Variation in Provision of Collaborative Medication Reviews on Entry to Long-Term Care Facilities

National surveillance using a clinical quality indicator for prolonged antipsychotic use among older Australians with dementia who access aged care services

OBJECTIVES

Dementia guidelines recommend antipsychotics are only used for behavioral and psychological symptoms when non-drug interventions fail, and to regularly review use. Population-level clinical quality indicators (CQIs) for dementia care in permanent residential aged care (PRAC) typically monitor prevalence of antipsychotic use but not prolonged use. This study aimed to develop a CQI for antipsychotic use >90 days and examine trends, associated factors, and variation in CQI incidence; and examine duration of the first episode of use among individuals with dementia accessing home care packages (HCPs) or PRAC.

METHODS

Retrospective cohort study, including older individuals with dementia who accessed HCPs (n = 50,257) or PRAC (n = 250,196). Trends in annual CQI incidence (2011-12 to 2015-16) and associated factors were determined using Poisson regression. Funnel plots examined geographical and facility variation. Time to antipsychotic discontinuation was estimated among new antipsychotic users accessing HCP (n = 2367) and PRAC (n = 15,597) using the cumulative incidence function.

RESULTS

Between 2011-12 and 2015-16, antipsychotic use for >90 days decreased in HCP recipients from 10.7% (95% CI 10.2-11.1) to 10.1% (95% CI 9.6-10.5, adjusted incidence rate ratio (aIRR) 0.97 (95% CI 0.95-0.98)), and in PRAC residents from 24.5% (95% CI 24.2-24.7) to 21.8% (95% CI 21.5-22.0, aIRR 0.97 (95% CI 0.96-0.98)). Prior antipsychotic use (both cohorts) and being male and greater socioeconomic disadvantage (PRAC cohort) were associated with higher CQI incidence. Little geographical/facility variation was observed. Median treatment duration in HCP and PRAC was 334 (interquartile range [IQR] 108-958) and 555 (IQR 197-1239) days, respectively.

CONCLUSIONS

While small decreases in antipsychotic use >90 days were observed between 2011-12 and 2015-16, findings suggest antipsychotic use among aged care recipients with dementia can be further minimized.

Comparison of polypharmacy and potentially inappropriate medication use in older adults with and without dementia receiving residential medication management reviews

OBJECTIVES

Among residents who had a residential medication management review (RMMR), there is a lack of studies assessing exposure to polypharmacy and potentially inappropriate medications (PIMs) in people with dementia. This study compared the exposure to polypharmacy and PIMs in residents with dementia and without dementia receiving RMMR.

METHODS

A retrospective analysis was performed using data of 16,261 residents living in 343 Australian residential aged care facilities who had an RMMR in 2019. Medication use was assessed as polypharmacy (defined as ≥9 medications) and use of ≥1 PIMs using the 2019 updated Beers criteria. Dementia diagnosis was determined with ICD-10 coding from medical records. Descriptive analyses reported resident demographics and patterns of medication use. Pearson's χ2 tests and logistic regression analysis were conducted to compare medication exposure between residents with and without dementia.

RESULTS

Among 16,261 residents, 6781 (42%) had dementia. Residents with dementia were significantly more likely to be exposed to polypharmacy and PIMs, compared to those without dementia (74% vs. 70% and 83% vs. 73%, p < .001 respectively). Residents with dementia had 1.31 times the odds of exposure to polypharmacy (adjusted OR: 1.31, 95% CI: 1.22-1.41, p < .001) and 1.88 times the odds of being prescribed ≥1 PIMs than people without dementia (adjusted OR: 1.88, 95% CI: 1.73-2.04, p < .001).

CONCLUSIONS

In a study of residents receiving RMMR, polypharmacy and PIMs were highly common, and those with dementia were more likely to be exposed to inappropriate polypharmacy. There is a need for targeted deprescribing strategies to immediately address inappropriate prescribing in residents, particularly those living with dementia.

Embedded on-site aged care pharmacists in Australia: Insights from early adopters of a new workforce model

OBJECTIVE

To explore the roles of early adopters of Australia's embedded on-site pharmacist model in supporting quality use of medications in residential aged care facilities (RACFs).

METHODS

Qualitative semistructured interviews were conducted with 15 pharmacists working as embedded on-site pharmacists, or beyond the scope of traditional consultant pharmacist roles in Australian RACFs. Interviews were audio-recorded, transcribed and thematically analysed independently by two investigators using an inductive approach. Deductive analysis was also undertaken using a knowledge broker framework: knowledge manager, linkage agent and capacity builder.

RESULTS

Dominant themes were roles and benefits of embedded pharmacists, factors associated with success and challenges. Roles and benefits included (1) resident-level interventions and an enhanced ability to provide collaborative outcome-focussed resident-centred care, including timely input and follow-up, and improved relationships with residents, family and interdisciplinary team; and (2) system-level interventions such as contributing to clinical governance and quality improvement. Factors associated with success included personal capabilities and approach of the pharmacist, and organisational culture and sector-wide support. Challenges included pharmacist workforce shortages, perceived lack of pharmacist readiness and difficulty determining an appropriate service model. Deductive coding demonstrated roles of embedded pharmacists were consistent with all three activities of a knowledge broker.

CONCLUSIONS

This study highlights the resident- and system-level roles and benefits of embedded on-site pharmacists, and provides a framework for defining this emerging workforce model in Australian RACFs.

Symptomatic and preventive medication use according to age and frailty in Australian and Japanese nursing homes

OBJECTIVE

To investigate symptomatic and preventive medication use according to age and frailty in Australian and Japanese nursing homes (NHs).

METHODS

Secondary cross-sectional analyses of two prospective cohort studies involving 12 Australian NHs and four Japanese NHs. Frailty was measured using the FRAIL-NH scale (non-frail 0-2; frail 3-6; most-frail 7-14). Regular medications were classified as symptomatic or preventive based on published lists and expert consensus. Descriptive statistics were used to compare the prevalence and ratio of symptomatic to preventive medications.

RESULTS

Overall, 550 Australian residents (87.7 ± 7.3 years; 73.3% females) and 333 Japanese residents (86.5 ± 7.0 years; 73.3% females) were included. Australian residents used a higher mean number of medications than Japanese residents (9.8 ± 4.0 vs 7.7 ± 3.7, p < 0.0001). Australian residents used more preventive than symptomatic medications (5.5 ± 2.5 vs 4.3 ± 2.6, p < 0.0001), while Japanese residents used more symptomatic than preventive medications (4.7 ± 2.6 vs 3.0 ± 2.2, p < 0.0001). In Australia, symptomatic medications were more prevalent with increasing frailty (non-frail 3.4 ± 2.6; frail 4.0 ± 2.6; most-frail 4.8 ± 2.6, p < 0.0001) but less prevalent with age (< 80 years 5.0 ± 2.9; 80-89 years 4.4 ± 2.6; ≥ 90 years 3.9 ± 2.5, p = 0.0042); while preventive medications remained similar across age and frailty groups. In Japan, there was no significant difference in the mean number of symptomatic and preventive medications irrespective of age and frailty.

CONCLUSIONS

The ratio of symptomatic to preventive medications was higher with increasing frailty but lower with age in Australia; whereas in Japan, the ratio remained consistent across age and frailty groups. Preventive medications remained prevalent in most-frail residents in both cohorts, albeit at lower levels in Japan.

Impact of on-site pharmacists in residential aged care facilities on the quality of medicines use: a cluster randomised controlled trial (PiRACF study)

Residents of residential aged care facilities (RACFs) have a high prevalence of use of potentially inappropriate medications (PIMs) and resultant medicines-related harm. This study investigated the effect of an on-site pharmacist model on PIMs use and other medication outcomes for residents in RACFs. A multi-facility, non-blind, cluster randomised controlled trial, with randomisation at the facility level, was conducted. Fifteen facilities enrolled and participated in the study, 7 facilities (560 residents) were allocated to the intervention arm and 8 facilities (737 residents) were allocated to the control arm. Each facility in the intervention arm employed an on-site pharmacist for 12 months to perform medication management activities as part of an interdisciplinary care team. The primary outcome was the proportion of residents taking at least one PIM according to the 2019 Beers® Criteria. Using generalised linear mixed-effects models, accounting for confounders and clustering, there was a significant reduction in the proportion of residents prescribed at least one PIM (odds ratio 0.50, 95% confidence interval, 0.335-0.750; p = 0.001) in the intervention arm. There were also significant decreases in the Anticholinergic Cognitive Burden scale and chlorpromazine equivalent daily dose of antipsychotics. The on-site pharmacist intervention significantly improved the appropriateness of medicines use in RACFs.

The role of on-site pharmacist in residential aged care facilities: findings from the PiRACF study

BACKGROUND

Residents in residential aged care facilities (RACFs) have a high number of medication-related problems. Integrating on-site pharmacists (OSPs) into this setting is a possible solution and is currently gaining traction in Australia and internationally. The Pharmacists in Residential Aged Care Facilities (PiRACF) cluster-randomised controlled trial integrated pharmacists into the RACF care team to improve medication management. The aim of this descriptive observational study is to explore the activities of OSPs when they are integrated into multidisciplinary care team in RACFs.

METHOD

An online survey tool was developed to record the activities of OSPs in RACFs using the Qualtrics© software. OSPs were asked questions about their activities in RACFs under categories that included description, time spent, outcomes where applicable and who the pharmacists communicated with to undertake the activity.

RESULTS

Six pharmacists were integrated into 7 RACFs. Overall, they recorded 4252 activities over 12 months. OSPs conducted 1022 (24.0%) clinical medication reviews; 48.8% of medication reviews identified and discussed potentially inappropriate medications with prescribers and 1025 other recommendations were made to prescribers. Overall, the prescriber accepted 51.5% of all recommendations made by OSPs. The most frequently accepted outcome was deprescribing of medications (47.5% for potentially inappropriate medications and 55.5% for other recommendations). OSPs performed facility-level activities including staff education (13.4%), clinical audits (5.8%), and quality improvement activities (9.4%). OSPs spent a large proportion of their time communicating (23.4%) extensively with prescribers, RACF's healthcare team, and residents.

CONCLUSION

OSPs successfully performed a wide range of clinical activities aimed both at improving residents' medication regimens, and organisational-level quality improvement. The OSP model presents an opportunity for pharmacists to enhance medication management in the residential aged care setting. Trial registration The trial was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN: ACTRN12620000430932) on April 1, 2020.

Registry of Senior Australians (ROSA): integrating cross-sectoral information to evaluate quality and safety of care provided to older people

PURPOSE

The Registry of Senior Australians (ROSA) was established to evaluate aged care experiences in Australia. In this manuscript, we describe the ROSA framework, the two ROSA cohorts, highlights from research findings, and future plans.

PARTICIPANTS

The South Australian ROSA Prospective Cohort (August 2018-June 2020) enrolled 26 605 participants, of which 59.2% (N=15 745) are women, with a median age of 83 (interquartile range (IQR) 77-88). The National ROSA Historical Cohort (January 2002-June 2020) includes 1 694 206 participants with an aged care eligibility assessment, of which 59.1% (N=1 001 705) are women and the median age is 78 (IQR 72-83).

FINDINGS TO DATE

Most research using the ROSA has focused on dementia, service accessibility, quality and safety of care, falls and injuries and quality use of medicines. The ROSA has also examined the experience of individuals with highly prevalent and understudied conditions in aged care settings (eg, eye and mental health) and aspects of services (eg, built environment) and innovation (eg, mobile radiological services) that can affect older people's health. Important learnings from the ROSA's development include the significant resources and multidisciplinary expertise required for establishing this platform. Between 2018 and 2022, 43 academic publications, eight reports of the Australian Government Royal Commission into Aged Care Quality and Safety, and several reports to state health authorities and professional societies have used the ROSA.

FUTURE PLANS

Our plans include to: (1) continue delivering high-quality evidence to support the improvement of ageing and aged care services; (2) influence and improve the quality of research in and for the aged care sector; (3) expand scope to facilitate examining aims in more depth; (4) include future aged care sector data collections within the ROSA; (5) inform best practices and innovate how consumer engagement occurs in research; (6) monitor and evaluate the impact of the 2021 Australian Aged Care Reforms.

Primary and Secondary Care Related Quality Indicators for Dementia Care Among Australian Aged Care Users: National Trends, Risk Factors, and Variation

Background: Studies related to clinical quality indicators (CQIs) in dementia have focused on hospitalizations, medication management, and safety. Less attention has been paid to indicators related to primary and secondary care. Objective: To evaluate the incidence of primary and secondary care CQIs for Australians with dementia using government-subsidized aged care. The examined CQIs were: comprehensive medication reviews, 75+ health assessments, comprehensive geriatric assessments, chronic disease management plans, general practitioner (GP) mental health treatment plans, and psychiatrist attendances. Methods: Retrospective cohort study (2011–2016) of 255,458 individuals. National trend analyses estimated incidence rates and 95% confidence intervals (CI) using Poisson or negative binomial regression. Associations were assessed using backward stepwise multivariate Poisson or negative binomial regression model, as appropriate. Funnel plots examined geographic and PRAC facility variation. Results: CQI incidence increased in all CQIs but medication reviews. For the overall cohort, 75+ health assessments increased from 1.07/1000 person-days to 1.16/1000 person-days (adjusted incidence rate ratio (aIRR) = 1.03, 95% CI 1.02–1.03).Comprehensive geriatric assessments increased from 0.24 to 0.37/1000 person-days (aIRR = 1.12, 95% CI 1.10–1.14). GP mental health treatment plans increased from 1.30 to 2.1/1000 person-days (aIRR = 1.13, 95% CI 1.12–1.15). Psychiatric attendances increased from 0.09 to 0.11/1000 person-days (aIRR = 1.05, 95% CI 1.03–1.07). Being female, older, having fewer comorbidities, and living outside a major city were associated with lower likelihood of using the services. Large geographical and facility variation was observed (0–92%). Conclusion: Better use of primary and secondary care services to address needs of individuals with dementia is urgently needed.

Provision of a comprehensive medicines review is associated with lower mortality risk for residents of aged care facilities: a retrospective cohort study

Background

no studies have examined the impact of residential medication management review (RMMR, a 24-year government subsidised comprehensive medicines review program) in Australian residential aged care facilities (RACFs) on hospitalisation or mortality.

Objective

to examine associations between RMMR provision in the 6–12 months after RACF entry and the 12-month risk of hospitalisation and mortality among older Australians in RACFs.

Design

retrospective cohort study.

Subjects

individuals aged 65–105 years taking at least one medicine, who entered an RACF in three Australian states between 1 January 2012 and 31 December 2015 and spent at least 6 months in the RACF (n = 57,719).

Methods

Cox regression models estimated adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) for associations between RMMR provision and mortality. Adjusted subdistribution hazard ratios were estimated for associations between RMMR provision and next (i) emergency department (ED) presentation or unplanned hospitalisation or (ii) fall-related ED presentation or hospitalisation.

Results

there were 12,603 (21.8%) individuals who received an RMMR within 6–12 months of RACF entry, of whom 22.2% (95%CI 21.4–22.9) died during follow-up, compared with 23.3% (95%CI 22.9–23.7) of unexposed individuals. RMMR provision was associated with a lower risk of death due to any cause over 12-months (aHR 0.96, 95%CI 0.91–0.99), but was not associated with ED presentations or hospitalisations for unplanned events or falls.

Conclusions

provision of an RMMR in the 6–12 months after RACF entry is associated with a 4.4% lower mortality risk over 12-months but was not associated with changes in hospitalisations for unplanned events or falls.

Medicines use before and after comprehensive medicines review among residents of long-term care facilities: a retrospective cohort study

Background

Residential Medication Management Review (RMMR) is a subsidized comprehensive medicines review program for individuals in Australian residential aged care facilities (RACFs). This study examined weekly trends in medicines use in the four months before and after an RMMR and among a comparison group of residents who did not receive an RMMR.

Methods

This retrospective cohort study included individuals aged 65 to 105 years who first entered permanent care between 1/1/2012 and 31/12/2016 in South Australia, Victoria, or New South Wales, and were taking at least one medicine. Individuals with an RMMR within 12 months of RACF entry were classified into one of three groups: (i) RMMR within 0 to 3 months, (ii) 3 to 6 months, or (iii) within 6 to 12 months of RACF entry. Individuals without RMMRs were included in the comparison group. Weekly trends in the number of defined daily doses per 1000 days were determined in the four months before and after the RMMR (or assigned index date in the comparison group) for 14 medicine classes.

Results

113909 individuals from 1979 RACFs were included, of whom 55021 received an RMMR. Across all three periods examined, decreased use of statins and proton pump inhibitors was observed post-RMMR in comparison to those without RMMRs. Decreases in calcium channel blockers, benzodiazepines/zopiclone, and antidepressants were observed following RMMR provision in the 3–6 and 6–12 months after RACF entry. Negligible changes in antipsychotic use were also observed following an RMMR in the 6–12 months after RACF entry by comparison to those without RMMRs. No changes in use of opioids, ACE inhibitors/sartans, beta blockers, loop diuretics, oral anticoagulants, or medicines for osteoporosis, diabetes or the cognitive symptoms of dementia were observed post-RMMR.

Conclusions

For six of the 14 medicine classes investigated, modest changes in weekly trends in use were observed after the provision of an RMMR in the 6–12 months after RACF entry compared to those without RMMRs. Findings suggest that activities such as medicines reconciliation may be prioritized when an RMMR is provided on RACF entry, with deprescribing more likely after an RMMR the longer a resident has been in the RACF.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03187-0.

How Do Pharmacists Practice in Aged Care? A Narrative Review of Models from Australia, England, and the United States of America

Medication management in residential aged care facilities (RACFs) is complex and often sub-optimal. Pharmacist practice models and services have emerged internationally to address medication-related issues in RACFs. This narrative review aimed to explore pharmacist practice models in aged care in Australia, England and the USA, and identify key activities and characteristics within each model. A search strategy using key terms was performed in peer-reviewed databases, as well as the grey literature. Additionally, experts from the selected countries were consulted to obtain further information about the practice models in their respective countries. Thirty-six documents met the inclusion criteria and were included in the review. Four major pharmacist practice models were identified and formed the focus of the review: (1) the NHS’s Medicine Optimisation in Care Homes (MOCH) program from England; (2) the Australian model utilising visiting accredited pharmacists; (3) the Centers for Medicare and Medicaid (CMS) pharmacy services in long-term care from the USA; and (4) the Medication Therapy Management (MTM) program from the USA. Medication reviews were key activities in all models, but each had distinct characteristics in relation to the comprehensiveness, who is eligible, and how frequently residents receive medication review activity. There was heterogeneity in the types of facility-level activities offered by pharmacists, and further research is needed to determine the effectiveness of these activities in improving quality use of medicines in the aged care setting. This review found that in some models, pharmacists have a limited level of collaboration with other healthcare professionals, emphasising the need to trial innovative models with integrated services and increased collaboration to achieve a holistic patient-centred approach to medication management.

National Trends and Policy Impacts on Provision of Home Medicines Reviews and Residential Medication Management Reviews in Older Australians, 2009-2019

Comprehensive medicines reviews such as Home Medicines Review (HMR) and Residential Medication Management Review (RMMR) can resolve medicines-related problems. Changes to Australia’s longstanding HMR and RMMR programs were implemented between 2011 and 2014. This study examined trends in HMR and RMMR provision among older Australians during 2009–2019 and determined the impact of program changes on service provision. Monthly rates of general medical practitioner (GP) HMR claims per 1000 people aged ≥65 years and RMMR claims per 1000 older residents of aged care facilities were determined using publicly available data. Interrupted time series analysis was conducted to examine changes coinciding with dates of program changes. In January 2009, monthly HMR and RMMR rates were 0.80/1000 older people and 20.17/1000 older residents, respectively. Small monthly increases occurred thereafter, with 1.89 HMRs/1000 and 34.73 RMMRs/1000 provided in February 2014. In March 2014, immediate decreases of –0.32 (95%CI –0.52 to –0.11) HMRs/1000 and –12.80 (95%CI –15.22 to –10.37) RMMRs/1000 were observed. There were 1.07 HMRs/1000 and 35.36 RMMRs/1000 provided in December 2019. In conclusion, HMR and RMMR program changes in March 2014 restricted access to subsidized medicines reviews and were associated with marked decreases in service provision. The low levels of HMR and RMMR provision observed do not represent a proactive approach to medicines safety and effectiveness among older Australians.

Process Evaluation of the SImplification of Medications Prescribed to Long-tErm Care Residents (SIMPLER) Cluster Randomized Controlled Trial: A Mixed Methods Study

Complex medication regimens are highly prevalent, burdensome for residents and staff, and associated with poor health outcomes in residential aged care facilities (RACFs). The SIMPLER study was a non-blinded, matched-pair, cluster randomized controlled trial in eight Australian RACFs that investigated the one-off application of a structured 5-step implicit process to simplify medication regimens. The aim of this study was to explore the processes underpinning study implementation and uptake of the medication simplification intervention. A mixed methods process evaluation with an explanatory design was undertaken in parallel with the main outcome evaluation of the SIMPLER study and was guided by an established 8-domain framework. The qualitative component included a document analysis and semi-structured interviews with 25 stakeholders (residents, family, research nurses, pharmacists, RACF staff, and a general medical practitioner). Interviews were transcribed verbatim and reflexively thematically content analyzed. Descriptive statistics were used to summarize quantitative data extracted from key research documents. The SIMPLER recruitment rates at the eight RACFs ranged from 18.9% to 48.6% of eligible residents (38.4% overall). Participation decisions were influenced by altruism, opinions of trusted persons, willingness to change a medication regimen, and third-party hesitation regarding potential resident distress. Intervention delivery was generally consistent with the study protocol. Stakeholders perceived regimen simplification was beneficial and low risk if the simplification recommendations were individualized. Implementation of the simplification recommendations varied between the four intervention RACFs, with simplification implemented at 4-month follow-up for between 25% and 86% of residents for whom simplification was possible. Good working relationships between stakeholders and new remunerated models of medication management were perceived facilitators to wider implementation. In conclusion, the one-off implicit medication simplification intervention was feasible and generally delivered according to the protocol to a representative sample of residents. Despite variable implementation, recommendations to simplify complex regimens were valued by stakeholders, who also supported wider implementation of medication simplification in RACFs.

What Is the Community Pharmacists' Role in Supporting Older Australians with Palliative Care Needs?

As the population ages, the number of older populations globally requiring palliative care is rapidly growing, requiring services of multidisciplinary teams—including community pharmacists. The aim of this study is to describe the community pharmacists’ perceived role in providing services to community dwelling older Australians receiving palliative care. Utilising an eight-domain End of Life Directions for Aged Care (ELDAC) care model, a national cross-sectional questionnaire was designed and undertaken online with Australian community pharmacists. Respondents were asked questions relating to socio-demographic characteristics, practice characteristics, and scope of services provided. Of the 62 pharmacists who responded to the questionnaire, 51 were included in the final data analysis and reporting. Pharmacists working in dispensing roles made up about half of the respondents, while the remainder worked in settings such as general practice, residential aged care, or providing medication review services. Pharmacists can identify patients with indicators of poor life expectancy and mostly work with older Australians daily. Dispensing and non-dispensing pharmacists offer a range of services that complement each other. Organisations caring for the aged should consider the role of the pharmacist, in caring for people with palliative care needs, along with their carers.