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Introduction Legislation in the United States has sought to regulate the delivery of care in nursing homes with resultant changes in the prevalence of pressure sores, use of physical restraints, and psychoactive medication.1 However, facility characteristics such as staffing, facility size and ownership have also been shown to have an impact on a number of indices of care in this setting.2 In the case of the latter, many studies have been limited in the number of variables which were examined and the number of facilities included in analysis.
Method The Health Care Financing Administration's online survey certification and automated record (OSCAR) data system provided facility-level information for all Medicare/Medicaid certified nursing homes (excluding those which were hospital-based) in the contiguous US (spring, 1997; n=14,774). The prevalence of anxiolytic and hypnotic usage was evaluated and facilities were categorised according to the proportion of residents receiving these drugs (high or low-use facilities, ie, those which were in the top or bottom quartile distribution respectively of anxiolytic and hypnotic use). Drug use was evaluated in relation to selected factors (eg, geographical location, ownership, staffing) using a polytomous multiple logistic regression model, with adjustment for potential confounders. |
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Results The majority of facilities (60 per cent) were being run for profit in all regions of the country and all facilities had at least 80 per cent occupancy. In the case of anxiolytics, over 20 per cent of residents were in high-use facilities in the north-east, mid-west and south. Hypnotic use was greater in the south (9.3 per cent of residents) compared with the north-east (6.0 per cent), mid-west (6.1 per cent) and west (6.8 per cent). For-profit facilities were more likely to be classified as high users of anxiolytics and hypnotics (relative risk ratio [RRR] 1.14; 95 per cent CI 1.02-1.27 in both drug categories) compared with not-for-profit organizations (RRR 1.0 [referent]).
The impact of staffing was somewhat variable. As the number of certified nurses' aides (CNAs) increased, facilities were less likely to be classified as high users of hypnotics or anxiolytic agents; in the case of registered nurses (RNs) and licensed practical nurses (LPNs), increased staffing had little effect on the use of anxiolytics and hypnotics.
As the percentage of Medicare (elderly) patients increased to more than 50 per cent of the total patient population, facilities were more likely to be classified as high hypnotic users (RRR 3.46; 95 per cent CI 2.43-4.93) compared with those facilities with less than 10 per cent Medicare patients (RRR 1.0 [referent]). This variable had no impact on the use of anxiolytic drugs.
Discussion Despite the presence of legislation (an external factor) governing the use of hypnotics and anxiolytics in US nursing homes, a number of facility characteristics (internal factors) appear to impact on the prescribing of these drugs. There was variation on a geographical level and prescribing was also influenced by staffing and patient case mix. However, it is acknowledged that these results are not conclusive and other factors which were not included in the model could also impact on drug use.
Prescribing decisions are influenced by a range of factors in practice, and similarly, in the nursing home environment, a combination of influences will ultimately affect the use of these drugs.3 Legislation alone will not necessarily lead to better ,care and hence the impact of internal factors in nursing homes should be considered in the development of an overall strategy to improve long-term care for the elderly.
Acknowledgment: We acknowledge the Commonwealth Fund, New York City, for supporting a fellowship for Carmel Hughes.
School of pharmacy, Queen's University of Belfast, 97 Lisburn Road, Belfast, BT9 7BL; *center for gerontology and healthcare research, Brown University, Providence, RI 02912, US
| 1. Elon R, Pawlson LG. The impact of OBRA on medical practices within nursing facilities. J Am Ger Soc 1992;40: 958-63. |
| 2. Davis MA. On nursing home quality: a review and analysis. Med Care Rev 1991;48:129-66. |
| 3. Schmidt I, Claesson CB, Westerholm B, Svarstad BL. Resident characteristics and organizational factors influencing the quality of drug use in Swedish nursing homes. Soc Sci Med 1998;47:961-71. |