Time to change care home resident management: reflections on a GP-led service

Barriers and enablers to deprescribing in long-term care: A qualitative investigation into the opinions of healthcare professionals in Ireland

INTRODUCTION

The prevalence of polypharmacy increases with age, increasing the exposure of older adults to potentially inappropriate medications (PIMs). Deprescribing has been shown to reduce PIMs for older residents in long-term care; however, deprescribing is not universally implemented. This study aims to identify the barriers and enablers to deprescribing in Irish long-term care facilities from the healthcare professionals' (HCPs) perspective.

METHODS

A qualitative descriptive approach was conducted using semi-structured interviews with HCPs working in long-term care (general practitioners, pharmacists and nurses). Purposive sampling with maximum variation was applied to select long-term care sites to identify HCPs, supplemented with convenience sampling of post-graduate HCPs from University College Cork. Data was thematically analysed and mapped to a framework of deprescribing barriers and enablers informed by the Theoretical Domains Framework.

RESULTS

Twenty-six HCPs participated from 13 long-term care facilities. The main barriers and enablers identified mapped to five domains. Barriers included insufficient resources, lack of co-ordination between healthcare settings and negative social influences. Additional barriers exist in private settings including deprescribing awareness, commitment and the need for incentives. Deprescribing enablers included interprofessional support and patient social influence. To encourage deprescribing, potential enablers include HCP education, pharmacist role expansion and tailored deprescribing guidelines within a structured process.

CONCLUSION

Interventions to support deprescribing should build on existing systems, involve stakeholders and utilise guidelines within a structured process. Any intervention must account for the nuanced barriers and enablers which exist in both public and private settings.

Antimicrobial stewardship in care homes: outcomes of importance to stakeholders

BACKGROUND

Heterogeneity of outcomes measured in trials to improve antimicrobial stewardship (AMS) in care homes has compromised quality of evidence. A core outcome set (COS) is needed to facilitate interpretation and synthesis of evidence in this area.

AIM

To determine outcomes deemed important by relevant stakeholders for interventions aimed at improving AMS in care homes, and to produce a refined list of outcomes that could be considered for use in future research.

METHODS

Semi-structured face-to-face or telephone interviews were conducted with key stakeholders. Outcomes reported in previous randomized controlled trials (RCTs) of AMS in care homes were included in a topic guide for interviews. Content analysis was undertaken to identify potential outcomes suggested by participants, followed by further review.

FINDINGS

Twenty-seven outcomes reported in RCTs were refined into a list of 12 overarching outcomes. Interviews with participants (six researchers, 31 healthcare professionals, and four family members of care home residents) identified 40 additional outcomes that were important to them. From these 52 outcomes, the total number of antimicrobials, the appropriateness of antimicrobial prescribing and adherence to guidelines were highlighted by most participants. After reviewing all 52 outcomes, a refined list of 14 outcomes potentially feasible for use in AMS trials in care homes was generated.

CONCLUSION

s: A number of potential outcomes for AMS in care homes, some of which had not been reported in previous studies, were identified. The refined list of 14 outcomes will be used in a future study to agree a COS for care home AMS trials.

The use of physiotherapy in nursing homes internationally: A systematic review

BACKGROUND

Physiotherapy can improve functional ability, prevent falls and reduce pain for older adults in nursing homes. However, there are no legislations or guidelines that specify the parameters of physiotherapy required in nursing homes. With the increasing healthcare demands of ageing populations worldwide, it is important to understand the current use of physiotherapy services to ensure they are both evidence-based and promote equity.

OBJECTIVES

(1) When and how are physiotherapy services used by older adults living in nursing homes? (2) What are the factors associated with use of physiotherapy services in nursing homes? (3) How are physiotherapy services in nursing homes documented and monitored?

METHODS

Several databases and grey literature (including MEDLINE, PubMed, Pedro and EMBASE) were searched following PRISMA guidelines in March 2018. Searches were limited to English language publications from 1997. Assessment for inclusion, data extraction and quality assessment were completed by two investigators independently using standardised forms. Studies were included if they considered any type of physiotherapy service that involved a qualified physiotherapist (such as exercise, massage and staff education) with older adults (aged 60 years and older) that were primarily permanent residents of a nursing home. Data extracted included proportion of clients that used physiotherapy services, type, frequency and duration of physiotherapy services, and factors associated with physiotherapy service use.

RESULTS

Eleven studies were included. Between 10% and 67% of nursing home clients used physiotherapy services. Factors associated with greater use of physiotherapy services included larger size facilities, and if clients had a physical impairment and mild or no cognitive impairment. Types of physiotherapy services reported were pain management and pressure ulcer management.

CONCLUSIONS

Physiotherapy service use in nursing homes varied widely. The development of physiotherapy benchmarks and quality standards are needed to support older adults in nursing homes. PROSPERO registration number: CRD42018082460.

Evidence of a care home effect on antibiotic prescribing for those that transition into a care home: a national data linkage study

We compared antibiotic prescribing to older people in different settings to inform antibiotic stewardship interventions. We used data linkage to stratify individuals aged 65 years and over in Northern Ireland, 1st January 2012–31st December 2013, by residence: community dwelling, care home dwelling or ‘transitioned’ if admitted to a care home. The odds of being prescribed an antibiotic by residence were analysed using logistic regression, adjusting for patient demographics and selected medication use (proxy for co-morbidities). Trends in monthly antibiotic prescribing were examined in the 6 months pre- and post-admission to the care home. The odds of being prescribed at least one antibiotic were twofold higher in care homes compared with community dwellers (adjusted odds ratio 2.05, 95% CI 1.93–2.17). There was a proportionate increase of 51.5% in the percentage prescribed an antibiotic on admission, with a monthly average of 23% receiving an antibiotic in the 6 months post admission. While clinical need likely accounts for some of the observed antibiotic prescribing in care homes we cannot rule out more liberal prescribing, given the twofold difference between care home residents and their community dwelling peers having accounted for co-morbidities. The appropriateness of antibiotic prescribing in the care home setting should be examined.