Neuroleptic and benzodiazepine use in long-term care in urban and rural Alberta: characteristics and results of an education intervention to ensure appropriate use.

OBJECTIVES: To examine the use of psychotropic drugs in 24 rural and urban long-term care (LTC) facilities, and compare the effect of an education intervention for LTC staff and family members on the use of psychotropic drugs in intervention versus control facilities. METHODS: Interrupted time series with a non-equivalent no-treatment control group time series. Data on drug use were collected in 24 Western Canadian LTC facilities (10 urban, 14 rural) for three 2-month time periods before and after the intervention. Pharmacy records were used to collect data on drug, class of drug, dose, administration, and start/stop dates. Chart reviews provided demographics, pro re nata (prn) use, and indications for drug use. Subjects comprised 2443 residents living in the 24 LTC facilities during the 1-year study. An average of 796.33 residents (32.7%) received a psychotropic drug. An education intervention on psychotropic drug use in LTC was offered to intervention physicians, nursing staff, pharmacists and family members. RESULTS: Approximately one-third of residents received a psychotropic drug during the study, often for considerable lengths of time. A minority of psychotropic drug prescriptions had a documented reason for their use, and 69.5% of the reasons would be inappropriate under Omnibus Budget Reconciliation Act (OBRA) legislation. Few psychotropic drug prescriptions were discontinued or reduced during the study. More urban LTC residents received neuroleptics and benzodiazepines than their rural counterparts (26.1% vs. 15.7%, and 18.0% vs. 7.6%, respectively). The education intervention did not result in any significant decline in the use of these drugs in intervention facilities. CONCLUSION: The results suggest substantial use of psychotropic drugs in LTC, although rural LTC residents received approximately half the number of psychotropic drugs compared with urban residents. A resource-intensive intervention did not significantly decrease the use of psychotropics. There is a need for better monitoring of psychotropic drugs in LTC, particularly given that voluntary educational efforts alone may be ineffective agents of change.

Antipsychotic drug use in Canadian long-term care facilities: prevalence, and patterns following resident relocation.

BACKGROUND AND AIMS: Data on antipsychotic use were collected in two Canadian long-term care (LTC) facilities. During the one-year study, residents in one facility were relocated to a new facility, allowing examination of the changes in antipsychotic use associated with relocation. METHOD: A comparative descriptive design was used. Pharmacy and chart data on antipsychotic use were gathered for three separate one-month periods during one year. Data were collected both in a facility experiencing relocation of all residents to a new facility, and in a facility not undergoing relocation. The three one-month data collection periods covered a one-month period before the relocation, immediately after the relocation, and six months after the relocation. RESULTS: In the facility not experiencing relocation, an average of 31.3% of all residents were receiving antipsychotics. Residents in this facility received antipsychotics for an average length of 0.81 years, and 20.8% of all antipsychotic prescriptions reflected dose reductions within six months of the start of the prescription. Only 8.1% of prescriptions had accompanying documentation on the behavioral indication for the use of antipsychotics. A total of 73.4% of all antipsychotics were 'atypical' antipsychotics, and 13.5% of all antipsychotic prescriptions were written as 'p.r.n.' (as needed). While the use of antipsychotics remained relatively constant in the non-relocation facility (between 30.3% and 33.1% of all residents), the percentage of residents receiving antipsychotics in the facility experiencing a relocation climbed significantly; from 21.5% six months before the move, to 32.6% immediately after the move, to 36.9% six months after the move. CONCLUSION: These findings, when compared with the U.S. standards on antipsychotic use (OBRA), suggest the need for additional research on antipsychotic use in Canadian LTC facilities.

A multicenter disease management program for hospitalized patients with heart failure.

BACKGROUND: Despite the availability of proven therapies, outcomes in patients with heart failure (HF) remain poor. In this 2-stage, multicenter trial, we evaluated the effect of a disease management program on clinical and economic outcomes in patients with HF. METHODS AND RESULTS: In Stage 1, a pharmacist or nurse assessed each patient and made recommendations to the physician to add or adjust angiotensin-converting enzyme (ACE) inhibitors and other HF medications. Before discharge (Stage 2), patients were randomized to a patient support program (PSP) (education about HF, self-monitoring, adherence aids, newsletters, telephone hotline, and follow-up at 2 weeks, then monthly for 6 months after discharge) or usual care. In Stage 1 (766 patients) ACE inhibitor use increased from 58% on admission to 83% at discharge (P < .0001), and the daily dose (in enalapril equivalents) increased from 11.3 +/- 8.8 mg to 14.5 +/- 8.8 mg (P < .0001). In Stage 2 (276 patients) there was no difference in ACE inhibitor adherence, but a reduction in cardiovascular-related emergency room visits (49 versus 20, P = .030), hospitalization days (812 versus 341, P = .003), and cost of care (2,531 Canadian dollars less per patient) in favor of the PSP. CONCLUSION: Simple interventions can improve ACE inhibitor use and patient outcomes.