Towards a geriatric palliative care approach in prescribing for older patients with complex multi-morbidity
Verpleeghuisbewoners gebruiken veel medicatie terwijl er twijfels zijn aan de zinvolheid van dit gebruik, gelet op hun beperkte levensverwachting. Bij hen zijn levensverlenging en preventie minder belangrijk als behandeldoelen en gaat het meer om welbevinden en kwaliteit van leven. Er is grote behoefte aan handvatten voor passend medicatiegebruik bij deze groep.
Criteria voor passend medicatiegebruik
In deze studie is zo’n handvat ontwikkeld. Met een panel van experts zijn in een zogenaamde Delphi procedure criteria vastgesteld voor passend medicatiegebruik bij verpleeghuisbewoners met een beperkte levensverwachting.
Dit project krijgt een vervolg in het project Improved prescribing for older patients with complex multi-morbidity in nursing homes.
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 the 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, resulting in heavy treatment burden, 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 provider related barriers to a change in prescribing practice. These include (amongst others): reluctance 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 a list of medication appropriateness indicators and tailored STOPP/START criteria. Use of the Supportive and Palliative Care Indicators Tool (SPICT) allows physicians to timely start a discussion on medication appropriateness with their patients. SPICT supports clinicians in the early identification of patients who will benefit from a GPC approach and advance care planning (ACP). It is hypothesized that in older patients with complex multi-morbidity targeted by the SPICT 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. Delphi study on medication appropriateness indicators related to GPC and adaptation of STOPP/START criteria, followed by a cluster randomized trial in 2 x 20 long term care wards of university affiliated NH. STUDY POPULATION. NH residents admitted for long term care with an indication for a GPC approach based on the SPICT. INTERVENTION. SMMR combined with ACP discussions with residents and/or their surrogates (ACP+) versus usual care. PRIMARY OUTCOME: Medication appropriateness in the setting of a GPC approach. 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 intervention group and controls. Secondary outcomes will be analyzed using multilevel logistic and linear regression analysis. Also, a qualitative process analysis will be performed. FEASIBILITY STUDY IN PRIMARY CARE. In addition to the main study a pilot evaluating the ACP+ intervention in ‘SPICT-positive’ community dwelling older patients with complex multi-morbidity will also be conducted as part of the collaboration between GPs and ECPs at the University Practice for Elderly Care Medicine of VUmc. TIME SCHEDULE. 72 months.