Reply

Abstract

In reacting to our article1 and Shorr's provocative commentary,2 Kozak emphasizes the potential value of a tool (specifically, computer software apparently marketed by his employer) to simplify decision-making processes of prescribing physicians. Before discussing limitations of this suggestion, we address the more fundamental issue alluded to by Kozak: specifically, what may be needed to improve drug prescribing practices and to modify drug use patterns in board and care (B & C) settings and how such changes can be encouraged. Quality issues — in relation to drug management, administration, and use — are very complex in these settings. Whereas B&C homes were not designed to provide nursing care, almost all do store drugs, and many offer some type of assistance with drug administration. Most residents routinely take prescription and over-the-counter drugs, polymedicine is common, and psychoactive drug use rates are high.1, 3, 4 These settings have been criticized for a lack of medical supervision, inadequate drug management programs, and unskilled staff.5, 6 To promote rational psychoactive drug use in B&C homes, multi-level interventions are necessary, ranging from regulatory reform to educational efforts targeted at physicians, facility administration, and staff, the development of pharmacy counseling and drug management programs, and use of tools to enhance the efforts of all “team members.” However, as currently configured, these facilities have no “team”; physicians don't relate to B&C homes even as irregularly as they do to nursing homes. In contrast to Kozak's perspective, we argue that regulatory reform may be required if minimum standards are to be met consistently nationwide. We recently reported that extent of psychotropic drug use was related to the regulatory environment and suggested that more extensive regulations may reduce psychoactive drug use in B&C facilities.3 Although one can debate the potential benefits and pitfalls in advocating even limited regulatory reform, we already know that specific, enforced OBRA-1987 regulations made a major difference in modifying psychotropic drug use patterns and reducing antipsychotic use in nursing homes.7-10 Nonetheless, as rudimentary as nursing home quality improvement systems were at the time OBRA-1987 was implemented, they were far more sophisticated than those that currently exist in B&C homes. In some circumstances, software aimed at simplifying the prescription decision-making process of physicians and enhancing their knowledge base may have some utility. However, a computerized guideline-and-feedback approach, such as that described by Kozak, is basically untested (in terms of applied scientific research) and appears somewhat impractical when one considers the realities of what is encountered in B&C settings. In closing, ensuring safety and maximizing quality of care — while neither sacrificing resident autonomy nor inadvertently stigmatizing the mentally ill — is a substantial, complex challenge for all states, requiring input and commitment from a range of “stakeholders.”11 What has been learned from interventions and reforms in the nursing home industry may prove useful as the ongoing debate continues on how to ensure rational psychoactive drug use in settings that are marginally regulated and serve as group homes for frail, dependent, older people who may require substantial oversight and management of drugs.