In the Literature
Compared with Australia, New Zealand, and the United Kingdom, U.S. nursing homes have been more successful in preventing or reducing the unnecessary use of psychotropic medications, but less so in promoting best practices of overall appropriate medication use, finds a Commonwealth Fund-supported review of nursing home medication policies in four nations.
Of the four countries, the United States has "led the way in implementing intense regulation and oversight of care provisions in nursing homes," concluded a multinational research team led by Carmel M. Hughes, Ph.D., a former Commonwealth Fund Harkness Fellow based at Queen's University in Belfast. Allegations of abuse and poor-quality care in U.S. nursing homes led to the passage of reforms and stringent regulations aimed at stopping the use of certain drugs as "chemical restraints."In "Improving Use of Medicines for Older People in Long-Term Care: Contrasting the Policy Approach of Four Countries">Healthcare Policy, vol. 3, no. 3, 2008), the team wrote that the regulatory approach taken in the U.S. has proven beneficial in some areas but not in others. The focus on preventing or reducing poor practices has not encouraged appropriate drug use, for example, in heart failure or Parkinson's disease, or in other conditions known to be undertreated in nursing homes.
Snapshot: Four Nations' Approaches
Policies on medication use in residential care vary among the four nations based on historical, funding, and other factors.
U.S.: The regulatory system, implemented to reduce unnecessary psychotropic medication, may issue sanctions for facilities not meeting regulations and other indices of care. The use of a number of quality indicators, including three pertaining to psychotropic drug use, is also reinforced by regulations. Nursing home data are routinely collected and stored in a national repository.
Australia: Australia established an "ambitious and comprehensive framework" for improving use of medicines across the whole community. Medication reviews and guidelines for medication management in nursing homes have been incorporated into accreditation standards. Because of a lack of data, measurement has not been possible.
U.K.: The system is in transition. While national minimum standards regarding medication have been adopted, these are seen as a code of practice lacking statutory force. Appropriate prescribing is not covered explicitly. A 2006 report showed that almost half of nursing homes were not meeting minimum standards relating to medication. Few studies have examined quality of nursing home care in the U.K., perhaps due to a lack of systematic data collection.
New Zealand: Medication policy has been focused on rationalizing drug expenditures. In 2005, a strategy for safe and high-quality use of medicines was released, but it did not specifically address nursing home care. Nursing home standards, including pharmaceutical review for long-term care residents, were released by the health ministry, but funding and other issues have made such reviews sporadic. While certain antipsychotic and other drugs are restricted to specialist prescribing, use of psychotropic drugs has been high historically. In New Zealand, there is an overall lack of data on medication use in nursing homes.
Medication use in nursing homes is problematic in all four nations. An aging population and the emergence of new medicines make it that much more important that providers, regulators, and policymakers understand the processes and systems that support appropriate medication use in nursing homes, the authors say.
"In Australia, New Zealand and the United Kingdom, systematically collected information about medication use in nursing homes is absent, meaning that drawing conclusions about relative success of strategies is problematic," the team wrote. "[D]evelopments in systematic data capture, greater collaboration and educational feedback to prescribers and facilities would represent a major step forward in long-term care in these countries."
While regulation in the U.S. has reduced antipsychotic use to about 20 percent, "U.S. regulation does not appear to encompass processes that may improve drug use more broadly," the team concluded. "In the U.S., development of an educational role for pharmacists, to supplement their regulatory role, may allow greater focus on improving medication use in general."
Framework for Policy Approaches, Selected Measures
|Australia||New Zealand||England||United States|
|Regulatory processes||Accreditation standards included in the Aged Care Act, 1997. Medication processes included in accreditation standards||Standards in place. Specialist required to authorize prescribing of atypical antipsychotic agents.||Care standards laid down under legislation.||OBRA legislation. Quality indicators|
|Institutional processes||Pharmacist reviews. Safe administration of medication part of accreditation. Medication Advisory committees recommended||Pharmacist review no longer in place. Inspections do not assess medication- related standards||Inspection as part of accreditation against care standards.||Nursing home auditors assess compliance with OBRA. Sanctions and payments linked to compliance|
|Medication monitoring process||None||None||None||MDS information, plus consultant pharmacist input.|
|Impact of national approach on prescribing||Reduction of hypnotics and anxiolytics, increased antidepressants. Antipsychotics persistently high.||Impact unclear.||Less than half of nursing homes meet medication- related code of practice.||Reduced poor practice with lower antipsychotic use. Reduced hypnotic and anxiolytic use.|
|Source: Adapted from C. M Hughes, E. Roughead, and N. Kerse, "Improving Use of Medicines for Older People in Long-Term Care: Contrasting the Policy Approach of Four Countries," Healthcare Policy, 2008 3(3):37-51.|