Kojima et al, 2014;Van der Linden et al, 2014). Finally, other settings also allow for polypharmacy interventions which have been successfully provided in various hospital settings such as teaching hospitals (Harugeri et al, 2010;Urfer et al, 2016;Lin et al, 2018), acute care hospitals (Komagamine and Hagane, 2017), acute geriatric wards (Mansur et al, 2012;Van der Linden et al, 2014).…”

“…Finally, other settings also allow for polypharmacy interventions which have been successfully provided in various hospital settings such as teaching hospitals (Harugeri et al, 2010;Urfer et al, 2016;Lin et al, 2018), acute care hospitals (Komagamine and Hagane, 2017), acute geriatric wards (Mansur et al, 2012;Van der Linden et al, 2014). It is worth emphasizing that such interventions are also advisable in the case of residential aged care facilities (Kojima et al, 2014;Jokanovic et al, 2017). Some studies highlight the need for an interdisciplinary approach, e.g., in order to execute Comprehensive Geriatric Assessment (CGA), the authors suggest an interdisciplinary team comprising nurses, occupational and physical therapists, social workers, general practitioners and geriatricians (Sergi et al, 2011).…”

“…A complex intervention to be used in a nursing home (covering a drug list review, identification of potentially inappropriate medications using the Beers criteria, potential drug-drug interactions and contraindicated medications using the Epocrates online drugdrug interaction program) has been assessed in a prospective study which demonstrated a decrease in potentially inappropriate medications, contraindicated drugs, and medication costs. (Kojima et al, 2014) Characteristics of the studies providing evidence of effectiveness for selected interventions that have been identified in our search are presented in the Supplementary Online Material S4.…”

Quality improvement in long-term care settings: a scoping review of effective strategies used in care homes

“…Other studies described components quality improvement, but without specifying a particular strategy. Components included education about clinical conditions or care ( n = 19) [ 28 , 31 , 33 , 36 , 38 , 43 , 46 , 49 , 52 , 55 , 58 , 60 , 65 , 67 – 69 , 83 , 86 , 94 ], care pathway development ( n = 12) [ 31 , 39 , 46 , 55 , 56 , 67 , 73 , 76 , 77 , 85 , 86 , 91 ], audit and feedback ( n = 14) [ 28 , 33 , 37 , 49 , 58 , 61 , 76 , 77 , 81 , 87 , 91 , 93 – 95 ], changes to multidisciplinary team working ( n = 11) [ 28 , 38 , 40 , 41 , 48 , 71 , 79 , 85 – 87 , 95 ], and enabling peers or champions to lead QI initiatives ( n = 10) [ 28 , 36 , 38 , 63 , 65 , 69 , 77 – 79 , 91 ].…”

Integrating Quality Improvement Education into the Nephrology Curricular Milestones Framework and the Clinical Learning Environment Review

“…Other subspecialty fellowship programs, notably gastroenterology (24) and geriatrics (25), have reported successful fellow QI projects that resulted in improvements in consultative communication and reduced polypharmacy among nursing home patients.…”