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Improved prescribing for older patients with complex multi-morbidity in nursing homes

Projectomschrijving

Geneesmiddelengebruik en palliatieve zorgdoelen van verpleeghuisbewoners met complexe multimorbiditeit beter op elkaar afstemmen

Verpleeghuisbewoners hebben vaak ziekten in gevorderde stadia (bijvoorbeeld dementie), een grote zorgbehoefte en een beperkte levensverwachting. Kwaliteit van leven behouden en verlichten van belastende symptomen zijn dan belangrijke palliatieve zorgdoelen. Behandeling moet daarop afgestemd worden en dat gebeurt in gesprekken over proactieve zorgplanning ( advance care planning (ACP)).

Aandacht voor gebruik van geneesmiddelen

Gebruik van geneesmiddelen krijgt in ACP-gesprekken nauwelijks aandacht: past het wel bij het palliatieve zorgdoel van de bewoner? Is een geneesmiddel gericht op preventie van toekomstige ziekte wel zinnig bij beperkte levensverwachting? Dit leidt tot onnodig geneesmiddelengebruik met wel de nadelen van bijwerkingen, maar niet de voordelen.

Doel

Dit onderzoek inventariseert redenen waarom geneesmiddelengebruik en palliatieve zorgdoelen niet goed op elkaar afgestemd zijn en kijkt of jaarlijkse evaluatie van het geneesmiddelengebruik - door arts, apotheker, zorg en bewoner - leidt tot geneesmiddelgebruik dat past bij het (palliatieve) zorgdoel.

Vervolgproject

Dit project is een voortzetting van het project Towards a geriatric palliative care approach in prescribing for older patients with complex multi-morbidity.

Producten

Titel: Opvattingen over het veranderen van (preventieve) medicatie onder verpleeghuisbewoners met een beperkte levensverwachting en hun naasten
Auteur: Marlies Dijk, Eefje Sizoo, Simone Laeven, Amna Panwar, Cees Hertogh, Rob van Marum, Jacqueline Hugtenburg, Martin Smalbrugge
Titel: Views On (De)prescribing Among Nursing Home Residents With A Limited Life Expectancy And Their Relatives: A Qualitative Study
Auteur: Margaretha T. Dijk, Eefje M. Sizoo, Simone Laeven, AmnaPanwar, Cees M.P.M. Hertogh, Rob J van Marum, Jacqueline G. Hugtenburg, Martin Smalbrugge
Titel: Opvattingen over het veranderen van medicatie onder verpleeghuisbewoners met een beperkte levensverwachting en hun naasten: een kwalitatieve studie
Auteur: Marlies Dijk, Eefje Sizoo, Simone Laeven, Amna Panwar, Cees Hertogh, Rob van Marum, Jacqueline Hugtenburg, Martin Smalbrugge

Verslagen


Samenvatting van de aanvraag

BACKGROUND AND PROBLEM DEFINITION. Patients receiving long term care in Dutch nursing homes (NH) are generally (very) old and suffer from late stage chronic disease, multi-morbidity and care dependency (= complex multi-morbidity). In the past decades the trend to postpone NH admission has resulted in patients having a more advanced stage of their illness and consequently a shorter time of survival following admission. As a result, NH care has gradually evolved in the direction of geriatric palliative care (GPC), which focuses on quality of life and relief of burdensome symptoms and not on life extension. For that reason, advance care planning (ACP) has become a relevant element of structuring care and treatment in the last years of life. Common ACP topics are hospital transfer, cardiopulmonary resuscitation and artificial rehydration. As yet medication appropriateness has seldom been a topic in care planning, although it is generally recognized that prescribing in this patient group should change from a focus on curative treatment and disease specific outcomes to a focus on comfort and management of symptoms, consistent with (geriatric-palliative) goals of care for that individual. However, this appears not to happen in practice. Over-prescribing is very prevalent in this patient group, not seldom accompanied by under treatment of pain and other symptoms of discomfort. The literature has identified many, patient and health care provider related barriers to a change in prescribing practice, knowledge about barriers of patients and their relatives in the nursing home setting is still scarce. Reported barriers include: reluctance of elderly care physicians to stop drugs (particularly those prescribed by specialists) which patients seem to tolerate, difficulty to attribute symptoms to the use of specific drugs, fear among prescribers and patients of unfavorable sequelae of discontinuing medication, fear of criticism from patients and their representatives suggesting ‘downgraded’ care in case of de-prescription, limited time for reappraising (chronic) medications and – very importantly: a lack of clear incentives to discuss medication appropriateness in the absence of clearly discernible medication-induced negative effects. OBJECTIVE. Building on successful approaches to better align medication prescribing with the principles and practice of GPC, the proposed study aims to implement and evaluate ACP discussions integrated with a structured multidisciplinary medication review (SMMR) based on a GPC paradigm and supported by STOPP/START criteria adjusted to older patients with a limited life expectancy and a palliative care goal. It is hypothesized that in older patients with complex multi-morbidity and a palliative care goal the ACP+ intervention (i.e. ACP + SMMR) increases the prescribing of appropriate medication, i.e. results in a reduction of chronic and preventive medications in favor of prescriptions for pain and symptom management, without adverse effects, such as falls, increased mortality or acute care referrals, and without negative effects (or even with positive effects) on quality of life. A positive effect on patient and surrogate satisfaction with (involvement in) decision-making is also expected. STUDY DESIGN. A qualitative study on barriers to discontinuation of chronic and preventive medications among nursing home residents and their representatives. An observational study in 2 NHs to evaluate the use of the adjusted STOPP/START criteria in SMMR and in subsequent ACP discussions. An intervention study using a stepped wedge design in 9 long term care wards of university affiliated NH of SMMR combined with ACP discussions, supported by a training based on the outcomes of the qualitative study and the observational study. STUDY POPULATION. NH residents admitted for long term care with an indication for a GPC approach based on existing palliative care goals. INTERVENTION. SMMR combined with ACP discussions with residents and/or their surrogates (ACP+) versus usual care. PRIMARY OUTCOME: Use of chronic and preventive medications. SECONDARY OUTCOMES: falls, hospitalizations/acute referrals, mortality, quality of life, patient/surrogate satisfaction with involvement in decision-making. DATA ANALYSIS. The primary outcome will be assessed using multilevel linear regression analysis and generalized estimated equations to test differences between the intervention group and the control group. Secondary outcomes will be analyzed using multilevel logistic and linear regression analysis. Also, a qualitative process analysis will be performed. TIME SCHEDULE. 72 months.

Kenmerken

Projectnummer:
839160003
Looptijd: 50%
Looptijd: 50 %
2020
2028
Gerelateerde subsidieronde:
Projectleider en penvoerder:
dr. E.M. Sizoo MD PhD
Verantwoordelijke organisatie:
Amsterdam UMC Locatie VUmc
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