The drive for quality care in US nursing homes in the era of the prospective payment system

Use of Medication Technicians in US Nursing Homes: Part of the Problem or Part of the Solution?

OBJECTIVES

To determine the relation between organizational characteristics and medication technician (MT) use and quantify the impact of MTs on increasing the likelihood of using medications, employing the example of antiosteoporosis medications.

DESIGN

Cross-sectional study.

SETTING

The setting included 6344 Medicare/Medicaid certified nursing homes in 23 states.

PARTICIPANTS

Residents older than 65 years of age.

MEASUREMENTS

On-line Survey and Certification of Automated Records (OSCAR) provided facility characteristics information including structural, resource, and staffing levels. The Minimum Data Set (MDS) provided information regarding use of antiosteoporosis medications and resident factors. Adjusted estimates of MT use on antiosteoporosis medication use were derived using logistic regression with generalized estimating equations.

RESULTS

MT use varied by state (6.7% in Alaska vs 85% in Kansas). Homes with greater nursing staffing levels per 100 beds (CNA, RN, LPN) were less likely to use MTs, while larger homes, homes using physician extenders, and contracting pharmacy services were more likely to use MTs. Homes with MTs were more likely to have medication error rates of at least 5% (10.1% vs 7.3%) than homes without MTs. After adjustment for resident and facility factors, residents in MT facilities were not more likely to receive antiosteoporosis treatment relative to those in homes without MTs.

CONCLUSION

These data call into question the use of MTs in nursing homes. Use of MTs may lead to more errors, yet not increase use of medications that are labor intensive to administer.

Did the Introduction of a Prospective Payment System for Nursing Home Stays Reduce the Likelihood of Pharmacological Management of Secondary Ischaemic Stroke?

BACKGROUND

Since 1998, a prospective payment system (PPS) for Medicare services provided by nursing homes in the US has been in operation. Concerns have been expressed that the PPS may affect the quality of care delivered to residents. This study evaluates the impact of the PPS on pharmacological secondary ischaemic stroke prevention in nursing homes.

STUDY DESIGN

The nationally mandated Minimum Data Set and Online Survey Certification and Automated Record data system from 1997 and 2000 for four states were used. We conducted a quasi-experimental study comparing the pharmacological treatment rates for secondary stroke prevention in the pre-PPS period (1997) with those in the post-PPS period (2000) in residents who experienced an ischaemic stroke within 6 months (n1997 = 5008; n2000 = 5243) of living in nursing facilities (n1997 = 1226; n2000 = 1092) in Kansas, Maine, Mississippi or Ohio. The sample was stratified according to recommendations for use of warfarin. Logistic regression models adjusting for clustering effects of residents residing in homes using generalised estimating equations provided estimates of the PPS effect on use of antiplatelets and the use of warfarin.

RESULTS

The unadjusted proportion of use of pharmacological agents for the secondary prevention of stroke was similar for warfarin in both time periods and increased for antiplatelets in 2000. Relative to the pre-PPS era, the likelihood of use of antiplatelets increased in the post-PPS era (adjusted odds ratio 1.26; 95% CI 1.15, 1.38); there was no effect on the use of warfarin.

CONCLUSION

Although the lack of a PPS effect on pharmacological management of secondary ischaemic stroke is encouraging, there is still room for improvement in overall stroke management.

Information is care: the need for data to assess the quality of care in UK nursing and residential homes

Prescribing is the most common medical intervention experienced by elderly residents in nursing and residential care homes. However, research would suggest that these residents may be subject to poor prescribing, with excessive use of some drugs and underprescribing of potentially beneficial drugs. At a more fundamental level, there is also evidence that poor medication record-keeping for nursing home residents is prevalent in nursing homes, general practice surgeries and community pharmacies. This may increase the risk of an adverse drug event. Furthermore, there is a lack of data on prescribing in UK nursing homes, which militates against assessing the quality of drug use. Consideration needs to be given to the structures and processes currently in place in order to promote better prescribing outcomes for this vulnerable population.

Providing pharmacy services to care homes in Northern Ireland: a survey of community pharmacists? views

OBJECTIVE

This study sought to explore the views of community pharmacists as to their present and potential role in providing care to the residents of nursing and residential home in Northern Ireland.

METHOD

A structured questionnaire was developed and mailed to all community pharmacists in Northern Ireland (n = 508) on 2 occasions.

RESULTS

A response rate of 50% was achieved. Over 40% of responding pharmacists (42.1%) were currently providing medication-related services to care homes for the elderly and 57.9% were not. Of those who were providing services, 50 to 80% were already providing advice to care homes regarding record-keeping, compliance devices, storage and administration of medicines and the use of more appropriate formulations. More than 75% of pharmacists who were not providing services to care homes for the elderly supported all services detailed in a checklist provided on the questionnaire. For pharmacists who were providing services to care homes, 89% agreed that they required access to an up-to-date medical history of care home residents. Over 60% of pharmacists who worked with care homes had experienced difficulties when ordering prescriptions from general practice surgeries. Just over 75% of all respondents stated that they wanted to be more involved in providing pharmaceutical services to care homes to the elderly.

CONCLUSION

Community pharmacists expressed enthusiasm for provision of services to care home residents. On-going developments in community pharmacy practice in the UK may facilitate the development of this role and may guide policy development for long-term care in other countries.

An Evaluation of the Impact of the Prospective Payment System on Antidepressant Use in Nursing Home Residents

OBJECTIVES

To determine the impact of the prospective payment system (PPS) for skilled nursing facilities on the pharmacologic treatment of depression.

METHODS

We used a quasi-experimental study comparing the pharmacological treatment rates for depression in the pre-PPS period (1997) to the post-PPS period (2000) in 8149 residents with documented depression living in over 500 nursing facilities in Ohio. Logistic regression models adjusting for clustering effects of residents residing in homes using generalized estimating equations provided estimates of the PPS effect on use of any antidepressant and the use of selective serotonin reuptake inhibitors (SSRIs). We evaluated the extent to which the PPS effect was modified by organizational characteristics, including structural characteristics, resource characteristics, and staff resources available in the homes.

RESULTS

Overall, there was no difference in the likelihood of any antidepressant [odds ratio (OR), 1.05; 95% confidence interval (CI), 0.93 to 1.18, resident-adjusted model] or an SSRI being used (OR, 0.98; 95% CI, 0.86 to 1.12, resident-adjusted model) after the introduction of PPS compared with 1997 when this reimbursement system was not in place (referent group). These trends did not appear to be modified substantially by organizational characteristics.

CONCLUSION

Although PPS did not appear to have influenced the treatment of depression in nursing homes, systems that provide checks and balances in relation to PPS are warranted.