Dissemination of Evidence‐Based Antipsychotic Prescribing Guidelines to Nursing Homes: A Cluster Randomized Trial

Tjia, Jennifer; Mazor, Kathleen M.; Lemay, Celeste A.; Kanaan, Abir O.; Donovan, Jennifer L.; Briesacher, Becky A.; Peterson, Daniel J.; Pandolfi, Michelle M.; Spenard, Ann; Gurwitz, Jerry H.

doi:10.1111/jgs.13488

Cited by 22 publications

(13 citation statements)

References 27 publications

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“…Most of the studies employed pharmacists and pharmacologists to deliver the academic detailing [ 9 – 12 , 21 , 24 , 30 ]. Physicians and nurses were also engaged as academic detailers [ 8 , 13 , 24 , 26 , 27 , 29 , 33 , 34 , 36 ].…”

Section: Resultsmentioning

confidence: 99%

The use of external change agents to promote quality improvement and organizational change in healthcare organizations: a systematic review

Alagöz¹,

Chih²,

Hitchcock³

et al. 2018

BMC Health Serv Res

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BackgroundExternal change agents can play an essential role in healthcare organizational change efforts. This systematic review examines the role that external change agents have played within the context of multifaceted interventions designed to promote organizational change in healthcare—specifically, in primary care settings.MethodsWe searched PubMed, CINAHL, Cochrane, Web of Science, and Academic Search Premier Databases in July 2016 for randomized trials published (in English) between January 1, 2005 and June 30, 2016 in which external agents were part of multifaceted organizational change strategies. The review was conducted according to PRISMA guidelines. A total of 477 abstracts were identified and screened by 2 authors. Full text articles of 113 studies were reviewed. Twenty-one of these studies were selected for inclusion.ResultsAcademic detailing (AD) is the most prevalently used organizational change strategy employed as part of multi-component implementation strategies. Out of 21 studies, nearly all studies integrate some form of audit and feedback into their interventions. Eleven studies that included practice facilitation into their intervention reported significant effects in one or more primary outcomes.ConclusionsOur results demonstrate that practice facilitation with regular, tailored follow up is a powerful component of a successful organizational change strategy. Academic detailing alone or combined with audit and feedback alone is ineffective without intensive follow up. Provision of educational materials and use of audit and feedback are often integral components of multifaceted implementation strategies. However, we didn’t find examples where those relatively limited strategies were effective as standalone interventions. System-level support through technology (such as automated reminders or alerts) is potentially helpful, but must be carefully tailored to clinic needs.

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Section: Resultsmentioning

confidence: 99%

The use of external change agents to promote quality improvement and organizational change in healthcare organizations: a systematic review

Alagöz¹,

Chih²,

Hitchcock³

et al. 2018

BMC Health Serv Res

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“…; Tjia et al. ), and focus on medications classified as “inappropriate” for older adults based on expert pharmacologic review (AGS ). Our finding that antihypertensive deintensification was associated with fewer falls among older NH residents is a signal that deintensification of antihypertensive under these circumstances may also be beneficial, and a prospective randomized trial may be warranted.…”

Section: Discussionmentioning

confidence: 99%

Antihypertensive Drug Deintensification and Recurrent Falls in Long‐Term Care

Song

Intrator

Lee

et al. 2018

Health Services Research

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Objective To examine the relationship between antihypertensive drug deintensification and recurrent falls in long‐term care. Data Sources/Settings Department of Veterans Affairs (VA) inpatient, outpatient, and purchased care data, Minimum Data Set assessments from VA nursing homes (NHs), and Medicare claims from fiscal years 2010 – 2015. Study Design We identified NH residents with evidence of overaggressive antihypertensive treatment, defined as systolic blood pressure (SBP) 80–120 and an index fall. Recurrent fall, hospitalization, and mortality within 30 days were compared between veterans whose antihypertensive medications were deintensified versus those whose antihypertensive medications were not using propensity score methods (PSM). Principal Findings Among 2,212 NH residents with possibly overaggressive antihypertensive treatment, 11 percent experienced antihypertensive drug deintensification. Lower blood pressure, >1 antihypertensive drug, no congestive heart failure, fracture from index fall, and older age were associated with higher likelihood of deintensification. Antihypertensive deintensification was associated with statistically significant (p‐value < .01) lower risk of recurrent fall among residents with SBP 80–100 (marginal effect = −11.4 percent; PSM = −13.6 percent) and higher risk of death among residents with SBP 101–120 (marginal effect = 2.1 percent, p‐value = .07; with PSM = 4.3 percent, p‐value = .04). Conclusions Results provide some needed evidence and guidelines for deintensifying antihypertensive medication among frail older residents; since hypertension is prevalent among 54 percent of NH residents, the potential impact of new evidence is great.

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“…Some studies suggested that educational interventions can reduce psychotropic drug prescribing if nursing home staff are involved and trained in non-drug management strategies, whereas academic detailing of physicians alone had minimal impact in one study [20] , [21] , [22] , [23] , [24] . More recently, Tjia et al conducted a cluster randomized trial of dissemination of evidence-based antipsychotic prescribing guidelines to nursing homes [25] . Their toolkit provided to all groups comprised many resources, including some IA-ADAPT decision aids.…”

Section: Discussionmentioning

confidence: 99%

Impact of programs to reduce antipsychotic and anticholinergic use in nursing homes

Carnahan

Brown

Letuchy

et al. 2017

A&D Transl Res & Clin Interv

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IntroductionAntipsychotics are used for managing behavioral and psychological symptoms of dementia (BPSD) but have risks. Anticholinergics can worsen outcomes in dementia. The Improving Antipsychotic Appropriateness in Dementia Patients educational program (IA-ADAPT) and Centers for Medicare and Medicaid Services Partnership to Improve Dementia Care (CMS Partnership) promote improved care for BPSD. The purpose of this study was to evaluate the impact of these programs on medication use and BPSD among nursing home residents.MethodsThis quasi-experimental longitudinal study used Medicare and assessment data for Iowa nursing home residents from April 2011 to December 2012. Residents were required to be eligible for six continuous months for inclusion. Antipsychotic use and anticholinergic use were evaluated on a monthly basis, and changes in BPSD were tracked using assessment data. Results are presented as odds ratios (ORs) per month after exposure to the IA-ADAPT or the start of the CMS Partnership.ResultsOf 426 eligible Iowa nursing homes, 114 were exposed to the IA-ADAPT in 2012. Nursing home exposure to the IA-ADAPT was associated with reduced antipsychotic use (OR [95% CI] = 0.92 [0.89–0.95]) and anticholinergic use (OR [95% CI] = 0.95 [0.92–0.98]), reduced use of excessive antipsychotic doses per CMS guidance (OR [95% CI] = 0.80 [0.75–0.86]), increased odds of a potentially appropriate indication among antipsychotic users (OR [95% CI] = 1.04 [1.00–1.09]), and decreased documentation of verbal aggression (OR [95% CI] = 0.96 [0.94–0.99]). Facilities with two or more IA-ADAPT exposures had greater reductions in antipsychotic and anticholinergic use than those with only one. The CMS Partnership was associated with reduced antipsychotic use (OR [95% CI] = 0.96 [0.94–0.98]) and decreased documentation of any measured BPSD (OR [95% CI] = 0.98 [0.97–0.99]) as well as delirium specifically (OR [95% CI] = 0.98 [0.96–0.99]).DiscussionThis study suggests that the IA-ADAPT and the CMS Partnership improved medication use with no adverse impact on BPSD.

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Dissemination of Evidence‐Based Antipsychotic Prescribing Guidelines to Nursing Homes: A Cluster Randomized Trial

Cited by 22 publications

References 27 publications

The use of external change agents to promote quality improvement and organizational change in healthcare organizations: a systematic review

The use of external change agents to promote quality improvement and organizational change in healthcare organizations: a systematic review

Antihypertensive Drug Deintensification and Recurrent Falls in Long‐Term Care

Impact of programs to reduce antipsychotic and anticholinergic use in nursing homes

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