Abstract
BackgroundAntipsychotic medication use in nursing homes is associated with potential for harms. In Ontario, Canada, an agency of the provincial government offers nursing home physicians quarterly audit and feedback on their antipsychotic prescribing. We compared the characteristics of physicians who did and did not engage with the intervention, and assessed early changes in prescribing.MethodsThis population-level, retrospective cohort study used linked administrative databases to track prescribing practices in nursing homes pre-intervention (baseline), immediately post-initiative (3 months), and at follow-up (6 months). Exposure variables identified whether a physician signed up to participate (or not) or viewed the feedback following sign up (or not). Differences in the proportion of days that residents received antipsychotic medications at 6 months compared to baseline by exposure(s) were assessed using a linear mixed effects regression analysis to adjust for a range of resident, physician, and nursing home factors. Benzodiazepine and statin prescribing were assessed as a balance and tracer measures, respectively.ResultsOf 944 eligible physicians, 210 (22.3%) signed up to recieve the feedback report and 132 (13.9%) viewed their feedback. Physicians who signed up for feedback were more likely to have graduated from a Canadian medical school, work in urban nursing homes, and care for a larger number of residents. The clinical and functional characteristics of residents were similar across physician exposure groups. At 6 months, antipsychotic prescribing had decreased in all exposure groups. Those who viewed their feedback report had a signicantly greater reduction in antipsychotic prescribing than those who did not sign up (0.94% patient-days exposed; 95% CI 0.35 to 1.54%, p = 0.002). Trends in prescribing patterns across exposure groups for benzodiazepines and statins were not statistically significant.InterpretationAlmost a quarter of eligible physicians engaged early in a voluntary audit and feedback intervention related to antipsychotic prescribing in nursing homes. Those who viewed their feedback achieved a small but statistically significant change in prescribing, equivalent to approximately 14,000 fewer days that nursing home residents received antipsychotic medications over 6 months. This study adds to the literature regarding the role of audit and feedback interventions to improve quality of care.
Highlights
Antipsychotic medication use in nursing homes is associated with potential for harms
This paper evaluates a natural experiment with the launch of a province-wide audit and feedback intervention to improve prescribing in nursing homes
Health systems have attempted to encourage appropriate antipsychotic medication prescribing through a range of quality improvement strategies [3], including public reporting of potentially inappropriate antipsychotic medication prescribing in nursing homes [9, 10]
Summary
Antipsychotic medication use in nursing homes is associated with potential for harms. The goal for clinicians, nursing homes, and health systems is not complete avoidance of antipsychotic medications but regular reassessment of the balance between risk for harms and benefits. Health systems have attempted to encourage appropriate antipsychotic medication prescribing through a range of quality improvement strategies [3], including public reporting of potentially inappropriate antipsychotic medication prescribing in nursing homes [9, 10]. These strategies are not consistently effective [2, 3, 11,12,13,14]. One challenge arising in the interpretation of such evidence to inform policy is that those individuals willing to participate in trials of quality improvement strategies are not necessarily representative of the target population [15] and would benefit most from the intervention
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