Implementing a novel strategy for interprofessional medication review using collegial mentoring and systematic clinical evaluation in nursing homes (COSMOS)

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Abstract

Background

Multimorbid patients in nursing homes are prescribed long lists of medication, often without sufficient clinical evaluations beforehand. This results in poor clinical effects of the prescribed medication and significant side-effects, especially in patients with impaired cognition. The aim of this paper is to describe the process, content and implementation of a clinical medication review encompassing clinical testing and collegial support to prescribers.

Methods

The implementation process of a novel approach to medication review in nursing homes was logged thoroughly by structured staff feedback. Staff experienced promotors and barriers to implementation also were collected. The study was part of a cluster randomized controlled trial, in which 36 long-term care units received the COSMOS intervention. Nurses and physicians randomized to the intervention group participated in educational programs, training in clinical evaluation of the patients, and interprofessional medication review with collegial mentoring.

Results

The intervention group contained 297 patients from 36 nursing home units. There were 105 staff attendees for the education program. The units were served by 21 different physicians. Clinical medication reviews were performed in all units and all patients were assessed prior to the medication reviews. Of the 240 patients with a logged intervention process, 220 (92%) underwent a medication review. The intervention generated enthusiasm and improved communication among nursing staff and between nursing staff and physicians. The interprofessional discussions helped to facilitate difficult decisions pertaining to treatment levels. Reported barriers were lack of time, low engagement of all nursing staff and physicians, and ethical dilemmas.

Conclusions

Clinical medication reviews were implemented for almost all patients, and every patient was systematically assessed prior to the medication review. The physicians perceived collegial mentoring as an asset, learning from each other facilitated decision making in terms of difficult aspects of prescribing. Knowledge about barriers and promotors can improve implementation of similar interventions in other nursing homes.

Trial registration

Clinicaltrials.gov ( NCT02238652). Registered July 7th 2014.

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Most cited references 32

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STOPP/START criteria for potentially inappropriate prescribing in older people: version 2

Denis O’Mahony, David O'Sullivan, Stephen Byrne … (2014)

Purpose: screening tool of older people's prescriptions (STOPP) and screening tool to alert to right treatment (START) criteria were first published in 2008. Due to an expanding therapeutics evidence base, updating of the criteria was required. Methods: we reviewed the 2008 STOPP/START criteria to add new evidence-based criteria and remove any obsolete criteria. A thorough literature review was performed to reassess the evidence base of the 2008 criteria and the proposed new criteria. Nineteen experts from 13 European countries reviewed a new draft of STOPP & START criteria including proposed new criteria. These experts were also asked to propose additional criteria they considered important to include in the revised STOPP & START criteria and to highlight any criteria from the 2008 list they considered less important or lacking an evidence base. The revised list of criteria was then validated using the Delphi consensus methodology. Results: the expert panel agreed a final list of 114 criteria after two Delphi validation rounds, i.e. 80 STOPP criteria and 34 START criteria. This represents an overall 31% increase in STOPP/START criteria compared with version 1. Several new STOPP categories were created in version 2, namely antiplatelet/anticoagulant drugs, drugs affecting, or affected by, renal function and drugs that increase anticholinergic burden; new START categories include urogenital system drugs, analgesics and vaccines. Conclusion: STOPP/START version 2 criteria have been expanded and updated for the purpose of minimizing inappropriate prescribing in older people. These criteria are based on an up-to-date literature review and consensus validation among a European panel of experts.

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Polypharmacy in elderly patients.

Emily Hajjar, Angela Cafiero, Joseph Hanlon (2007)

Polypharmacy (ie, the use of multiple medications and/or the administration of more medications than are clinically indicated, representing unnecessary drug use) is common among the elderly. The goal of this research was to provide a description of observational studies examining the epidemiology of polypharmacy and to review randomized controlled studies that have been published in the past 2 decades designed to reduce polypharmacy in older adults. Materials for this review were gathered from a search of the MEDLINE database (1986-June 2007) and International Pharmaceutical Abstracts (1986-June 2007) to identify articles in people aged >65 years. We used a combination of the following search terms: polypharmacy, multiple medications, polymedicine, elderly, geriatric, and aged. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. From these, the authors identified those studies that measured polypharmacy. The literature review found that polypharmacy continues to increase and is a known risk factor for important morbidity and mortality. There are few rigorously designed intervention studies that have been shown to reduce unnecessary polypharmacy in older adults. The literature review identified 5 articles, which are included here. All studies showed an improvement in polypharmacy. Many studies have found that various numbers of medications are associated with negative health outcomes, but more research is needed to further delineate the consequences associated with unnecessary drug use in elderly patients. Health care professionals should be aware of the risks and fully evaluate all medications at each patient visit to prevent polypharmacy from occurring.

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Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity.

Lloyd D. Hughes, Marion McMurdo, Bruce Guthrie (2013)

currently one of the major challenges facing clinical guidelines is multimorbidity. Current guidelines are not designed to consider the cumulative impact of treatment recommendations on people with several conditions, nor to allow comparison of relative benefits or risks. This is despite the fact that multimorbidity is a common phenomenon. to examine the extent to which National Institute of Health and Clinical Excellence (NICE) guidelines address patient comorbidity, patient centred care and patient compliance to treatment recommendations. five NICE clinical guidelines were selected for review (type-2 diabetes mellitus, secondary prevention for people with myocardial infarction, osteoarthritis, chronic obstructive pulmonary disease and depression) as these conditions are common causes of comorbidity and the guidelines had all been produced since 2007. Two authors extracted information from each full guideline and noted the extent to which the guidelines accounted for patient comorbidity, patient centred care and patient compliance. The cumulative recommended treatment, follow-up and self-care regime for two hypothetical patients were then created to illustrate the potential cumulative impact of applying single disease recommendations to people with multimorbidity. comorbidity and patient adherence were inconsistently accounted for in the guidelines, ranging from extensive discussion to none at all. Patient centred care was discussed in generic terms across the guidelines with limited disease-specific recommendations for clinicians. Explicitly following guideline recommendations for our two hypothetical patients would lead to a considerable treatment burden, even when recommendations were followed for mild to moderate conditions. In addition, the follow-up and self-care regime was complex potentially presenting problems for patient compliance. clinical guidelines have played an important role in improving healthcare for people with long-term conditions. However, in people with multimorbidity current guideline recommendations rapidly cumulate to drive polypharmacy, without providing guidance on how best to prioritise recommendations for individuals in whom treatment burden will sometimes be overwhelming.

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Author and article information

Contributors

Christine Gulla: Christine.Gulla@uib.no

Elisabeth Flo: Elisabeth.Flo@uib.no

Reidun L. S. Kjome:

ORCID: http://orcid.org/0000-0002-9454-5188

Reidun.kjome@uib.no

Bettina S. Husebo: Bettina.Husebo@uib.no

Journal

Journal ID (nlm-ta): BMC Geriatr

Journal ID (iso-abbrev): BMC Geriatr

Title: BMC Geriatrics

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2318

Publication date (Electronic): 7 May 2019

Publication date PMC-release: 7 May 2019

Publication date Collection: 2019

Volume: 19

Electronic Location Identifier: 130

Affiliations

[1 ]ISNI 0000 0004 1936 7443, GRID grid.7914.b, Centre for Elderly and Nursing Home Medicine, Department of Global Public Health and Primary Care, , University of Bergen, ; Bergen, Norway

[2 ]ISNI 0000 0004 1936 7443, GRID grid.7914.b, Department of Clinical Psychology, , University of Bergen, ; Bergen, Norway

[3 ]ISNI 0000 0004 1936 7443, GRID grid.7914.b, Department of Global Public Health and Primary Care/Centre for pharmacy, , University of Bergen, ; Bergen, Norway

Author information

Reidun L. S. Kjome http://orcid.org/0000-0002-9454-5188

Article

Publisher ID: 1139

DOI: 10.1186/s12877-019-1139-6

PMC ID: 6505068

PubMed ID: 31064365

SO-VID: c0e24076-3145-48d9-8a60-d38b40e2ade0

License:

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 30 June 2018

Date accepted : 18 April 2019

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100005416, Norges Forskningsråd;

Award ID: 222113

Award Recipient : Bettina S. Husebo

Custom metadata

ScienceOpen disciplines: Geriatric medicine

Keywords: medication review,nursing homes,neuropsychiatric symptoms,implementation,symptom assessment,needs assessment,behavioral and psychological symptoms of dementia

Data availability:

ScienceOpen disciplines: Geriatric medicine

Keywords: medication review, nursing homes, neuropsychiatric symptoms, implementation, symptom assessment, needs assessment, behavioral and psychological symptoms of dementia

Implementing a novel strategy for interprofessional medication review using collegial mentoring and systematic clinical evaluation in nursing homes (COSMOS)

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Abstract

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Conclusions

Trial registration

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Hogrefe Medicine

Most cited references 32

STOPP/START criteria for potentially inappropriate prescribing in older people: version 2

Polypharmacy in elderly patients.

Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity.

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