- Email: [email protected]
Prioritizing interventions to manage polypharmacy in Australian aged care facilities
Research in Social and Administrative Pharmacy j (2016) j–j
Original Research
Prioritizing interventions to manage polypharmacy in Australian aged care facilities Natali Jokanovic, B.Pharm. (Hons.)a,b,*,e, Kate N. Wang, B.Pharm. (Hons.)a,e, Michael J. Dooley, Ph.D.a,b, Samanta Lalic, B.Pharm. (Hons.)a,c, Edwin CK. Tan, Ph.D.a, Carl M. Kirkpatrick, Ph.D.a, J. Simon Bell, Ph.D.a,d a
Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia b Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia c Pharmacy Department, Austin Health, Melbourne, Victoria, Australia d Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
Abstract Background: Polypharmacy is highly prevalent in residential aged care facilities (RACFs). Although polypharmacy is sometimes unavoidable, polypharmacy has been associated with increased morbidity and mortality. Objective: To identify and prioritize a range of potential interventions to manage polypharmacy in RACFs from the perspectives of health care professionals, health policy and consumer representatives. Methods: Two nominal group technique (NGT) sessions were convened in August 2015. A purposive sample (n ¼ 19) of clinicians, researchers, managers and representatives of consumer, professional and health policy organizations were asked to nominate interventions to address the prevalence and appropriateness of medication use. Participants were then asked to prioritize five interventions suitable for possible implementation at the system level. Results: Six of 16 potential interventions were prioritized highest for possible implementation in clinical practice, with two interventions prioritized as second highest. The top interventions in rank order were ‘implementation of a pharmacist-led medication reconciliation service for new residents,’ ‘conduct facilitylevel audits and feedback to staff and health care professionals,’ ‘develop deprescribing scripts to assist clinician-resident discussion,’ ‘develop or revise prescribing guidelines specific to older people with multimorbidity in RACFs,’ ‘implement electronic medication charts and records’ and ‘better support Medication Advisory Committees (MACs) to address medication appropriateness.’
Conflicts of interest: none. e These authors contributed equally to this work. * Corresponding author. Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University (Parkville Campus), 381 Royal Parade Parkville, Victoria 3052, Australia. Tel.: þ61 3 9903 9244. E-mail address: [email protected] (N. Jokanovic). 1551-7411/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2016.06.003
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Conclusion: This study prioritized a range of potential interventions that may be used to assist clinicians and policy makers develop a comprehensive strategy to manage polypharmacy in RACFs. Ó 2016 Elsevier Inc. All rights reserved. Keywords: Long-term care; Nursing homes; Polypharmacy; Deprescribing; Nominal group technique
Introduction An increasing body of literature has highlighted the high prevalence of polypharmacy in residential aged care facilities (RACFs). A RACF, synonymous with the terms ‘nursing home’ and ‘long-term care facility,’ refers to a specialpurpose facility which provides supported accommodation for people requiring assistance with daily living and nursing care.1,2 Up to 74% of residents of RACFs take nine or more medications on a regular basis.3 While polypharmacy is not always inappropriate, it has been associated with delirium, falls, hospital admissions and increased mortality.4–6 Polypharmacy is also associated with a higher likelihood of drug–drug interactions and adverse drug reactions.7,8 Polypharmacy has become a global issue, driven by the aging population and increasing multimorbidity worldwide. Managing polypharmacy in RACFs has been identified as a research priority in the United States (US).9 The recent Australian National Stakeholders Meeting on Quality Use of Medicines to Optimize Aging in Older Australians has called for a national strategic plan to reduce polypharmacy.10 Increasing awareness of the benefits of the palliative approach in older people with limited life expectancy suggests reducing inappropriate or unnecessary polypharmacy is likely to offer important public health benefits.11 Between 2004 and 2005, it was estimated that up to 177,504 hospital emergency department visits in older people 65 years and above were due to adverse drug events in the US.12 In Australia, medications are implicated in up to 30% of all unplanned hospital admissions in people aged 75 years and older, with up to three-quarters of these admissions potentially preventable.13 While there is a large body of literature on the prevalence of polypharmacy,3 much less has been published regarding strategies and approaches to effectively manage polypharmacy. Recent research has identified potential factors contributing to increasing polypharmacy in RACFs.14 These factors reflected a range of resident, clinician and system level factors for consideration during the
development of future interventions. A Cochrane review of 12 randomized controlled trials (RCTs) evaluated interventions aimed at optimizing prescribing for residents in RACFs.15 These interventions focused on pharmacist-led medication review, multidisciplinary case-conferences, education to RACF staff and the use of clinical decision support technology.15 There remains a paucity of research on interventions delivered by other health care professionals, the role of families and caregivers, and the impact of policy and regulatory changes. The objective of this study was to identify and prioritize a range of potential interventions to manage polypharmacy in RACFs from the perspectives of health care professionals, health policy and consumer representatives.
Methods Study participants Potential participants (n ¼ 36) were purposively sampled from metropolitan and regional Victoria, Australia. Participants were identified through existing contacts with the research team for their aged care experience either though clinical practice, research or involvement in health policy, consumer or professional organizations. Email invitations were sent to all participants. Participants who were not able to attend were invited to nominate a representative to attend on their behalf. The study was approved by the Monash University Human Research Ethics Committee. All participants provided written informed consent prior to participation. Modified nominal group technique (NGT) Nominal group technique (NGT) is a structured method of generating and prioritizing ideas in a group.16 This method is designed to facilitate a comfortable and open discussion to generate a broad range of ideas through equal participation.16 The NGT was chosen in favor of the Delphi technique or a focus group as it encourages participants to discuss their ideas as a group
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Fig. 1. The modified nominal group technique process used for this study.
but ensures that the discussion cannot be dominated by one or more participants.17 This study used a modified NGT (Fig. 1). The suggested size of a nominal group is between five and nine participants. To enable small group discussions, two NGT sessions were convened in August 2015 and were moderated by a facilitator experienced in NGT. The first NGT session primarily comprised of a group of clinicians, researchers and managers with extensive work experience in the aged care sector. The second session involved nominated representatives of consumer, professional and health policy organizations. This grouping was performed to minimize the potential reluctance of participants to express their opinions in front of all participants. Participants who
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could not attend one session were invited to attend the other scheduled session. Each session was held over four hours, including refreshments and breaks. Participants did not receive any payment for their participation in the sessions. Each session followed the same modified NGT process. Background information including published and unpublished research on the prevalence of polypharmacy in RACFs in Australia and internationally was presented to each group.3 Participants were asked the following question: “What interventions are needed to address the prevalence and appropriateness of medication use in RACFs?” For the purpose of the research, polypharmacy was operationally defined as the use of nine of more regular medications. This is the most common definition in RACFs and the definition of polypharmacy used by the Victorian Government Department of Health and Human Services.3,18 There is currently no definitive cutoff for polypharmacy that reflects medication appropriateness in RACFs. As polypharmacy was viewed an indicator of potential inappropriate medication use rather than necessarily being inappropriate itself, participants were broadly asked to consider the appropriateness of medication use when formulating their ideas. Participants worked in mixed discipline groups of two or three to generate a list of potential interventions suitable for implementation. Participants were prompted that organizational change may involve interventions at different health system levels (e.g. individual resident, care team, organization, health care environment).19 Novel interventions or additional components to existing interventions in RACFs were considered. Although a nominal group typically begins with the silent generation of ideas, participants were paired in this study to further encourage the discussion and generation of ideas. The facilitator then led a round-robin session to record interventions presented by each group. Each potential intervention was discussed at length by participants and revised accordingly. Any new interventions were also noted by the facilitator. All interventions generated from both NGT sessions were thematically combined and refined into a final list of 16 potential interventions for prioritization. Interventions that were deemed to be closely related by a panel of three pharmacist aged care researchers (NJ, SB and MD) were combined into broader interventions. Care was taken to ensure all interventions were captured in the final list. Disagreements were resolved through
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Table 1 Characteristics of participants Group
1
2
Participant
Sex
Profession
Duration of aged care experience (years)
1 2 3 4 5 6 7 8 9 1 2 3 4
Male Female Male Male Female Female Female Male Male Male Male Male Male
25 15 33 10 4 3 4 20 14 25 Unknown 21 40
5 6 7 8 9 10
Male Female Male Female Male Female
Research pharmacist Research nurse General medical practitioner Research pharmacist Executive director of nursing Hospital pharmacist Medication review pharmacist General medical practitioner Aged care research pharmacist Hospital pharmacy professional organization representative Health care advisor Geriatrician General medical practitioner professional organization representative Community pharmacy professional organization representative Hospital pharmacist Pharmacy professional organization representative Health care advisor Consumer representative Consumer representative
discussion with the study investigators. A limit was not set on the final number of interventions for prioritization. An online survey containing the list of 16 potential interventions was developed using the commercial tool SurveyMonkeyÒ and emailed to all participants within one week of the NGT sessions. This modification in the NGT was performed to obtain overall consensus from both nominal groups. The online survey was pilot tested for face validity by a convenience sample of independent quality use of medicine researchers (n ¼ 3) who did not participate in the research study. Participants were presented with the same question as in the NGT sessions and were asked to select and rank five interventions from the list of 16 interventions they perceived to have the highest priority for implementation at the system level. The ranking of five interventions is commonly used in the literature.20,21 A reminder email was sent to participants who had not completed the survey within one week. Data analysis A weighted ranking process was used to determine overall consensus of the two groups. This is a common method used in NGT research.21 Individually ranked interventions
20 3 20 25 30 35
were assigned points, with 5 points allocated to the highest priority intervention and 1 point allocated to the fifth highest priority intervention. The sums of the individual scores were tallied to provide the overall prioritized list of interventions. This study was conducted and reported in accordance with consolidated criteria for reporting qualitative studies (COREQ) guidelines.22
Results Participant characteristics Nineteen participants comprising of six female and thirteen male health care professionals, health policy and consumer representatives participated in the two nominal group sessions (Table 1). Three of the 19 participants were invited on the recommendation of the original invitee who could not attend. The participants comprised pharmacists (n ¼ 9), general practitioners (GPs) (n ¼ 3), nurses (n ¼ 2), medical specialist (n ¼ 1), health care advisors (n ¼ 2) and consumer representatives (n ¼ 2). Health care advisors included individuals responsible for providing health policy advice to government agencies. Consumer representatives included individuals who represent
Table 2 Features of proposed interventions Components of the proposed interventions
Novel, improvement or extension of current practicea
Pharmacist-led medication reconciliation service for new residents
Targeted to new residents of RACFs. Specific focus on polypharmacy reduction and regimen simplification. In addition to compiling an accurate medication history, determine indications for each medication and provide recommendations for regimen simplification.
An extension of the currently renumerated collaborative medication reconciliation service in RACFs (RMMRsb) or a novel intervention
Facility-level audit and feedback to staff and health care professionals on high risk medications
Facilitate benchmarking through feedback of facility-level audit data to facility staff and health care professions on the usage of high risk medications. Incorporation of a ‘traffic light system’ to assist health professionals identify high risk medications and encourage medication review.
Extension of current practice
Develop ‘deprescribing scripts’ to assist GPs and other clinicians to discuss medication discontinuation
Provide sample phrases to assist prescribers and other clinicians to initiate a conversation about deprescribing with residents and their families.
Novel intervention
Develop or revise prescribing guidelines specific to older people with multimorbidity in RACFs
Update the 2006 Australian ‘medical care of older persons in RACFs’ guideline.c Develop new evidence-based clinical practice guidelines tailored to older people with multimorbidity.
Improvement on current practice/novel intervention
Implement electronic medication charts and records
Electronic charts and records accessible to GPs, pharmacists, nurses and aged care workers across settings. With or without clinical decision support software.
Improvement on current practice
Investigate the current role of MACs at each facility and better support MACs to address medication appropriateness
Determine the current composition and roles of MACs in RACFs. Identify characteristics of effective MACs required to address medication appropriateness.
Improvement on current practice
Develop a ‘quality use of medicines (QUM) tick of approval’ scheme for RACFs
Develop a minimum set of standards for RACFs to obtain certification as a facility which adheres to quality use of medicines practices.
Novel intervention
Better communicate the findings of pharmacists’ residential medication management reviews (RMMRs), including to residents, family and carers
Provide findings from RMMRs which are easily interpretable to residents, family and carers in addition to prescribers.
Improvement on current practice
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Proposed intervention
5 (continued)
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Table 2 (continued ) Components of the proposed interventions
Novel, improvement or extension of current practicea
Encourage residents to incorporate their desires in relation to medication use in advance care plans
Improve awareness and consideration of medication use in advance care planning for all residents in RACFs.
Improvement on current practice
Improve medication-related research culture within RACFs
Fostering a research culture within RACFs to improve the quality use of medicines.
Improvement on current practice
Develop a 1-page fact sheet to empower residents, family and carers to talk to their GP and other health professionals about deprescribing
A 1-page educational fact sheet on deprescribing provided to residents and their families to encourage the initial discussion with their prescribers or other health professional.
Novel intervention
Identify aged care facilities with optimal medication use and publish case studies to highlight best practice
Promotion of examples of best practice in medication use in RACFs to guide improvements across facilities.
Novel intervention
Implement initiatives to increase the knowledge and uptake of non-pharmacological management approaches in RACFs
Provide education to prescribers and RACF staff on nonpharmacological approaches to reduce inappropriate medication use.
Novel intervention
Encourage prescribers to conduct more frequent reviews of medications through regulatory changes
Regulatory changes including shortening the length of medication charts to encourage more frequent medication review by prescribers.
Improvement on current practice
Improve medication literacy by training nurses and aged care workers to recognize potentially harmful medications and adverse events
Provide education to RACF staff on common high risk medications and adverse events to empower staff to report potentially inappropriate medication use.
Improvement on current practice
Develop a 1-page fact sheet with practical advice for locums and other visiting health care professionals to better interact with RACFs
Practical advice specific to each facility in relation to existing procedures and practices for visiting prescribers and other health care professionals.
Novel intervention
GP ¼ general practitioner; MAC ¼ medication advisory committee; RACF ¼ residential aged care facility; RMMR ¼ residential medication management review. Refers to current practice in Australian RACFs. b Residential medication management reviews are collaborative medication reviews conducted by accredited pharmacists which are funded by the Australian Government. c The current Australian guideline was last updated by the Royal Australian College of General Practitioners in 2006. a
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Proposed intervention
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Fig. 2. Ranking of interventions.
consumers (e.g. residents, carers and their families) on committees. Four participants who accepted their invitation to participate were unable to attend on the day. Eight of the 19 participants had more than 20 years of aged care work experience.
each facility and better support MACs to address medication appropriateness’ (18). The priorities of the interventions were calculated into percentages based on the scores each intervention received, with the top 8 interventions receiving 79% of the total score.
Potential interventions to manage polypharmacy in RACFs
Discussion
Seventeen of the 19 participants completed the survey and prioritized their top five interventions (Table 2, Fig. 2). The intervention ranked as the highest priority was ‘implementation of a pharmacist-led medication reconciliation service for new residents of RACFs’ (sum of scores: 41). The interventions that were ranked second were to ‘facilitate benchmarking by conducting facility-level audit and feedback to staff and health care professionals on the prevalence of high risk and/or highly prevalent medications’ (31), and to ‘develop “deprescribing scripts” to assist GPs and other clinicians to proactively discuss the topic of medication discontinuation’ (31). The interventions ranked third to fifth highest were to ‘develop or revise prescribing guidelines specific to older people with multimorbidity in RACFs’ (25), ‘implement electronic medication charts and records for health care professionals’ (24) and to ‘investigate the current role of the Medication Advisory Committees (MACs) at
As far as the authors are aware, this is the first study to prioritize interventions to manage polypharmacy in RACFs. Six of the 16 potential interventions were prioritized highest for possible implementation in clinical practice. The remaining 10 interventions received varied degrees of support, suggesting a broad ranging and multifaceted strategy may be needed to comprehensively manage the issue of increasing polypharmacy. The 16 interventions represented a range of approaches that were additional to those highlighted in the Cochrane review published by Alldred et al.15 Whilst Alldred et al identified interventions including medication review, clinical education and the use of clinical decision support software, this study has identified interventions that are novel or an extension of current practice. Implementation of a pharmacist-led medication reconciliation service for new RACF residents was ranked highest for managing
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polypharmacy. This proposed intervention is in addition to the medication review interventions identified in 10 studies reviewed by Alldred et al.15 Opinion was divided on whether this service should be distinct from the current model of collaborative medication review in RACFs funded by the Australian government.23 The current model, residential medication management review (RMMR), is a well-established service introduced in 1997 to improve the quality use of medicines in RACFs.24 This may explain why this service was not specifically considered for prioritization by the study participants. Medication reconciliation conducted by pharmacists during transition from hospitals to RACFs improves medication history accuracy and health outcomes, through reductions in hospital admissions and pain in the older residents in RACFs.25 Pharmacist-led medication reviews in the primary care setting have resulted in significant reductions in the mean number of medications and drug-related problems.26 This service was deemed necessary for reducing polypharmacy because having a complete medication list is a key initial step in the deprescribing process.27 The equal second highest ranked intervention was to develop ‘deprescribing scripts’ to assist GPs and other clinicians to proactively discuss the topic of medication discontinuation. The process of deprescribing involves a discussion of the overall risk and future benefit of medications with consideration of predicted life expectancy.27 Discussions about deprescribing are often challenging for prescribers and confronting for residents and their caregivers.28 Residents’ willingness to cease medications may be influenced by disagreement about the appropriateness of medication cessation, limited opportunity to discuss deprescribing and fear of negative consequences on cessation.29 Good patient-physician relationships and a patient centered approach are important for deprescribing.29 Prescribers often find it difficult to discuss changing goals of care.29 Furthermore, reluctance to question other prescribers’ decisions is also a significant barrier to deprescribing.30 Despite this, it has been reported that up to 79% of residents are willing to cease one or more of their medications if their prescribers indicate that it is possible.31 The development of ‘deprescribing scripts’ was perceived as valuable to assist prescribers and other clinicians to approach the topic of medication discontinuation with residents and their families. Facilitating benchmarking by conducting facility-level audit and feedback to staff and
health care professionals on the prevalence of high risk and/or highly prevalent medications was ranked equal second highest. Audit and feedback is an evidence-based approach to improving professional practice.32 It has been shown that providing patient-specific prescriber feedback, including a list of potential medication-related problems (MRPs) and educational material, resolved MRPs and reduced hospitalizations in Australian veterans and their dependents.33 Five studies incorporating educational interventions to RACF staff were identified by Alldred et al, however facility-level and feedback was not specifically investigated.15 Further studies are required to explore the impact of facility-level audit and feedback to RACF staff and health care professionals. The third highest ranked intervention was to develop or revise prescribing guidelines specific to older people with multimorbidity in RACFs. Clinical practice guidelines are often diseasespecific and rarely provide guidance for older people with multimorbidity in RACFs.34,35 This may create tension for prescribers who feel pressured to comply with prescribing guidelines.36 Polypharmacy and medication regimen complexity may arise due to prescribers’ desire to achieve strict blood glucose or blood pressure targets that are not specific to older people in RACFs.3,37 Up-to-date and evidence-based prescribing guidelines tailored towards older people with multimorbidity in RACFs may reduce the prevalence of polypharmacy. Implementation of electronic medication charts and records was ranked as the fourth highest intervention. Electronic charts and records accessible to health professionals and facility staff across settings would ensure access to the most recent medication history. A complete medication history including indications for each medication, intended duration and goals of care are important for deprescribing.27 Electronic records with integrated clinical decision support will improve communication between health care professionals, minimize medication discrepancies and allow clinicians to readily identify medications suitable for deprescribing.38,39 The intervention ranked fifth highest was to better support MACs to address medication appropriateness. MACs comprise of representatives from different health care professions, RACF management and residents who advise and evaluate medication management policies, procedures and practices in RACFs, ensuring
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the safe and quality use of medicines.40 Limited research has investigated the composition and functions of MACs in RACFs and their potential impact on polypharmacy. Future research should be directed toward a better understanding of MACs in RACFs. Strengths and limitations The use of NGT methodology allowed for the generation and prioritization of a range of potential interventions to manage polypharmacy. The participants were purposively sampled to represent a diverse range of opinions and experiences across different health care sectors, however the potential for selection bias cannot be excluded. Interventions from both sessions were thematically grouped into 16 potential interventions, some of which may be interrelated. The research specifically focused on interventions suited for adoption at the system level. Wider education initiatives (e.g. inter-professional learning for medical, pharmacy and nursing students) are likely to be important but were not considered as part of the present research. The feasibility of interventions presented in this study for implementation in clinical practice was not evaluated and should be considered in future research. Further investigations into the feasibility and outcomes following implementation of these strategies into clinical practice are required.
Conclusion Potential interventions needed to manage polypharmacy in RACFs were identified and prioritized. These interventions may assist clinicians and policy makers develop a comprehensive strategy to manage polypharmacy in this setting. Further research is needed to determine the feasibility of these interventions and their impact on polypharmacy in RACFs. Acknowledgment We would like to express our sincere gratitude to all the participants in the study who donated valuable time and effort. We also gratefully acknowledge the Ageing and Aged Care Branch, Department of Health and Human Services, State Government of Victoria for commissioning and funding this research.
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Original Research
Prioritizing interventions to manage polypharmacy in Australian aged care facilities Natali Jokanovic, B.Pharm. (Hons.)a,b,*,e, Kate N. Wang, B.Pharm. (Hons.)a,e, Michael J. Dooley, Ph.D.a,b, Samanta Lalic, B.Pharm. (Hons.)a,c, Edwin CK. Tan, Ph.D.a, Carl M. Kirkpatrick, Ph.D.a, J. Simon Bell, Ph.D.a,d a
Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia b Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia c Pharmacy Department, Austin Health, Melbourne, Victoria, Australia d Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
Abstract Background: Polypharmacy is highly prevalent in residential aged care facilities (RACFs). Although polypharmacy is sometimes unavoidable, polypharmacy has been associated with increased morbidity and mortality. Objective: To identify and prioritize a range of potential interventions to manage polypharmacy in RACFs from the perspectives of health care professionals, health policy and consumer representatives. Methods: Two nominal group technique (NGT) sessions were convened in August 2015. A purposive sample (n ¼ 19) of clinicians, researchers, managers and representatives of consumer, professional and health policy organizations were asked to nominate interventions to address the prevalence and appropriateness of medication use. Participants were then asked to prioritize five interventions suitable for possible implementation at the system level. Results: Six of 16 potential interventions were prioritized highest for possible implementation in clinical practice, with two interventions prioritized as second highest. The top interventions in rank order were ‘implementation of a pharmacist-led medication reconciliation service for new residents,’ ‘conduct facilitylevel audits and feedback to staff and health care professionals,’ ‘develop deprescribing scripts to assist clinician-resident discussion,’ ‘develop or revise prescribing guidelines specific to older people with multimorbidity in RACFs,’ ‘implement electronic medication charts and records’ and ‘better support Medication Advisory Committees (MACs) to address medication appropriateness.’
Conflicts of interest: none. e These authors contributed equally to this work. * Corresponding author. Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University (Parkville Campus), 381 Royal Parade Parkville, Victoria 3052, Australia. Tel.: þ61 3 9903 9244. E-mail address: [email protected] (N. Jokanovic). 1551-7411/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2016.06.003
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Conclusion: This study prioritized a range of potential interventions that may be used to assist clinicians and policy makers develop a comprehensive strategy to manage polypharmacy in RACFs. Ó 2016 Elsevier Inc. All rights reserved. Keywords: Long-term care; Nursing homes; Polypharmacy; Deprescribing; Nominal group technique
Introduction An increasing body of literature has highlighted the high prevalence of polypharmacy in residential aged care facilities (RACFs). A RACF, synonymous with the terms ‘nursing home’ and ‘long-term care facility,’ refers to a specialpurpose facility which provides supported accommodation for people requiring assistance with daily living and nursing care.1,2 Up to 74% of residents of RACFs take nine or more medications on a regular basis.3 While polypharmacy is not always inappropriate, it has been associated with delirium, falls, hospital admissions and increased mortality.4–6 Polypharmacy is also associated with a higher likelihood of drug–drug interactions and adverse drug reactions.7,8 Polypharmacy has become a global issue, driven by the aging population and increasing multimorbidity worldwide. Managing polypharmacy in RACFs has been identified as a research priority in the United States (US).9 The recent Australian National Stakeholders Meeting on Quality Use of Medicines to Optimize Aging in Older Australians has called for a national strategic plan to reduce polypharmacy.10 Increasing awareness of the benefits of the palliative approach in older people with limited life expectancy suggests reducing inappropriate or unnecessary polypharmacy is likely to offer important public health benefits.11 Between 2004 and 2005, it was estimated that up to 177,504 hospital emergency department visits in older people 65 years and above were due to adverse drug events in the US.12 In Australia, medications are implicated in up to 30% of all unplanned hospital admissions in people aged 75 years and older, with up to three-quarters of these admissions potentially preventable.13 While there is a large body of literature on the prevalence of polypharmacy,3 much less has been published regarding strategies and approaches to effectively manage polypharmacy. Recent research has identified potential factors contributing to increasing polypharmacy in RACFs.14 These factors reflected a range of resident, clinician and system level factors for consideration during the
development of future interventions. A Cochrane review of 12 randomized controlled trials (RCTs) evaluated interventions aimed at optimizing prescribing for residents in RACFs.15 These interventions focused on pharmacist-led medication review, multidisciplinary case-conferences, education to RACF staff and the use of clinical decision support technology.15 There remains a paucity of research on interventions delivered by other health care professionals, the role of families and caregivers, and the impact of policy and regulatory changes. The objective of this study was to identify and prioritize a range of potential interventions to manage polypharmacy in RACFs from the perspectives of health care professionals, health policy and consumer representatives.
Methods Study participants Potential participants (n ¼ 36) were purposively sampled from metropolitan and regional Victoria, Australia. Participants were identified through existing contacts with the research team for their aged care experience either though clinical practice, research or involvement in health policy, consumer or professional organizations. Email invitations were sent to all participants. Participants who were not able to attend were invited to nominate a representative to attend on their behalf. The study was approved by the Monash University Human Research Ethics Committee. All participants provided written informed consent prior to participation. Modified nominal group technique (NGT) Nominal group technique (NGT) is a structured method of generating and prioritizing ideas in a group.16 This method is designed to facilitate a comfortable and open discussion to generate a broad range of ideas through equal participation.16 The NGT was chosen in favor of the Delphi technique or a focus group as it encourages participants to discuss their ideas as a group
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Fig. 1. The modified nominal group technique process used for this study.
but ensures that the discussion cannot be dominated by one or more participants.17 This study used a modified NGT (Fig. 1). The suggested size of a nominal group is between five and nine participants. To enable small group discussions, two NGT sessions were convened in August 2015 and were moderated by a facilitator experienced in NGT. The first NGT session primarily comprised of a group of clinicians, researchers and managers with extensive work experience in the aged care sector. The second session involved nominated representatives of consumer, professional and health policy organizations. This grouping was performed to minimize the potential reluctance of participants to express their opinions in front of all participants. Participants who
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could not attend one session were invited to attend the other scheduled session. Each session was held over four hours, including refreshments and breaks. Participants did not receive any payment for their participation in the sessions. Each session followed the same modified NGT process. Background information including published and unpublished research on the prevalence of polypharmacy in RACFs in Australia and internationally was presented to each group.3 Participants were asked the following question: “What interventions are needed to address the prevalence and appropriateness of medication use in RACFs?” For the purpose of the research, polypharmacy was operationally defined as the use of nine of more regular medications. This is the most common definition in RACFs and the definition of polypharmacy used by the Victorian Government Department of Health and Human Services.3,18 There is currently no definitive cutoff for polypharmacy that reflects medication appropriateness in RACFs. As polypharmacy was viewed an indicator of potential inappropriate medication use rather than necessarily being inappropriate itself, participants were broadly asked to consider the appropriateness of medication use when formulating their ideas. Participants worked in mixed discipline groups of two or three to generate a list of potential interventions suitable for implementation. Participants were prompted that organizational change may involve interventions at different health system levels (e.g. individual resident, care team, organization, health care environment).19 Novel interventions or additional components to existing interventions in RACFs were considered. Although a nominal group typically begins with the silent generation of ideas, participants were paired in this study to further encourage the discussion and generation of ideas. The facilitator then led a round-robin session to record interventions presented by each group. Each potential intervention was discussed at length by participants and revised accordingly. Any new interventions were also noted by the facilitator. All interventions generated from both NGT sessions were thematically combined and refined into a final list of 16 potential interventions for prioritization. Interventions that were deemed to be closely related by a panel of three pharmacist aged care researchers (NJ, SB and MD) were combined into broader interventions. Care was taken to ensure all interventions were captured in the final list. Disagreements were resolved through
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Table 1 Characteristics of participants Group
1
2
Participant
Sex
Profession
Duration of aged care experience (years)
1 2 3 4 5 6 7 8 9 1 2 3 4
Male Female Male Male Female Female Female Male Male Male Male Male Male
25 15 33 10 4 3 4 20 14 25 Unknown 21 40
5 6 7 8 9 10
Male Female Male Female Male Female
Research pharmacist Research nurse General medical practitioner Research pharmacist Executive director of nursing Hospital pharmacist Medication review pharmacist General medical practitioner Aged care research pharmacist Hospital pharmacy professional organization representative Health care advisor Geriatrician General medical practitioner professional organization representative Community pharmacy professional organization representative Hospital pharmacist Pharmacy professional organization representative Health care advisor Consumer representative Consumer representative
discussion with the study investigators. A limit was not set on the final number of interventions for prioritization. An online survey containing the list of 16 potential interventions was developed using the commercial tool SurveyMonkeyÒ and emailed to all participants within one week of the NGT sessions. This modification in the NGT was performed to obtain overall consensus from both nominal groups. The online survey was pilot tested for face validity by a convenience sample of independent quality use of medicine researchers (n ¼ 3) who did not participate in the research study. Participants were presented with the same question as in the NGT sessions and were asked to select and rank five interventions from the list of 16 interventions they perceived to have the highest priority for implementation at the system level. The ranking of five interventions is commonly used in the literature.20,21 A reminder email was sent to participants who had not completed the survey within one week. Data analysis A weighted ranking process was used to determine overall consensus of the two groups. This is a common method used in NGT research.21 Individually ranked interventions
20 3 20 25 30 35
were assigned points, with 5 points allocated to the highest priority intervention and 1 point allocated to the fifth highest priority intervention. The sums of the individual scores were tallied to provide the overall prioritized list of interventions. This study was conducted and reported in accordance with consolidated criteria for reporting qualitative studies (COREQ) guidelines.22
Results Participant characteristics Nineteen participants comprising of six female and thirteen male health care professionals, health policy and consumer representatives participated in the two nominal group sessions (Table 1). Three of the 19 participants were invited on the recommendation of the original invitee who could not attend. The participants comprised pharmacists (n ¼ 9), general practitioners (GPs) (n ¼ 3), nurses (n ¼ 2), medical specialist (n ¼ 1), health care advisors (n ¼ 2) and consumer representatives (n ¼ 2). Health care advisors included individuals responsible for providing health policy advice to government agencies. Consumer representatives included individuals who represent
Table 2 Features of proposed interventions Components of the proposed interventions
Novel, improvement or extension of current practicea
Pharmacist-led medication reconciliation service for new residents
Targeted to new residents of RACFs. Specific focus on polypharmacy reduction and regimen simplification. In addition to compiling an accurate medication history, determine indications for each medication and provide recommendations for regimen simplification.
An extension of the currently renumerated collaborative medication reconciliation service in RACFs (RMMRsb) or a novel intervention
Facility-level audit and feedback to staff and health care professionals on high risk medications
Facilitate benchmarking through feedback of facility-level audit data to facility staff and health care professions on the usage of high risk medications. Incorporation of a ‘traffic light system’ to assist health professionals identify high risk medications and encourage medication review.
Extension of current practice
Develop ‘deprescribing scripts’ to assist GPs and other clinicians to discuss medication discontinuation
Provide sample phrases to assist prescribers and other clinicians to initiate a conversation about deprescribing with residents and their families.
Novel intervention
Develop or revise prescribing guidelines specific to older people with multimorbidity in RACFs
Update the 2006 Australian ‘medical care of older persons in RACFs’ guideline.c Develop new evidence-based clinical practice guidelines tailored to older people with multimorbidity.
Improvement on current practice/novel intervention
Implement electronic medication charts and records
Electronic charts and records accessible to GPs, pharmacists, nurses and aged care workers across settings. With or without clinical decision support software.
Improvement on current practice
Investigate the current role of MACs at each facility and better support MACs to address medication appropriateness
Determine the current composition and roles of MACs in RACFs. Identify characteristics of effective MACs required to address medication appropriateness.
Improvement on current practice
Develop a ‘quality use of medicines (QUM) tick of approval’ scheme for RACFs
Develop a minimum set of standards for RACFs to obtain certification as a facility which adheres to quality use of medicines practices.
Novel intervention
Better communicate the findings of pharmacists’ residential medication management reviews (RMMRs), including to residents, family and carers
Provide findings from RMMRs which are easily interpretable to residents, family and carers in addition to prescribers.
Improvement on current practice
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Proposed intervention
5 (continued)
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Table 2 (continued ) Components of the proposed interventions
Novel, improvement or extension of current practicea
Encourage residents to incorporate their desires in relation to medication use in advance care plans
Improve awareness and consideration of medication use in advance care planning for all residents in RACFs.
Improvement on current practice
Improve medication-related research culture within RACFs
Fostering a research culture within RACFs to improve the quality use of medicines.
Improvement on current practice
Develop a 1-page fact sheet to empower residents, family and carers to talk to their GP and other health professionals about deprescribing
A 1-page educational fact sheet on deprescribing provided to residents and their families to encourage the initial discussion with their prescribers or other health professional.
Novel intervention
Identify aged care facilities with optimal medication use and publish case studies to highlight best practice
Promotion of examples of best practice in medication use in RACFs to guide improvements across facilities.
Novel intervention
Implement initiatives to increase the knowledge and uptake of non-pharmacological management approaches in RACFs
Provide education to prescribers and RACF staff on nonpharmacological approaches to reduce inappropriate medication use.
Novel intervention
Encourage prescribers to conduct more frequent reviews of medications through regulatory changes
Regulatory changes including shortening the length of medication charts to encourage more frequent medication review by prescribers.
Improvement on current practice
Improve medication literacy by training nurses and aged care workers to recognize potentially harmful medications and adverse events
Provide education to RACF staff on common high risk medications and adverse events to empower staff to report potentially inappropriate medication use.
Improvement on current practice
Develop a 1-page fact sheet with practical advice for locums and other visiting health care professionals to better interact with RACFs
Practical advice specific to each facility in relation to existing procedures and practices for visiting prescribers and other health care professionals.
Novel intervention
GP ¼ general practitioner; MAC ¼ medication advisory committee; RACF ¼ residential aged care facility; RMMR ¼ residential medication management review. Refers to current practice in Australian RACFs. b Residential medication management reviews are collaborative medication reviews conducted by accredited pharmacists which are funded by the Australian Government. c The current Australian guideline was last updated by the Royal Australian College of General Practitioners in 2006. a
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Proposed intervention
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Fig. 2. Ranking of interventions.
consumers (e.g. residents, carers and their families) on committees. Four participants who accepted their invitation to participate were unable to attend on the day. Eight of the 19 participants had more than 20 years of aged care work experience.
each facility and better support MACs to address medication appropriateness’ (18). The priorities of the interventions were calculated into percentages based on the scores each intervention received, with the top 8 interventions receiving 79% of the total score.
Potential interventions to manage polypharmacy in RACFs
Discussion
Seventeen of the 19 participants completed the survey and prioritized their top five interventions (Table 2, Fig. 2). The intervention ranked as the highest priority was ‘implementation of a pharmacist-led medication reconciliation service for new residents of RACFs’ (sum of scores: 41). The interventions that were ranked second were to ‘facilitate benchmarking by conducting facility-level audit and feedback to staff and health care professionals on the prevalence of high risk and/or highly prevalent medications’ (31), and to ‘develop “deprescribing scripts” to assist GPs and other clinicians to proactively discuss the topic of medication discontinuation’ (31). The interventions ranked third to fifth highest were to ‘develop or revise prescribing guidelines specific to older people with multimorbidity in RACFs’ (25), ‘implement electronic medication charts and records for health care professionals’ (24) and to ‘investigate the current role of the Medication Advisory Committees (MACs) at
As far as the authors are aware, this is the first study to prioritize interventions to manage polypharmacy in RACFs. Six of the 16 potential interventions were prioritized highest for possible implementation in clinical practice. The remaining 10 interventions received varied degrees of support, suggesting a broad ranging and multifaceted strategy may be needed to comprehensively manage the issue of increasing polypharmacy. The 16 interventions represented a range of approaches that were additional to those highlighted in the Cochrane review published by Alldred et al.15 Whilst Alldred et al identified interventions including medication review, clinical education and the use of clinical decision support software, this study has identified interventions that are novel or an extension of current practice. Implementation of a pharmacist-led medication reconciliation service for new RACF residents was ranked highest for managing
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polypharmacy. This proposed intervention is in addition to the medication review interventions identified in 10 studies reviewed by Alldred et al.15 Opinion was divided on whether this service should be distinct from the current model of collaborative medication review in RACFs funded by the Australian government.23 The current model, residential medication management review (RMMR), is a well-established service introduced in 1997 to improve the quality use of medicines in RACFs.24 This may explain why this service was not specifically considered for prioritization by the study participants. Medication reconciliation conducted by pharmacists during transition from hospitals to RACFs improves medication history accuracy and health outcomes, through reductions in hospital admissions and pain in the older residents in RACFs.25 Pharmacist-led medication reviews in the primary care setting have resulted in significant reductions in the mean number of medications and drug-related problems.26 This service was deemed necessary for reducing polypharmacy because having a complete medication list is a key initial step in the deprescribing process.27 The equal second highest ranked intervention was to develop ‘deprescribing scripts’ to assist GPs and other clinicians to proactively discuss the topic of medication discontinuation. The process of deprescribing involves a discussion of the overall risk and future benefit of medications with consideration of predicted life expectancy.27 Discussions about deprescribing are often challenging for prescribers and confronting for residents and their caregivers.28 Residents’ willingness to cease medications may be influenced by disagreement about the appropriateness of medication cessation, limited opportunity to discuss deprescribing and fear of negative consequences on cessation.29 Good patient-physician relationships and a patient centered approach are important for deprescribing.29 Prescribers often find it difficult to discuss changing goals of care.29 Furthermore, reluctance to question other prescribers’ decisions is also a significant barrier to deprescribing.30 Despite this, it has been reported that up to 79% of residents are willing to cease one or more of their medications if their prescribers indicate that it is possible.31 The development of ‘deprescribing scripts’ was perceived as valuable to assist prescribers and other clinicians to approach the topic of medication discontinuation with residents and their families. Facilitating benchmarking by conducting facility-level audit and feedback to staff and
health care professionals on the prevalence of high risk and/or highly prevalent medications was ranked equal second highest. Audit and feedback is an evidence-based approach to improving professional practice.32 It has been shown that providing patient-specific prescriber feedback, including a list of potential medication-related problems (MRPs) and educational material, resolved MRPs and reduced hospitalizations in Australian veterans and their dependents.33 Five studies incorporating educational interventions to RACF staff were identified by Alldred et al, however facility-level and feedback was not specifically investigated.15 Further studies are required to explore the impact of facility-level audit and feedback to RACF staff and health care professionals. The third highest ranked intervention was to develop or revise prescribing guidelines specific to older people with multimorbidity in RACFs. Clinical practice guidelines are often diseasespecific and rarely provide guidance for older people with multimorbidity in RACFs.34,35 This may create tension for prescribers who feel pressured to comply with prescribing guidelines.36 Polypharmacy and medication regimen complexity may arise due to prescribers’ desire to achieve strict blood glucose or blood pressure targets that are not specific to older people in RACFs.3,37 Up-to-date and evidence-based prescribing guidelines tailored towards older people with multimorbidity in RACFs may reduce the prevalence of polypharmacy. Implementation of electronic medication charts and records was ranked as the fourth highest intervention. Electronic charts and records accessible to health professionals and facility staff across settings would ensure access to the most recent medication history. A complete medication history including indications for each medication, intended duration and goals of care are important for deprescribing.27 Electronic records with integrated clinical decision support will improve communication between health care professionals, minimize medication discrepancies and allow clinicians to readily identify medications suitable for deprescribing.38,39 The intervention ranked fifth highest was to better support MACs to address medication appropriateness. MACs comprise of representatives from different health care professions, RACF management and residents who advise and evaluate medication management policies, procedures and practices in RACFs, ensuring
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the safe and quality use of medicines.40 Limited research has investigated the composition and functions of MACs in RACFs and their potential impact on polypharmacy. Future research should be directed toward a better understanding of MACs in RACFs. Strengths and limitations The use of NGT methodology allowed for the generation and prioritization of a range of potential interventions to manage polypharmacy. The participants were purposively sampled to represent a diverse range of opinions and experiences across different health care sectors, however the potential for selection bias cannot be excluded. Interventions from both sessions were thematically grouped into 16 potential interventions, some of which may be interrelated. The research specifically focused on interventions suited for adoption at the system level. Wider education initiatives (e.g. inter-professional learning for medical, pharmacy and nursing students) are likely to be important but were not considered as part of the present research. The feasibility of interventions presented in this study for implementation in clinical practice was not evaluated and should be considered in future research. Further investigations into the feasibility and outcomes following implementation of these strategies into clinical practice are required.
Conclusion Potential interventions needed to manage polypharmacy in RACFs were identified and prioritized. These interventions may assist clinicians and policy makers develop a comprehensive strategy to manage polypharmacy in this setting. Further research is needed to determine the feasibility of these interventions and their impact on polypharmacy in RACFs. Acknowledgment We would like to express our sincere gratitude to all the participants in the study who donated valuable time and effort. We also gratefully acknowledge the Ageing and Aged Care Branch, Department of Health and Human Services, State Government of Victoria for commissioning and funding this research.
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