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Review finds high level of inappropriate prescriptions for home nursing patients


The prevalence of potentially inappropriate medication (PIMs) among home nursing clients is very high, a study has found, with three quarters of this group taking drugs linked to a risk of adverse events including falls and hospitalisation.

It also suggests that the message may not be getting through to GPs, who might just be replacing one inappropriate medicine with another.

Dr Cik Lee

Dr Cik Lee

The findings arose after an evaluation of a pharmacist home-visit program carried out in Melbourne between July 2017-June 2018.

Dr Cik Lee, program officer with North Western Melbourne PHN who led the TEAMM (Timely Enhanced Access to Medication Management) project, told the AAG conference in Melbourne last week that the project was designed to reduce the risk of adverse drug reactions among older people receiving home care.

The program, funded by Eastern Melbourne PHN, was integrated within Bolton Clarke’s Eastern Clinical Hub with the aim of improving medication management for older people at risk of adverse medicine events, following on from the success of the VIP (Visiting Pharmacist) pilot conducted between 2014-15.

Polypharmacy

In the TEAMM project two Bolton Clarke pharmacists accompanied home care nurses on visits to conduct medication reviews of aged care clients, many of whom where on multiple drugs.

“One of the medication challenges that home nursing clients are facing is that they have multi-prescribing from multi-GPS and multi-specialists,” Lee said.

“Their medication lists are very messy and that becomes a risk for the nurses when they go into a client’s home.

“One of the major tasks of our TEAMM pharmacist was to look at medication lists and conduct medication reviews and write a medication report for the GP.”

GPs were then able to make a new medication list and send it to the nurses to reduce the risk of medication errors and polypharmacy.

A review of patients found a long list of PIMs including drugs linked to a risk of falls, fractures, adverse events and hospitalisations in elderly people.

Interacting drugs

Discussing the results, Georgia Major, a research officer with the Bolton Clarke Research Institute, said the  average age of patients was 82 and they were taking an average of 12 medicines. Seventy-five per cent were using one or more PIM.

“A very high proportion of participants were using one or more PIM,” she said. “This included a total of 151 PIMS across 125 participants.”

Interacting drugs were identified in 17 of the 125 clients.

The most PIM drug classes were gastrointestinal, central nervous system and cardio vascular drugs including proton pump inhibitors and benzodiazepines.

GPs not getting the message

Georgia Major

Georgia Major

While the study was successful in picking up potentially inappropriate medicines,  the reduction in PIMS after the pharmacist review was a statistically insignificant decrease to 73 per cent, the conference heard.

Major said this suggested that while the pharmacists were effectively identifying PIMs, GPs simply prescribed an alternative PIM once they were informed.

For example, while there was a one per cent decrease in short acting benzodiazepines after the review, there was also a one per cent increase in SSRIs.

“Overall, the prevalence of PIMS in home-based nursing clients is very high but deprescribing is an approach that can reduce PIMs and therefore strategies and interventions are required that facilitate deprescribing in this population,” she said.

“Whilst there was no statistically significant overall reduction in PIMS across the whole cohort, results from the study show that the model has potential to facilitiate deprescribing for these very high-risk clients.”

The initiative received federal funding under the PHN program.

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