Explicit,evidence-based criteria to assess the quality of prescribing to elderly nursing home residents

BACKGROUND: prescribing in nursing homes is frequently suboptimal. Indicators to measure prescribing quality, including appropriateness of prescribing certain drugs or combinations of drugs, to hospital inpatients have been developed previously. OBJECTIVE: to modify prescribing indicators, including appropriateness of prescribing algorithms developed in the hospital setting, for use in nursing homes. DESIGN: an audit of prescribing to patients resident in a random sample of nursing homes on a single day. Setting, subjects: 22 nursing homes in the former South Thames Region selected from lists of nursing homes with more than 35 residents. All residents aged 65 years or over were eligible. METHODS: prescribing indicators, including evidence-based indicators of appropriateness of prescribing benzodiazepines, steroids with beta(2) agonists, antithrombotics with digoxin and aspirin with nitrates were adapted: to reflect where prophylaxis was not justified in terms of quality of life; and for use with primary care clinical records. Indicators were used to evaluate drugs prescribed to each resident to determine whether prescribing was appropriate. RESULTS: 13 indicators were successfully modified and applied. The 934 residents included were prescribed a mean of 5.1 regular items. Only 496/934 (55%) drug sensitivity statements were completed. Although 24% residents received benzodiazepines, clinical data indicated that only 7% received benzodiazepines appropriately. Over three-quarters of residents with ischaemic heart disease received appropriate aspirin therapy, but fewer than half residents with atrial fibrillation received appropriate antithrombotic therapy. It was not possible to derive reference ranges of observed prescribing that included homes demonstrating appropriate prescribing whilst excluding those with inappropriate prescribing. Intra-cluster correlations ranged from 0.027 to 0.335. CONCLUSION: quality of prescribing indicators were successfully modified for the nursing home setting. Application identified suboptimal prescribing to nursing home residents.     

Nitrate therapy in angina and congestive heart failure

Nitrates are vasodilators of venous and arterial smooth muscle commonly prescribed both for angina and congestive heart failure. Primarily venodilators, nitrates also affect the systemic circulation if administered in sufficient dosage. In the coronary circulation, the principal effect is on the large epicardial and collateral vessels. Blood is shunted toward the ischemic subendocardium. In the majority of patients with angina, relief of symptoms by nitrates is primarily due to hemodynamic effects on preload and afterload, unless the patient has coronary spasm. In patients with congestive heart failure, nitrates decrease the resistance to the emptying of blood from the left ventricle as well as the filling pressure. Nitrates are relatively well tolerated, except for an initial throbbing headache which rapidly resolves as tolerance develops. Nitrates are available in a multitude of forms including sublingual, oral, topical, transmucosal, intravenous, and spray preparations. Oral preparations undergo a first-pass effect in the liver, requiring larger doses. Other forms avoid this problem by direct transdermal absorption or the intravenous route. The latter has the advantage of rapid administration and ease of titration. The choice of nitrate depends upon the clinical situation.     

衰老对硝酸酯类药物引起活性氮介质和活性氧介质增高的影响

目的:以往研究显示,硝酸酯类药物和衰老都会引发体内活性氧介质(ROS)和活性氮介质(RNS)的增加,本研究旨在探讨年龄是否会影响硝酸酯类药物的这种促进作用。方法:75例不稳定心绞痛患者,分成32例中年组和43例老年两组。所有患者均给予硝酸酯类药物(50μg/min)48h。在试验开始时和用药48小时时,获取血样标本,对血样中的ROS[丙二醛(MDA),髓过氧化物酶(MPO)和还原性谷胱甘肽(GSH)]和RNS(硝基、亚硝基,NOX;过氧亚硝酸阴离子,ONOO-)]的水平进行检测。结果:硝酸酯类药物的使用,引起中年组血浆MDA水平[用药前(1.22±0.37)nmol/m L,用药后(1.61±0.47)nmol/m L,P0.05]增加60%;老年组MDA水平[用药前(2.07±0.77)nmol/m L,用药后(4.05±0.80)nmol/m L,P0.05],增加140%;GSH两组分别减少了9%和48%;硝酸酯类药物使用前,老年组血浆硝基化酪氨酸(398.29±117.0)nmol/L水平为仅为中年组(296.57±120.48)nmol/L的105%,药物使用48h后,老年组血浆硝基化酪氨酸水平(1 182.30±295.01)nmol/L增高到中年组(610.82±217.36)nmol/L,增高210%。结论:在硝酸酯类药物的使用过程中,除了药物本身增加机体内ROS和RNS,年龄增加能够促进硝酸酯类药物的这种作用。     

Providing guidelines and education is not enough: an audit of gentamicin use at The Royal Melbourne Hospital

BACKGROUND: Aminoglycoside antibiotics are commonly prescribed for the treatment of Gram-negative infections. Appropriate dosing and therapeutic monitoring of aminoglycosides are important because these agents have a narrow therapeutic index. AIM: To audit gentamicin use at our hospital, focusing on selection of the initial dose and therapeutic monitoring practices, and to compare the results against recommendations in the existing hospital aminoglycoside guidelines, which had recently been promoted to doctors. METHODS: This audit included all inpatients receiving gentamicin at The Royal Melbourne Hospital from 1 February to 12 March 2004. The principal researcher checked the drug charts of all inpatients to identify those receiving gentamicin and collected data from the medical records and the pathology database. Doses were considered 'concordant' if the dose given was within the recommended dosing range +/-20 mg. RESULTS: A total of 132 courses of gentamicin was included in the study. Gentamicin was prescribed for prophylaxis in 31.1% of courses. Thirty-six per cent of patients prescribed gentamicin were more than 65 years of age. Eighty-two per cent of the gentamicin used therapeutically was given as a single daily dose. Sixty-six per cent of gentamicin initial dosing was not in accordance with existing hospital guidelines. Seventy-seven per cent of gentamicin courses requiring therapeutic drug monitoring received such monitoring; however, in only 8.8% of these was the monitoring conducted according to guidelines. CONCLUSION: Aminoglycoside prescribing practices at our hospital are suboptimal, despite ready access to prescribing guidelines. Provision of a guideline and education sessions with doctors do not necessarily lead to widespread adoption of recommended practices. We suggest that changes to hospital systems related to prescribing and monitoring of aminoglycosides are required.     

Management of heart failure in Canadian long-term care facilities

BACKGROUND: In long-term care (LTC) facilities, heart failure is common but undertreated. No Canadian studies of heart failure in LTC facilities have been reported. OBJECTIVES: To estimate the prevalence of heart failure in Canadian LTC facilities; to document the management of heart failure in LTC; and to describe characteristics of LTC residents with heart failure and predictors of adherence to treatment guidelines. METHODS: Cross-sectional survey in eight LTC facilities lodging 1223 residents. RESULTS: The prevalence of heart failure was 20%. LTC residents with heart failure were older, more often women, and more functionally impaired and burdened by comorbidity than were participants in heart failure trials. Documentation supporting the heart failure diagnosis was inadequate, with some symptoms possibly misattributed to chronic obstructive pulmonary disease. Angiotensin-converting enzyme (ACE) inhibitors were prescribed to 55% of residents, although only 45% received appropriate doses. Residents with hypertension or diabetes mellitus, using nitrates or who were male were more likely to receive ACE inhibitors. Appropriate ACE inhibitor doses were associated with functional impairment, nitrate use and recent hospitalization. Documentation of systolic dysfunction was associated with a greater likelihood of ACE inhibitor use. Beta-blockers were prescribed to 25% of residents, who were more likely to be using nitrates, have ischemic heart disease or had been recently hospitalized, and less likely to have chronic obstructive pulmonary disease. Residents with atrial fibrillation were more likely to be prescribed digoxin. Potentially hazardous regimens were prescribed to 43% of residents. CONCLUSIONS: Heart failure is common in Canadian LTC facilities. Management of heart failure in LTC does not conform to guidelines. Improved diagnostic methods tailored for frail elderly patients must be developed. Studies are needed to understand and identify factors influencing prescribing for heart failure medication in LTC.     

An indicator of appropriate neuroleptic prescribing in nursing homes

OBJECTIVE: To derive and apply objective criteria which assess the appropriateness of neuroleptic prescribing, in a random sample of nursing homes. DESIGN: Cross-sectional survey of prescribing in a random sample of nursing homes. SETTING: 22 homes with more than 35 residents in the former South Thames Region. SUBJECTS: 934 nursing home residents aged 65 years or over. METHODS: We compared criteria of appropriate neuroleptic prescribing, including appropriate indication and review, to clinical data documented in the nursing and GP notes of residents prescribed neuroleptics. RESULTS: Of the 229 (24.5%) residents prescribed neuroleptics, clinical notes were available for 225. Clinical data indicated that only 40/225 (17.8%) residents receiving neuroleptics received appropriate therapy. The intra-cluster correlations for appropriate and inappropriate prescribing of neuroleptics were 0.038 and 0.12 respectively. It was not possible to derive reference ranges of observed prescribing that included homes demonstrating appropriate prescribing whilst excluding those with inappropriate prescribing. Thus, clinical data are needed whenever neuroleptic appropriateness is assessed. Criteria were readily applicable in nursing homes. CONCLUSION: Application of criteria of appropriate neuroleptic prescribing in a random sample of nursing homes identified suboptimal prescribing to elderly residents.