Abstract
BackgroundQuality use of medicines for the elderly is key to preventing adverse health effects, especially for residents of residential aged care facilities (RACFs). Potentially inappropriate medications increase the risk of hospitalisation and adverse drug events. This PhD research program first explored the literature on how pharmacists practise in aged care and identifies services and their characteristics. As part of a clustered randomised controlled trial of integrating pharmacists into the healthcare team of residential aged care facilities (PiRACF study), this research assessed the extent of potentially inappropriate medications prescribing and associated risk factors amongst residents of aged care facilities. Research was undertaken to examine the activities of on-site pharmacists (OSPs) when they are integrated as part of the multidisciplinary team in RACFs. The research also examined the impact of the OSP model on key quality use of medicines indicators in RACFs.
Method
Four studies were conducted to address the objectives of the research. In study 1, a literature review, including grey literature, was conducted. Peer-reviewed databases (PubMed and EMBASE) were searched for terms that describe the selected models and clinical services. Study 2 used a cross-sectional analysis of the baseline data involving 15 RACFs from the PiRACF study. The Beers® 2019 criteria were used to evaluate residents’ use of potentially inappropriate medications (PIMs). The third study explored the role and activities of OSPs as part of the RACFs multidisciplinary team. An online activity diary was developed to record the activities conducted and how pharmacists spend their time when they are practising as OSPs in RACFs. Study 4 assessed the impact of OSPs intervention on key QUM outcomes including residents’ exposure to PIMs and psychotropic medicines (defined as antipsychotics and benzodiazepines), and the Anticholinergic Cognitive Burden (ACB) score. The study utilised generalised linear mixed models (GLMMs) to compare outcome variables between intervention and control groups.
Results
In study 1, the literature review identified four major pharmacist practice models from Australia, England and the United States of America. Medication reviews were key activities in all models, but 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. The cross-sectional analysis of 1368 residential care participants in study 2 revealed most residents (68.1%) were prescribed at least one regular PIM, 16.9% were taking regular antipsychotics and 11.1% were taking regular benzodiazepines. Long-term proton pump inhibitors were the most frequent class of PIMs. History of falls and higher Charlson Comorbidity Index (CCI), and residents in facilities with lower nurse-to-resident ratios were associated with an increased number of prescribed PIMs (p <0.05). Study 3 analysed 4253 activities by six OSPs over the 12-month period of the intervention. OSPs conducted 1022 (24.0%) comprehensive medication reviews and performed various facilities-level activities including education (13.4%), clinical audits (5.8%) and quality improvement activities (9.3%). In study 4, using generalised linear mixed models, results showed there was a significant reduction with the intervention arm in the proportion of residents prescribed at least one PIM (odds ratio 0.50, 95% confidence interval [CI], 0.335–0.750, p = 0.001). There were also reductions, per resident, in ACB score (relative risk 0.800, 95% CI, 0.678–0.944, p = 0.008) and chlorpromazine equivalent daily dose of antipsychotics (B Coeff −.250, 95% CI, −0.456 to −.043, p = 0.018).
Conclusion
In spite of initiatives aimed at enhancing the Quality Use of Medicines (QUM), this body of research reaffirmed the use of potentially inappropriate medications remains high in RACFs, necessitating a need to trial interventions that focus on residents at highest risk. The OSPs from the PiRACF study successfully performed a wide range of clinical activities aimed both at improving residents’ medication regimens, as well as organisational-level quality improvement. The main findings of the PiRACF study demonstrate that the OSP intervention improved the appropriateness of medicines use in RACFs by successfully reducing residents’ exposure to PIMs and anticholinergic burden. The OSP model presents an opportunity for pharmacists to enhance medication management and safety in the residential aged care setting.
| Date of Award | 2024 |
|---|---|
| Original language | English |
| Supervisor | Sam KOSARI (Supervisor), Mark NAUNTON (Supervisor) & Rachel DAVEY (Supervisor) |