Skip navigation

Systematic review of nursing home resident medicines

 

Bottom line: Reviewing repeat prescribing in nursing homes improves care and saves money


Residents of nursing homes have medical problems, take many drugs, with many repeat prescriptions. There is a history of inappropriate use, in part because things done for good reason in the past may not be relevant now. Avoiding adverse effects and unnecessary cost through a comprehensive review of records from time to time is a mark of good quality control. A study [1] shows that the process has significant potential to simplify treatments and reduce costs.

Study

The study took place in a 9600 patient practice in Leicester. There were 212 patients in seven nursing homes. GPs visited the nursing homes about twice every week to look after acute problems, but not to review notes.

Two GPs visited four of the nursing homes chosen at random. The visits lasted about three hours, and all patients in the four homes were discussed with a senior member of staff. Prescribing records of each patient were examined, and items stopped or changed if prescribing was thought to be inappropriate. Appropriateness was defined as in Table 1.

Table 1: Appropriateness of prescribing

Indication Reason for prescribing should be appropriate according to BNF
Cost minimisation Drug prescribed must be cheaper than available alternatives
Contraindications Drugs are not prescribed if there are contraindications of potential for drug interactions
Dose Dose not to exceed that recommended by BNF

Results

There were 109 residents aged 57 to 99 years, 71% of whom were women. Repeat prescriptions were being made for 107 of them (98%). Repeat prescriptions were altered for 71 patients (65%). Items were stopped for 53 patients, changed to a cheaper alternative in 28, eight had a new medicine prescribed and one had the dose of a medicine increased.

In all 87 prescriptions were stopped, 26 altered and 16 had the dose reduced. The major drug classes involved are shown in Table 2.

Table 2: Major drug groups stopped or changed

Drug group

Number of prescriptions

Non-opioid analgesics

21

Histamine antagonists

15

Diuretics

14

Laxatives

11

Antipsychotics

10

Antidepressants

8

NSAIDs

6

All other drugs affected fewer than 5 prescriptions

 

The mean number of repeat items was reduced from 4.3 to 3.5 per patient. This resulted in an average saving of £6.90 per patient a month, and a total saving of £750 a month. No deterioration in the residents condition or any adverse effects were seen at any subsequent visit.

Comment

This is interesting stuff. It shows that a small intervention to examine the quality and appropriateness of repeat prescribing in nursing homes can deliver benefits to patients and to resources. In these four nursing homes, the intervention amounted to the investment of 24 hours of GP time (two GPs, three hours per home, four homes). The saving (over and above benefits to the residents) was £9000 in a full year. If we assume that 8 hours is a working day, this has to be beneficial overall unless we pay GPs more than £3000 a day. Unlikely, that.

The implications for the NHS are profound. The nursing home population in this practice was 212/9600, or 2.2%. If the demography of this Leicester practice is anything like comparable to the UK as a whole and the UK population is 55 million, then we have 1.2 million nursing home residents. If we both improve their prescribing, and save £6.90 a month, then the overall saving in the NHS could be as much as £100 million. Do the sums yourself (1.2 million multiplied by 6.9 multiplied by 12). And this takes no other potential savings into account, like dispensing costs.

The authors are cautious in their conclusions, but suggest that nursing home reviews should be systematic and regular, and conducted by a multi-disciplinary team of GPs, pharmacists and nursing home staff. It would seem to make sense, though it is another task for our hard-pressed GPs. At about 13 minutes per resident, we would need to find the equivalent of 150 full time GPs to do this.

Reference

1 K Khunti, B Kinsella. Effect of systematic review of medication by general practitioner on drug consumption among nursing-home residents. Age and Ageing 2000 29: 451-453.