The Pharmaceutical Journal Vol 267 No 7169 p510-525
13 October 2001

BPC 2001 summary

Legislation alone cannot ensure quality

Legislation alone cannot ensure high quality prescribing for nursing home residents, Dr Carmel Hughes, senior lecturer, Queen’s University of Belfast, believes, having examined the situation in the United States.

Following scandals in the 1980s, the American Congress enacted the Nursing Home Reform Act (known as OBRA because it was part of the Omnibus Budget Reconciliation Act) in 1987. This was designed to reduce the use of psychoactive drugs to restrain patients who were inconvenient to staff. During a year based at the Centre for Gerontology and Health Care Research at Brown University, Rhode Island, Dr Hughes undertook a comparative study, using a large medical records database, of the effect on patient outcomes of the implementation of OBRA. The study compared prescribing in five American states with data from Sweden, Japan, Italy, Iceland and Denmark where such reforms had not been made.

The use of anxiolytic or hypnotic drugs was between two and three times lower in the US than the other countries after OBRA and the use of antipsychotics was about half that in Iceland, Italy and Sweden.

“Physical restraint is still being used in the United States, although there has been a major improvement since before OBRA. This confirms the impact of regulations,” Dr Hughes said. However, when the data on patient falls (associated with psychoactive drug use) were examined, no clear pattern was seen. “It is difficult to conclude that legislation leads to better quality prescribing.”

Some of the other factors which influence prescribing and patient outcomes were seen when data about nursing homes, rather than patients, was examined. Increased antipsychotic use was seen in for-profit institutions, where there were more physicians or mental health professions, and where more patients were receiving State funding (Medicaid). Greater prescribing was also seen where residents had a psychiatric diagnosis or behavioural symptoms.

“In for-profit environments, the facilities of the home itself had more influence on antipsychotic use. For example, where there more care assistants and fewer nurses, antipsychotic use rose. In not-for-profit environments, it was the condition of the residents that influenced prescribing.”

She said that consultant pharmacists now inspect prescribing in US nursing homes. In the United Kingdom, pharmacy services are largely limited to a supply role. Legislation in the US seems to have worked, but there is a fixation with the drugs under inspection, principally psychoactives, and this leads to the prevention of bad prescribing rather than the promotion of good prescribing. There is an underuse of pain medication and underprescribing in diabetes, heart failure and Parkinson’s disease.

Concluding, Dr Hughes said that the UK needs more systematic data collection about prescribing for nursing home residents and a regulatory system that promotes quality improvement rather than paper compliance with regulations.

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