Evaluating Antipsychotic Medicine Prescribing in Nursing Homes
In 2014, a report by the Toronto Star pushed government administrators to revisit prescribing antipsychotic medicine in nursing homes, a type of medication that holds sedative-like properties and is used as a type of chemical restraint on residents with behavioural disturbances.
In response, the Ontario Ministry of Health and Long-Term Care, in partnership with the Ontario Medical Association (OMA), Health Quality Ontario and the Centre for Effective Practice, created an intervention program to prevent future inappropriate prescribing of antipsychotic medications in nursing homes. The intervention used interactive and tailored teaching approaches that encouraged physicians, nurses, and nursing home staff to find alternatives to prescribing antipsychotics. The hope was that the project would also become an example of how health quality improvement programs could be assessed and analyzed in future.
"We decided together that there was a need for a quality improvement intervention directed both at the system and the clinician levels,'' said Dr. Noah Ivers, an Assistant Professor at the Department of Family and Community Medicine and Innovation Fellow at the Women’s College Hospital Institute for Health System Solutions and Virtual Care.
Dr. Ivers, who was invited to be the research lead due to his interest in implementation science and health quality initiatives, worked alongside policymakers to evaluate the project using a variety of methods.
Through semi-structured interviews with staff in 40 randomly-selected nursing homes, the team investigated the results of the intervention and explored how different factors within the nursing homes, such as teamwork and communication, played a role in safe prescribing. The team also used administrative data to examine the overall impact of the intervention on antipsychotic prescribing.
In the team's report on the intervention, participants expressed how different factors affected and influenced prescribing patterns inside the nursing homes. For instance, they spoke about the benefit of having engaged leaders in the homes who were committed to improving quality and how this drove changes in prescribing practice by facilitating engagement and uptake of the intervention.
One nursing home administrator who was interviewed said that the intervention created a surge in motivation to invest in change: “I started looking at the research and then the evidence-based practice guidelines and I said, well, we have a serious (antipsychotic prescribing) problem... (and so) we started an initiative immediately without anybody saying that we had to."
While results from the report showed no significant differences observed in antipsychotic medicine prescribing at the interim checkpoint, the qualitative analysis brought forth great promise. Participants expressed that they were pleased with the positive effects of implementing the intervention, which included better documentation processes, the introduction of a common language around prescribing, the increased use of non-pharmacological approaches, and more collaborative practices within the home.
"Before the program, physicians were not that cautious about writing their reasons for prescribing the medications directly on their orders,” says Ivers. “Now, they have started communicating with colleagues about why medications are called for so they know exactly why it’s being used.”
Dr. Ivers highlights how small changes like these can improve care – even if it’s not readily captured in the crude quantitative analyses and administrative databases. More importantly, the results offer insights into future health system improvement initiatives and demonstrate how embedded research can support evidence-based health policy decisions.
"We need to partner with health system decision makers and health service organizations to evaluate large-scale implementations in the real world,” says Ivers. “And we need to see not just whether it works, but rather why and how so that we can work with those partners in the future to optimize these quality improvement initiatives. That’s how we build a learning health system."
As the team finalizes the upcoming analysis and presents the findings of the full study to the Ministry and the OMA, Dr. Ivers hopes that this project will set an example for why studying the effects of health care quality improvement initiatives is needed to both inform future research in the field and ultimately improve the lives of patients.