title: Interventions to improve suboptimal prescribing in nursing homes: A narrative review.
abstract: BACKGROUND
  Appropriate medication prescribing for nursing home residents remains a challenge.
  
  
  OBJECTIVE
  The purpose of this study was to conduct a narrative review of the published literature describing randomized controlled trials that used interventions to improve suboptimal prescribing in nursing homes.
  
  
  METHODS
  The PubMed, International Pharmaceutical Abstracts, and EMBASE databases were searched for articles published in the English language between January 1975 and December 2009, using the terms drug utilization, pharmaceutical services, aged, long-term care, nursing homes, prescribing, geriatrics, and randomized controlled trial. A manual search of the reference lists of identified articles and the authors' files, book chapters, and recent review articles was also conducted. Abstracts and posters from meetings were not included in the search. Studies were included if they: (1) had a randomized controlled design; (2) had a process measure outcome for quality of prescribing or a distal outcome measure for medication-related adverse patient events; and (3) involved nursing home residents.
  
  
  RESULTS
  Eighteen studies met the inclusion criteria for this review. Seven of those studies described educational approaches using various interventions (eg, outreach visits) and measured suboptimal prescribing in different manners (eg, adherence to guidelines). Two studies described computerized decision-support systems to measure the intervention's impact on adverse drug events (ADEs) and appropriate drug orders. Five studies described clinical pharmacist activities, most commonly involving a medication review, and used various measures of suboptimal prescribing, including a measure of medication appropriateness and the total number of medications prescribed. Two studies each described multidisciplinary and multifaceted approaches that included heterogeneous interventions and measures of prescribing. Most (15/18; 83.3%) of these studies reported statistically significant improvements in >or=1 aspect of suboptimal prescribing. Only 3 of the studies reported significant improvements in distal health outcomes, and only 3 measured ADEs or adverse drug reactions.
  
  
  CONCLUSIONS
  Mixed results were reported for a variety of approaches used to improve suboptimal prescribing. However, the heterogeneity of the study interventions and the various measures of suboptimal prescribing used in these studies does not allow for an authoritative conclusion based on the currently available literature.
authors.affiliation: Department of Medicine (Geriatrics), School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
authors.forename: Zachary A
authors.initials: ZA
authors.lastname: Marcum
authors.forename: Steven M
authors.initials: SM
authors.lastname: Handler
authors.forename: Rollin
authors.initials: R
authors.lastname: Wright
authors.forename: Joseph T
authors.initials: JT
authors.lastname: Hanlon
mesh_terms: D000368:Aged; D064420:Drug-Related Side Effects and Adverse Reactions; D006707:Homes for the Aged / Q000458:organization & administration / Q000706:statistics & numerical data; D006801:Humans; D009735:Nursing Homes / Q000458:organization & administration* / Q000706:statistics & numerical data; D004364:Pharmaceutical Preparations / Q000008:administration & dosage; D010818:Practice Patterns, Physicians' / Q000592:standards*; D011785:Quality Assurance, Health Care / Q000379:methods*; D016032:Randomized Controlled Trials as Topic
chemical_list: D004364:Pharmaceutical Preparations