Variations in the treatment culture of nursing homes and responses to regulations to reduce drug use.

OBJECTIVE: The study examined the relationship between treatment cultures of nursing homes and their responses to regulations to reduce use of psychotropic drugs mandated by the 1987 Omnibus Budget Reconciliation ACT: The authors hypothesized that reduction in use of antipsychotic drugs was more likely to occur in homes with a resident-centered culture emphasizing psychosocial care, avoidance of psychotropic drugs, pharmacist feedback, and involvement of mental health workers. The authors also predicted greater reductions in drug use in facilities with a less severe case mix and better capacity for change. METHODS: Data were collected in a stratified random sample of 16 skilled nursing facilities in Wisconsin. Participants included 1,181 residents in the baseline study and 1,650 residents in the follow-up study. Treatment culture was measured with a questionnaire for assessing nurses' beliefs and philosophies of care and their interactions with pharmacists and mental health workers. RESULTS: No significant change was observed in the use of benzodiazepines, antidepressants, or polymedicine (two or more psychotropic medications). However, use of antipsychotic drugs decreased significantly, from 24 percent to 16 percent. The change in use varied dramatically across facilities, from an 85 percent reduction to a 19 percent increase. Findings also revealed significant variability in treatment cultures. Greater reductions in use of antipsychotic drugs were found in facilities with a resident-centered culture, a less severe case mix, and a higher nurse-to-resident staffing ratio. CONCLUSIONS: Future policy and quality improvement efforts must address treatment cultures, staffing, and other organizational barriers to nursing home reform.

Using drug claims data to assess the relationship of medication adherence with hospitalization and costs.

OBJECTIVE: This naturalistic study used claims data to examine the relationship of medication nonadherence to hospital use and costs among severely mentally ill clients in Wisconsin. METHODS: Data for 619 clients were obtained from Medicaid drug and hospital claims, county records, and case managers as part of a larger study in eight county-based mental health systems. Study participants were eligible for Medicaid, had a severe and persistent mental illness, were 18 years or older, and were receiving neuroleptics, lithium, or antidepressants. Drug claims were analyzed for a 12-month period to determine how regularly clients obtained their medications. Regression analyses were used to assess the effects of irregular medication use on any hospitalization for psychiatric problems, the number of days hospitalized, and hospital costs. The analyses controlled for several risk factors. RESULTS: Among clients with schizophrenia or schizoaffective disorder, 31 percent used medications irregularly. The rates were 33 percent among those with bipolar disorder and 41 percent among those with other severe mental illnesses. In the total sample, irregular users had significantly higher rates of hospitalization than regular users (42 percent versus 20 percent), more hospital days (16 days versus four days), and higher hospital costs ($3,992 versus $1,048). Irregular medication use was one of the strongest predictors of hospital use and costs even after the analyses controlled for diagnosis, demographic characteristics, baseline functioning, and previous hospitalizations. CONCLUSIONS: The availability of drug claims data and the ability to use them in predictive analyses make them a potentially useful data source in studies of medication adherence among persons with severe mental illness.

Chronic benzodiazepine use in nursing homes: effects of federal guidelines, resident mix, and nurse staffing.

OBJECTIVES: To assess the overall prescribing and chronic use of benzodiazepines (BZs) in nursing homes before and after implementation of BZ guidelines by the Health Care Finance Administration (HCFA). A second aim was to identify facility predictors of BZ prescribing and chronic use after guideline implementation. DESIGN: Nonexperimental, observational study design. SETTING: Drug use was assessed in 16 randomly selected skilled nursing facilities in Wisconsin before 1990 and again in 1993-1994. PARTICIPANTS: One thousand one hundred eighty-one Medicaid-funded residents at baseline and 1,650 Medicaid-funded residents at follow-up. MEASUREMENTS: Drug use measures included percentage of residents with prescribed BZs and percentage of residents with chronic BZ use (defined as >or=4 months of continuous use). A 4-month cutoff was used because HCFA guidelines consider this length of continuous use to be potentially excessive. Facility predictors of drug use included resident demographic and diagnostic mix, size, ownership, Medicaid per diem, and nurse staffing. RESULTS: Before 1990, one-fourth of all residents were prescribed a BZ and nearly one-tenth of all residents had chronic BZ use. Federal guidelines had nonsignificant effects on these measures; BZ prescribing declined only 3.6% (26.4-22.8%) and chronic use declined only 1.3% (9.2-7.9%). Regression results showed that overall prescribing at follow-up was higher in facilities with more female residents (beta= .52, P= .018) and residents with psychiatric disorders (beta= .41, P= .045). However, nurse staffing was the only significant predictor of chronic BZ use. As expected, better nurse staffing was associated with lower rates of chronic use (beta= -0.46, P= .037). CONCLUSION: Efforts to improve BZ use in nursing homes must address the need for better nurse staffing and better assessment and management of psychiatric disorders that can trigger BZ prescribing.

Effects of physician communication style on client medication beliefs and adherence with antidepressant treatment.

The goals of this study were to examine how physician communication style impacts client beliefs and medication taking behavior during treatment for depression. The study uses a communication framework and prospective design to examine physician communication and client beliefs as treatment is initiated and again 2 months later. Two telephone interviews were conducted with 100 clients enrolled from 23 community pharmacies. Clients report that physician communication styles vary. In follow-up, 25% of the clients were not satisfied with their medication and 82% reported missing doses or stopping treatment earlier than recommended. Path analysis showed that physician initial communication style positively influences client knowledge and initial beliefs about the medication. Clients with more positive beliefs about the treatment are more likely to see the physician in follow-up and are more satisfied with treatment after attempting medication use. Physician follow-up communication style and client satisfaction are both predictive of better medication adherence.

Hemodialysis patients' noncompliance with oral medications.

The purpose of this study was to describe the prevalence, severity, and patterns of noncompliance with prescribed medications among hemodialysis patients; and to identify patient, disease and/or treatment characteristics associated with noncompliance. Demographic and medical history information were collected from chart reviews and patient interviews. Compliance data were collected via self-report, pill count, and a medication event monitoring system (MEMS, Product of Aprex, a division of Apria Healthcare; Costa Mesa, CA). A total of 135 hemodialysis patients from 11 dialysis facilities in a large Midwestern metropolitan area participated. Overall, medication compliance rates were very low. Of the patient, disease, and treatment characteristics considered, only race was found to be associated with patient noncompliance; African-American patients had higher rates of noncompliance with both monitored medications. The results of this study confirm that noncompliance with medication regimens continues to be an unremitting problem for hemodialysis patients and that demographic, medical history, and treatment characteristics do not adequately explain this behavior. Also, estimates of patient compliance as measured by self-report, pill count, and microelectronic monitoring are disparate enough to suggest that relying exclusively on patients' self-report of compliance might be insufficient.

The Brief Medication Questionnaire: a tool for screening patient adherence and barriers to adherence.

Self-report tools for monitoring adherence can be useful in identifying patients who need assistance with their medications, assessing patient concerns, and evaluating new programs. The aim of this study is to test the validity of the Brief Medication Questionnaire (BMQ), a new self-report tool for screening adherence and barriers to adherence. The tool includes a 5-item Regimen Screen that asks patients how they took each medication in the past week, a 2-item Belief Screen that asks about drug effects and bothersome features, and a 2-item Recall Screen about potential difficulties remembering. Validity was assessed in 20 patients using the Medication Events Monitoring System (MEMS). Results varied by type of non-adherence, with the Regimen and Belief Screens having 80-100% sensitivity for "repeat" non-adherence and the Recall Screen having 90% sensitivity for "sporadic" non-adherence. The BMQ appears more sensitive than existing tools and may be useful in identifying and diagnosing adherence problems.

Resident characteristics and organizational factors influencing the quality of drug use in Swedish nursing homes.

Appropriateness of drug use is an important indicator of the quality of care in nursing homes. In this study, we analyzed the influence of resident characteristics and selected organizational factors on the appropriateness of psychotropic drug use in 33 Swedish nursing homes. Specific criteria based on published guidelines and recommendations were developed to measure appropriateness. Residents diagnosed with a psychiatric disorder and younger residents had more deviations from the criteria; however, resident mix did not explain variations in appropriateness of drug use at the facility level. Facilities with better nurse staffing and drug intervention teams had fewer deviations from the criteria, but only 15-20% of the variation in drug prescribing was explained by these predictors.

The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes.

OBJECTIVE: To evaluate the impact of regular multidisciplinary team interventions on the quantity and quality of psychotropic drug prescribing in Swedish nursing homes. DESIGN: A randomized controlled trial. SETTING: A sample of 33 nursing homes: 15 experimental homes and 18 control homes representing 5% of all Swedish nursing homes. PARTICIPANTS: The sample consisted of 1854 long-term care residents with an average age of 83 years. Seventy percent of the residents were women, and 42% had a documented diagnosis of dementia. An additional 5% had a psychotic disorder, and 7% had a diagnosis of depression. INTERVENTION: Experimental homes participated in an outreach program that was designed to influence drug use through improved teamwork among physicians, pharmacists, nurses, and nurses' assistants. Multidisciplinary team meetings were held on a regular basis throughout the 12-month study period. MEASUREMENTS: Lists of each resident's prescriptions were collected 1 month before and 1 month after the 12-month intervention. Measures included the proportion of residents with any psychotropic drug, polymedicine, and therapeutic duplication and proportion of residents with nonrecommended and acceptable drugs in each psychotropic drug class, as defined by current Swedish guidelines. RESULTS: Baseline results show extensive psychotropic drug prescribing, with the most commonly prescribed drugs being hypnotics (40%), anxiolytics (40%), and antipsychotics (38%). After 12 months of team meetings in the experimental homes, there was a significant decrease in the prescribing of psychotics (-19%), benzodiazepine hypnotics (-37%), and antidepressants (-59%). Orders for more acceptable antidepressants also increased in the experimental homes. In the control homes there was increased use of acceptable antidepressants, but there were no significant reductions in other drug classes. CONCLUSIONS: There is excessive prescription of psychotropic drugs in Swedish nursing homes. Improved teamwork among caregivers can improve prescribing as defined by clinical guidelines.

Differences in older versus younger hemodialysis patients' noncompliance with oral medications.

Hemodialysis patients' compliance with their therapeutic regimens, including dietary and fluid restrictions, dialysis treatments and medications, is generally suboptimal. Recently, the mean age of the dialysis population has increased. Since impaired cognitive function, which sometimes accompanies aging, interferes with the ability to comprehend instructions, elderly dialysis patients might be at greater risk for noncompliance than are their younger counterparts. In this project, 135 hemodialysis patients (68 patients > 65 years of age and 67 patients < or = 65 years) were studied. Rates of noncompliance with oral antihypertensives and phosphate binders, as tracked by a medication event monitoring system (MEMS), are reported here. More than 42% of older patients (> 65) and 47% of younger patients (< or = 65) were repeated noncompliers with antihypertensives, missing at least 20% of the prescribed doses. Similarly, 65% of older patients and 80% of younger patients exhibited repeated noncompliance with phosphate binders. Almost 30% of older patients and more than 32% of younger patients missed their antihypertensives completely on 20% or more of the prescribed days. Only 18% of the older subjects, but 33% of younger patients missed taking their phosphate binders for 20 or more percent of the prescribed days. Rates of noncompliance were found to differ between the two populations of patients in that younger patients made significantly more dosing errors with their antihypertensives and missed taking their phosphate binders on more days than did their older counterparts.

Verbal consultation regarding prescription drugs: findings from a statewide study.

In 1984 the Wisconsin Division of Health showed interest in patients' receipt of verbal consultation for prescription drugs and included relevant questions in the Wisconsin Health Status survey to: 1) investigate the receipt of verbal consultation for new and refill prescriptions, 2) allow a comparison of state results with those of a national study that used similar sampling and data collection procedures, and 3) more closely examine the relationships between receipt of verbal consultation and such variables as prescription status (new or refill), age, sex, race, and education. Data were collected from 2,135 randomly selected respondents using Computer Assisted Telephone Interviewing with random digit dialing. After controlling for elapsed time since last prescription, log-linear analyses showed the importance of prescription status (new and refill) and respondent's age as correlates of consultation by pharmacy personnel, while prescription status, age, and sex were significant for prescribers. For both prescribers and pharmacy personnel, the authors found no association between client education and receipt of verbal consultation. The absence of verbal consultation cannot be entirely accounted for by client characteristics or prescription status. Based upon their experience, the authors encourage continued monitoring of prescribers' and pharmacists' provision of verbal consultation through questions contained in state and national health status surveys.

Nursing home resources and tranquilizer use among the institutionalized elderly.

OBJECTIVE: To examine the relationship between selected resident and facility characteristics and the frequency and quality of tranquilizer prescribing and use in skilled nursing facilities. DESIGN: Retrospective review of medication profiles and pharmacy billing records using standardized protocol. SETTINGS: Seven skilled nursing facilities. PARTICIPANTS: All residents aged 65 years or older were eligible. Consent was given by 760 residents or guardians. Six refused permission. OUTCOME MEASURES: Drug use measures included the presence or absence of a tranquilizer order, any tranquilizer use during previous 30 days, and any deviation from selected drug use criteria. RESULTS: Of 760 residents, 38% had an order for an antipsychotic or antianxiety agent, and 28% actually received a tranquilizer. Comparing tranquilizer practices with specific drug-use criteria showed that nearly 19% of all elderly residents were exposed to some type of excess use such as long duration, polymedicine, or therapeutic duplication. Residents in facilities with less adequate staffing and other resources were significantly more likely to have a tranquilizer order, to have a tranquilizer administered, and to have any deviation from drug-use criteria. The data also show higher rates of deviation from criteria among residents with a diagnosed mental disorder, younger residents, and Medicaid recipients. CONCLUSION: More attention must be paid to environmental factors that may undermine current efforts to improve psychotropic drug prescribing and use in skilled nursing facilities.

Gender, employment and medication use.

Analyses using self reports and medical and pharmacy records of 762 men and women were conducted to assess the impact of general health status, health factors related to women's reproductive role and employment status on their use of over the counter and prescription drugs. Results showed that factors related to general health status and women's reproductive role are major contributors to gender differences in drug use. Employment is associated with a lower incidence and prevalence of drug use for men, but not for women, and the patterns of over the counter and prescription drug use are differentially affected by employment status, gender and health status variables.

Factors affecting outcomes of medication-history interviewing by pharmacy students.

Factors affecting outcomes of medication-history interviewing by pharmacy students were studied. Data were obtained from fourth-year pharmacy students enrolled in a required course in fall 1984. Each student conducted a medication-history interview with one of two simulated patients who presented a predetermined history; interviews were videotaped from behind a one-way mirror. Students also completed an interviewing-orientation survey and a personal report of communication apprehension (PRCA). Trained raters evaluated the videotaped interviews using measures of interview skill and interview completeness. The simulated patients completed a patient-satisfaction form after each interview. Two path models were developed that were identical except that one had completeness and one had patient satisfaction as the dependent variable. Interview skill was the final factor in each model, preceded by variables representing the student's background and orientation factors, PRCA, and simulated-patient gender. Of 112 students conducting the interview, 107 (95.5%) and 95 (84.8%) completed the PRCA and orientation surveys, respectively. The models explained 36% and 27% of the variance in patient satisfaction and completeness, respectively. Shown in parentheses are the significant direct predictors of variables in the model of patient satisfaction: satisfaction (skill, prepharmacy grade point average [preGPA], people and health-care [PHC] orientation); skill (interviewing orientation, preGPA); interviewing orientation PHC orientation, preGPA, PRCA); and (PHC orientation (student gender). All effects were positive except for PRCA on interviewing orientation. For the model of completeness, direct predictors were as follows: completeness (skill, PHC orientation, student gender, simulated-patient gender); skill (interviewing orientation, preGPA); interviewing orientation (PRCA, preGPA, PHC orientation); and PHC orientation (student gender). All effects were positive except for PRCA on interviewing orientation and PHC orientation on completeness. Results suggest that one path model reflects the patient's assessment of interviewer competence in terms of satisfaction, and the other reflects the clinician-rater's assessment of interviewer competence in terms of interview completeness. The interviewing process positively influences both patient satisfaction and interview completeness.

Nurse administration of sleep medication: a comparison of registered nurses and licensed practical nurses.

This study examines differences in the administration of PRN (pro re nata or give "as needed") sleep medication between licensed practical nurses and registered nurses working in long-term care facilities. Work characteristics, characteristics of the residents cared for, and the extent of orders and administration of PRN sleep medications were similar in the two groups. No significant differences in the administration of PRN sleep medication were found.

Gender differences in the acquisition of prescribed drugs: an epidemiological study.

It is often assumed that women received more prescribed drugs because they have different attitudes towards illness and medical care, higher anxiety and more time to visit physicians, or because physicians are biased. This study examines an alternative explanation, that is, much of the excess is associated with women's reproductive role. The study involved a detailed audit of the medical and pharmacy records of 862 men and women. Results showed that women received more prescribed drugs during the 2-year study period. However, the differences between men and women were not the same for all age groups. As expected, the differences were most apparent during the peak child-bearing years. Further analysis showed that the gender differences were virtually eliminated after excluding women with female-specific diagnoses and excluding the drug categories used to prevent or treat female-specific conditions. Previous studies based on gross measures of self-reported drug use seem to have underestimated the importance of factors that relate to women's reproductive role.

Medication counseling behaviors and attitudes of rural community pharmacists.

There is a continued emphasis on developing the pharmacist's medication counseling role to better serve the public. To understand this role, the present study utilized a shopper methodology to describe the extent to which 40 rural community pharmacists engage in five dimensions of counseling for each of two drug products. The study demonstrates a significant relationship between the attitudes toward counseling held by these practitioners and their actual counseling behaviors.