Effects of an interprofessional Quality Circle-Deprescribing Module (QC-DeMo) in Swiss nursing homes: a randomised controlled trial

Damien Cateau,Anne Niquille,Pierluigi Ballabeni

doi:10.1186/s12877-021-02220-y

Abstract

BackgroundPotentially inappropriate medications (PIMs) are common among nursing homes (NH) residents, as is polypharmacy. Deprescribing has emerged in the past decade as a safe and effective way to reduce the use of PIMs and improve patient outcomes. However, effective deprescribing interventions are expensive, as they require specialised staff and a great amount of time for each resident.The Quality Circle Deprescribing Module (QC-DeMo) intervention was designed to be less resource-intensive than medication reviews, the current deprescribing gold standard. It consists of a QC session in which physicians, nurses, and pharmacists define a local deprescribing consensus for specific PIMs classes, which is then implemented in the NH. The intervention was trialled in a RCT, with the NH as unit of analysis.MethodsAfter randomisation, intervention NHs enacted the QC-DeMo at the start of the follow-up year. The primary outcomes were the proportion of PIM galenic units and number of PIM defined daily dose per average resident and per day (DDD/res). PIM status was assessed by a combination of the 2015 Beers list and the Norwegian General Practice-Nursing Home criteria. Secondary outcomes were the number of DDD/res to avoid and to reevaluate; safety outcomes were mortality, hospitalisations, falls, and use of physical restraints. Outcomes were evaluated at follow-up using linear regression models, adjusting for the outcome baseline values.ResultsFifty-eight NHs took part in the trial; no individual residents were recruited. The intervention did not reduce the primary outcomes, but a strong trend towards reduction was seen for the number of PIM DDD/res, which accounts for the doses used. PIM DDD/res to reevaluate were significantly reduced, mostly through a reduction in the use of proton-pump inhibitors. Falls and use of physical restraints were not affected, but a statistical interaction between the mission of the NH (geriatric unit or specialised dementia unit) and the intervention group was seen for mortality and hospitalisations.ConclusionsThe QC-DeMo intervention can reduce the use of some PIM classes, and could usefully complement other deprescribing interventions.Trial registrationClinicalTrials.gov (NCT03688542), registered on 26.09.2018, retrospectively registered.

Highlights

Inappropriate medications (PIMs) are common among nursing homes (NH) residents, as is polypharmacy
The Quality Circle (QC)-DeMo intervention can reduce the use of some Potentially Inappropriate Medication (PIM) classes, and could usefully complement other deprescribing interventions
Potentially inappropriate medications (PIMs), i.e. drugs likely to cause more harm than benefits, and polypharmacy are both highly prevalent in the geriatric population, and especially so in older people living in nursing homes (NHs) [1,2,3,4]

Summary

Introduction

Inappropriate medications (PIMs) are common among nursing homes (NH) residents, as is polypharmacy. Deprescribing interventions have been proven to be effective and safe at doing so: recent meta-analyses showed that, both in the community and in NHs, deprescribing reduces polypharmacy and the use of PIMs, and has a positive impact on falls and mortality [6, 7] In both meta-analysis, the most effective interventions were patient-centred medication reviews, a time-consuming intervention requiring specialised clinicians, which may not be available in every setting. In the NHs of the Swiss canton of Vaud, an integrated pharmacist service (IPS) has been active since 2010; in the neighbouring canton of Fribourg, a similar IPS was active between 2002 and 2018 This IPS consists, for the most part, of regular meetings (quality circles, QC) between the pharmacists, physicians and nurses active in a NH, with the goal of producing local prescribing consensus to improve drug use [8]. This approach led, in particular, to a reduction in drug costs and improved antibiotics stewardship [9, 10]

Methods

Results

Conclusion