No current or updated narrative review of RCTs evaluating interventions to improve prescribing in nursing homes was found in the literature search. In a review that was published in 1990,1
only one RCT had been published on this topic at the time. Only 18 trials met the inclusion criteria for the present review. These 18 trials used a variety of interventional approaches. Previous research assessing the process of prescribing has been conducted in a variety of settings.1,5–11
The present review found that 15 (83.3%) of the 18 studies, regardless of the interventional approach taken, reported a significant improvement in ≥1 prescribing-related process outcome. Unfortunately, clinical outcomes were much less likely to be improved significantly, probably because the studies were underpowered to detect such differences in multifactorial outcomes. One positive finding is that 3 recent studies24,26,32
did examine medication-related adverse patient events.
It is interesting to note that 3 major medication classes for unique conditions were targeted by the studies included in this review: (1) central nervous system (CNS) medications, (2) anti-infectives, and (3) musculoskeletal system medications. The first class, CNS medications, was studied in 4 of the trials.17,20–22
Educational approaches were used in all of these studies, and the targeted medications included neuroleptics, anti- psychotics, and antidepressants. This is an important target because ~50% of nursing home residents are cognitively impaired.39
Thus, CNS medications should be used cautiously and with diligent monitoring because of the potential to both worsen cognitive impairment and lead to falls. Prescribing-related process outcomes were found to be improved in almost all of the studies; specifically, a significant decrease (19%–59%; all, P
< 0.05) in the proportion of residents taking CNS medications was reported in 3 of the 4 studies.17,20,22
Regarding clinical outcomes, falls were measured in only one of the studies,21
with no significant difference found between the intervention and control groups. It is important to note that simply decreasing the number of CNS medications is not as clinically important as the potential benefits of reducing falls and improving cognitive function without worsening of the underlying disease process. Therefore, future studies should focus on measuring the clinical outcomes associated with interventions targeted at these medication classes.
Anti-infectives, the second class examined, were assessed in 3 of the studies.19,23,34
used an educational approach to improve prescribing by reeducating the prescribers on appropriate antibiotics and duration of therapy for infections commonly found in nursing homes (eg, UTIs, NHAP, skin and soft-tissue infections). One study34
used a multifaceted approach. Two of the 3 studies23,34
measured clinical outcomes, but neither study reported statistically significant results. One study34
measured hospital admissions and mortality rates, whereas the other study23
measured the 30-day postintervention mortality rate. It is promising that all of the studies found significant improvements in the appropriateness of antibiotic prescribing after intervention based on the guidelines or recommendations implemented in the trials.
As with any educational intervention, the possibility exists for the intervention’s effect to decrease over time. Future studies should build on this research by identifying appropriate clinical outcomes to measure as primary outcomes in the nursing home setting and by conducting follow-up studies to assess retention of the knowledge gained from the educational intervention.
The final medication class, musculoskeletal system medications, was examined in 2 studies.18,33
addressed musculoskeletal pain using an educational intervention, and the other study33
focused on osteoporosis management using a multifaceted approach. The trial using an educational approach reported a significant decrease in the mean number of days of NSAID use per week in the intervention group (decrease of 7.0 to 1.9 days; P
< 0.001) and a significant increase in the mean number of days of APAP use in the intervention group (increase of 3.1 days; P
< 0.001) compared with the control group.18
The multifaceted-approach trial reported that completion of an educational module (P
= 0.001) and direct physician contact by an academic detailer (P
= 0.03) were significantly associated with prescribing osteoporosis pharmacotherapy.33
Unfortunately, neither trial found a significant improvement in a clinical outcome. Because osteoarthritis and osteoporosis are common causes of disability and decreased quality of life among older adults,40,41
more attempts should be made to improve prescribing for patients with these diseases. These 2 trials18,33
were only 3 to 6 months in length; longer studies might be needed to detect a difference in musculoskeletal pain and/or falls.
This review has several potential limitations worth mentioning. Publication bias may exist because negative studies are less likely to have been published. In addition, although the PubMed, IPA, and EMBASE databases were searched for relevant articles, it is possible that some studies may have been missed if they were indexed in other databases. To minimize the chance of missing such studies, the authors manually searched the reference lists of the identified articles, recent review articles, as well as their personal files to identify potential studies for inclusion. The search strategy was also limited to the English language, to older adults (=65 years of age), to nursing home residents, and to RCTs, because the intent of this study was to evaluate the impact of interventions on older adults in the nursing home setting. Using such strict inclusion criteria may limit the generalizability of this review.