Evaluation of nationally mandated drug use reviews to improve patient safety in nursing homes: a natural experiment.
OBJECTIVE
To test whether nationally required drug use reviews reduce exposure to inappropriate medications in nursing homes.


METHODS
Quasi-experimental, longitudinal study.


METHODS
Data source is the 1997-2000 Medicare Current Beneficiary Survey, a nationally representative survey of Medicare beneficiaries.


METHODS
Nationally representative population sample of 8 million nursing home (NH) residents (unweighted n=2,242) and a comparative group of 2 million assisted living facility (ALF) residents (unweighted n=664).


METHODS
Prevalence and incident use of 38 potentially inappropriate medications compared before and after the policy: 32 restricted for all NH residents and six for residents with certain conditions. Inappropriate medications were stratified by potential for legitimate exceptions: always avoid, rarely appropriate, or some acceptable indications.


RESULTS
In July 1999, the Centers for Medicare and Medicaid Services (CMS) mandated expansions to the drug use review policy for nursing home certification. Using explicit criteria, surveyors and consultant pharmacists must evaluate resident records for potentially inappropriate medication exposures and related adverse drug reactions. Nursing homes in noncompliance may receive citations for deficient care. Before the CMS policy, 28.8% (95% confidence interval (CI)=27.3-30.3) of Medicare beneficiaries in NHs and 22.4% (95% CI=19.8-25.0) in ALFs received potentially inappropriate medications. Nearly all prepolicy use came from medications with some acceptable indications: 23.4% in NHs (95% CI=20.4-26.4) and 18.0% in ALFs (95% CI=15.6-20.4). After the policy, exposures in NHs declined to 25.6% (95% CI=24.1-27.1, P<.05), but similar declines occurred in ALFs (19.0%, 95% CI=16.7-21.3, nonsignificant). Postpolicy use of inappropriate medications with exempted indications remained high, and more than half was incident use: 20.6% of NH residents (95% CI=19.0-22.0) and 15.6% of ALF residents (95% CI=15.2-15.7). Use of drugs that are restricted with certain diseases increased 33% in NHs between 1997 and 2000 (from 9.3% to 13.2%; P<.05). Multivariate results detected no postpolicy differences in inappropriate drug use between long-term care facilities with mandatory drug use reviews and those without.


CONCLUSIONS
Some postpolicy declines were noted in NH use of potentially inappropriate medications, but the decrease was uneven and could not be attributed to the national drug use reviews. This study is the first evaluation of the CMS policy, and it highlights the unclear effectiveness of drug use reviews to improve patient safety in NHs even though state and federal agencies have widely adopted this strategy.
Briesacher
Becky
B
Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, MA 01605, USA. Becky.Briesacher@umassmed.edu
Limcangco
Rhona
R
Simoni-Wastila
Linda
L
Doshi
Jalpa
J
Gurwitz
Jerry
J
D000368:Aged; D000369:Aged, 80 and over; D017723:Drug Utilization Review; D005260:Female; D006707:Homes for the Aged / Q000458:organization & administration / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D008137:Longitudinal Studies; D008297:Male; D037141:Mandatory Programs; D006278:Medicare / Q000706:statistics & numerical data; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D009735:Nursing Homes / Q000458:organization & administration / Q000706:statistics & numerical data*; D015995:Prevalence; D011785:Quality Assurance, Health Care / Q000379:methods*; D017751:Safety Management / Q000379:methods*; D014481:United States