Abstract
BackgroundAntipsychotic medications are routinely prescribed in nursing homes to address the behavioral and psychological symptoms of dementia. Unfortunately, inappropriate prescribing of antipsychotic medications is common and associated with increased morbidity, adverse drug events, and hospitalizations. Multifaceted interventions can achieve a 12–20 % reduction in antipsychotic prescribing levels in nursing homes. Effective interventions have featured educational outreach and ongoing performance feedback.Methods/DesignThis pragmatic, cluster-randomized control trial and embedded process evaluation seeks to determine the effect of adding academic detailing to audit and feedback on prescribing of antipsychotic medications in nursing homes, compared with audit and feedback alone. Nursing homes within pre-determined regions of Ontario, Canada, are eligible if they express an interest in the intervention. The academic detailing intervention will be delivered by registered health professionals following an intensive training program including relevant clinical issues and techniques to support health professional behavior change. Physicians in both groups will have the opportunity to access confidential reports summarizing their prescribing patterns for antipsychotics in comparison to the local and provincial average. Participating homes will be allocated to one of the two arms of the study (active/full intervention versus standard audit and feedback) in two waves, with a 2:1 allocation ratio. Homes will be randomized after stratifying for geography, baseline antipsychotic prescription rates, and size, to ensure a balance of characteristics. The primary outcome is antipsychotic dispensing in nursing homes, measured 6 months after allocation; secondary outcomes include clinical outcomes and healthcare utilization.DiscussionPolicy-makers and the public have taken note that antipsychotics are used in nursing homes in Ontario far more than other jurisdictions. Academic detailing can be an effective technique to address challenges in appropriate prescribing in nursing homes, but effect sizes vary widely. This opportunistic, policy-driven evaluation, embedded within a government-initiated demonstration project, was designed to ensure policy-makers receive the best evidence possible regarding whether and how to scale up the intervention.Trial registrationClinicalTrials.gov NLM Identifier: NCT02604056.
Highlights
Antipsychotic medications are routinely prescribed in nursing homes to address the behavioral and psychological symptoms of dementia
Policy-makers and the public have taken note that antipsychotics are used in nursing homes in Ontario far more than other jurisdictions
The Ontario Drug Benefit Program covers prescription drug costs for individuals who reside in nursing homes, including some nutritional products and diabetic testing agents, provided they are prescribed by an Ontario doctor or other authorized prescriber
Summary
Ontario has one of the highest rates of APM prescriptions in Canada, with approximately 30.5 % of nursing home residents receiving inappropriately prescribed APMs in the absence of diagnosed psychosis [31]. The results of the embedded process evaluation will help identify the core components and the contextual factors that influence its success, providing an overarching understanding of how the intervention works, for whom, and in what circumstances. By exploring both causal attribution and causal explanation, this program evaluation will have significant implications for healthcare administrators, government agencies, and other stakeholders seeking to use academic detailing, alone or combined with other quality improvement strategies, to support large-scale initiatives to scale up and support quality improvement.
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