Reducing Psychotropic Use in Older Non-demented Spanish Care Home Residents: a Before-After Comparison of Three Methods
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The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA; 2Sanitas Mayores (a subsidiary of Bupa, London, England), Barcelona, Spain.
J Gen Intern Med DOI: 10.1007/s11606-019-05517-2 © Society of General Internal Medicine 2019
INTRODUCTION
Recognizing that Spain has the highest rate of antipsychotic prescribing in Western Europe,1 the Spanish Geriatrics and Gerontology Society has encouraged reducing psychotropic medication use in long-term settings.2 In a quality improvement effort designed to do that, we found that administration of any of 3 interventions—application of STOPP/START criteria, medication-focused team rounds (TR), or a decision aid (DA)—effectively reduced psychotropic use among older Spanish nursing home residents with dementia, though STOPP/START criteria application was most effective.3 While care home residents with dementia are at risk for psychotropic overuse and their sequelae, so might be those without dementia.4 Therefore, we sought to analyze patients without dementia who obtained any of the 3 interventions we studied in Sanitas Mayores (Spain), a Bupa-affiliated aged care network.
METHODS
Subject and intervention selection and study implementation are detailed elsewhere.3 In brief, we examined the short-term effects of implementation of 3 aforementioned interventions on mean equivalent daily doses (MEDDs) of 3 psychotropic medication classes: antidepressants, anxiolytics, and antipsychotics. We limited our analysis to residents aged 70–99 who lacked an Electronic Health Record (EHR)–documented dementia diagnosis (no ICD-9 or ICD-10 dementia diagnosis; Short Portable Mental Status Questionnaire or Functioning Assessment Staging Scores lower than 5). Age, sex, length of time living in the care home, Charlson score, and the EHRThis work has not been previously presented or published elsewhere. Received April 26, 2019 Accepted October 22, 2019
derived MEDD for each drug of interest were used to generate propensity scores; in each drug class, we matched 2 controls to each intervention resident. We used a mixed effects model to adjust for correlation within intervention sites and within patients over time. For each drug class/intervention combination, we compared MEDDs in the 4 weeks before intervention with those in the 4 weeks after intervention. During the same time frame, we examined 2 potential adverse effects: patient fall and physical restraint use rates We used R (v4.5), 2-tailed statistical significance of 0.05, and report standardized differences in MEDD amounts and proportions. Dartmouth’s IRB approved the study, which follows STROBE guidelines.
RESULTS
Intervention and matched control care home residents were similar at baseline, having similarly low prevalence of psychiatric disorders (Table 1). Relative to propensity-matched controls, all 3 interventions were associated with significant reductions in both antipsychotic MEDDs (STOPP/START, − 20.4% (− 15.6 milligram equivalents) [95% confidence interval, − 29.4%, − 11.5%]; DA, − 15.8% (− 49.6) [− 21.
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