The challenge of safer prescribing

Abstract

Doctors should pay greater attention to managing the risk-benefit relationship to improve care of patients over 65, urge Jerry Avorn and William Shrank (doi: 10.1136/bmj.39520.671053.94). The challenge of safer prescribing, says Anne Spinewine, lies in shared decision making

Quality improvement for the care of older people has become a priority in many countries. Elderly people consume a large proportion of health care, including drugs, and evidence shows that prescribing to this group is often inappropriate.¹ Inappropriate prescribing occurs in all care settings and at the transition between settings. Negative consequences include adverse drug events, higher costs for the patient and society, and impaired quality of life.

Specific approaches tailored to the needs of frail elderly people are needed. A recent review of ways to optimise prescribing to older people found that geriatric medicine services (involving a multidisciplinary team that includes a geriatrician and other healthcare providers with specialised geriatrics training), involvement of pharmacists in care, and computerised decision support can all improve the quality of prescribing to this group in different settings.² Quality improvement strategies are more likely to be effective when there is direct interaction with the prescriber and when the strategies are provided at the time of prescribing. In nursing homes, involvement of nurses in strategies is another important factor. The effect of educational interventions is mixed, although the lack of training of doctors in geriatrics is often cited as a cause of inappropriate prescribing.

However, widespread diffusion of effective approaches has not yet occurred. As in many other fields, translating research into practice is a delicate task. In the domain of quality improvement for safer prescribing to older people, this is further complicated by a lack of strong data showing the impact of effective approaches on important health outcomes. Also, the question of who should meet the cost of such approaches is a matter for debate. And we lack data on the cost effectiveness of strategies. With regard to computerised decision support systems, we first need systems that have been tailored to elderly patients before they can be implemented more widely.

It is important to take environmental barriers into account. Some barriers can be specific to the setting of care or even to the country of practice.³ For example, improving the quality of prescribing of neuroleptics in nursing homes is less likely to occur without an increase in staffing and resources. Direct contact with prescribers (such as with a clinical pharmacist) is not always feasible in nursing homes, and this can decrease the efficacy of the intervention. In some countries pharmacists do not have access to patients’ records. Consequently, a quality improvement strategy that is effective in one care setting cannot be directly transposed to another without adaptation. The same applies to transposition between countries, because of differences in practice environments and culture.⁴

Big improvements in communication at the interface between primary and secondary care are urgently needed too. Many adverse drug events result from problems with communication relating to management of drugs during the transition between care settings.⁵ National online databases of drugs dispensed to patients (as in Denmark),⁶ to which all doctors and pharmacists have access, should help to tackle such problems. The same should apply to patient records. Such a challenge should be taken up at the national level, although of course steps must be taken to protect patients’ privacy. Better communication among prescribers to track changes in treatment and to record the reasons for those changes will also help to avoid the fragmentation of care. This aspect should be included in measures of quality performance.

Quality improvement strategies for safer prescribing in older people must include shared decision making. The beliefs and preferences of older patients concerning treatment affect adherence and, in turn, the safe use of drugs.^{7 8} Several recent studies have shown the importance of considering patients’ wishes, but many questions remain unanswered. The high prevalence of people with dementia and the need to involve carers in decisions complicate further the task of shared decision making. Furthermore, many prescribers are not familiar with the principles of shared decision making or are reluctant to engage in it because of the extra time needed. Therefore a huge amount of work needs to be done here, from research to implementation. Education and training programmes for prescribers should include sessions on communicating with patients and on involving them in decisions. Health authorities should also consider including this dimension of care in quality performance measures.

What are the most urgent of the unanswered research questions? We need more clinical trials that enrol frail elderly patients, to enhance our knowledge of the benefits and risks of treatments in this group. With regard to quality improvement strategies, we need to evaluate the effect of multifaceted approaches on important health outcomes and costs. This is a challenging task that will certainly require multicentre trials with large samples. It is important that quality improvement approaches are multidisciplinary in nature, use computerised decision support systems that are specific to this age group, and take the patient’s view into account. Meanwhile, national health systems should provide incentives for prescribers to regularly review treatments, develop information systems to facilitate seamless care, and encourage the implementation of multidisciplinary approaches including geriatric medicine services. Quality improvement strategies need to be customised to account for differences in patients, prescribers, and environmental factors.