Medication errors that cause injury, permanent impairment, and even death are especially prevalent in nursing homes. Over the next few months, a new medication review process known as the Fleetwood Model will be tested and evaluated in 26 North Carolina nursing homes. Developed by the American Society of Consultant Pharmacists, the program aims to reduce errors by identifying at-risk patients and coordinating their pharmaceutical care. An economic evaluation and feasibility study have been completed; the North Carolina trials, which are being supported by The Commonwealth Fund and the Retirement Research Foundation, are part of studies to evaluate the effectiveness of prospective drug management in reducing drug-related problems and their costs. We spoke with Brown University's Kate Lapane, Ph.D., who is leading the evaluation, about the project.
Rates of adverse drug events in nursing homes are startlingly high. What are some of the factors contributing to the problem?
Kate Lapane: There are many reasons. First, the elderly, particularly frail elders, are often on many drugs at once. When they enter a nursing home, it may be the first time they're taking all their medications at the correct dose and time, so that side effects from overuse or from interactions between drugs would not appear until then. Often an acute episode brings an elderly person to a nursing home via a hospital, where physicians may change his or her drug regimen. Maybe the intention was not to be on this regimen forever, but the situation isn't carefully monitored. The elderly are also at risk due to changes associated with aging--the body begins to process and absorb drugs differently than before.
The federal Centers for Medicare and Medicaid Services mandates that consultant pharmacists perform monthly reviews of the drug regimens of all nursing home patients. What are some weaknesses of this system, in your view?
Lapane: The spirit behind the regulations is good, but there are problems. The regulations don't specifically say that drug regimen reviews should occur retrospectively, but in practice this is what seems to happen. Often residents go 30 days without having a review. They're at highest risk for adverse drug events during the first month of residence, so the review may be too late. Consultant pharmacists are responsible for up to 1,000 residents a month; considering that residents can be on eight to 10 drugs, they simply don't have time to do a comprehensive job.
Your trials aim to identify patients at high risk for medication complications. How does this process work?
Lapane: We worked with a software vendor to create a computer model focusing on preventable drug events. Take the example of a resident with a history of stroke who is taking the blood-thinning drug warfarin. If he develops an infection and is prescribed an antibiotic, the interaction of the two drugs could cause problems, like the blood becoming too thin. In this case, the software would automatically raise a flag to alert the dispensing pharmacists of the potential risk, who could then alert nurses, physicians, and consultant pharmacists to monitor the situation.
How does prospective drug management encourage a team approach to care?
Lapane: We're trying to use technology to enhance communication. Using this software, dispensing pharmacists can enter their recommendations into a patient's computer file, and those recommendations will be transferred to the field the next day so consultant pharmacists can view them. We also hope that pharmacists will be encouraged to go out onto the floor to meet residents and speak to nurses and family members about residents' care.
What do you hope to accomplish in the trials?
Lapane: We expect to see a reduction in hospitalizations due to adverse drug events. A lot of attention has been given to overmedication, with residents on multiple psychotropic drugs, for instance. But there are also sins of omission. Prospective drug management could be used to proactively look for situations where a drug could help a resident, such as aspirin therapy for those who have suffered a stroke.