Effects of polypharmacy in New Brunswick long-term care facilities

Multiple Medications

Project Title: Examining the Effects of Multiple Medications

Project Description and Background

Seniors in New Brunswick long-term care facilities are often prescribed multiple different drugs. This polypharmacy comes with particular risks. The drugs treat different conditions. Each drug comes with contraindications . Some contraindications indicate that the drugs should not be used together at all, but in other instances the situation is less serious, and caution must be used. The question at hand is how often do such contraindications result in difficulties for the patient. There are situations where a patient will need to be prescribed multiple drugs to manage different conditions, and it is better medically to do so than to avoid potentially dangerous combinations. Medical staff are advised under such circumstances to be aware of the contraindications, and have a plan in place to manage any adverse effects that might occur.

This study will examine the outcomes associated with polypharmacy in New Brunswick's long-term care facilities. The research question is as follows:

"What are the effects of prescribing multiple medications to patients at New Brunswick's long-term care facilities." This study will be able to examine specific anecdotal situations, but will also be able to provide aggregate information about the ability of these facilities to handle polypharmacy situations where contraindications exist. There are two significant benefits to this study. The first is to provide aggregate evidence of the performance of these facilities, so that if gaps in performance are identified that actions can be taken to improve outcomes. The second is to provide some information about the types of polypharmacy that are being practiced in New Brunswick at present. These can be compared with norms elsewhere. Furthermore, the study is beneficial for being able to have some explanatory information regarding the quality of health care outcomes in New Brunswick. The ability to manage complex pharmaceutical regimes is important for delivering positive health outcomes, and it will be valuable to know how well New Brunswick's long-term care facilities are performing, their readiness level in the event of adverse reaction and the degree to which this type of polypharmacy needs to be practiced in these facilities.

The study will be conducted at a number of long-term care facilities in the province of New Brunswick, chosen via the convenience sampling method. Information will be collected from different personnel within the facilities, including physicians, pharmacists and nurses. This information will be in survey form, and will include data about patient outcomes. There will be confidentiality in the study. The study will focus on the processes by which risks are identified, the means by which health care personnel reconcile those risks and ultimately how they make the best decisions pertaining to patient health. Patient outcomes will also be measured to determine the effectiveness of the current techniques that are being used in New Brunswick's long-term care facilities.

Literature Review

Polypharmacy is a trend in geriatrics that has been the subject of some concern. White (2012) notes that polypharmacy not only can lead to contraindications but also can result in excessive medication. The average number of medications in long-term care in BC, for example, is nine (White, 2012). Some of the outcomes of polypharmacy are a decrease in global health, a decrease in cognitive function, increased risk of falls, and increased visits to acute care (White, 2012). Nationwide, the number of seniors taking more than five drugs has increased from 13% to 27-30%, just in the ten years from 1998-2008 (UBC, 2014).

Polypharmacy arises in long-term care in part because some medications are taken for a long time. New medications are prescribed on top of that, but without consideration for the way a person's health changes as they age (NS, 2013). Moreover, a new prescriber is typically reticent to change the prescriptions made by another prescriber, unless absolutely necessary (Kwan & Farrell, 2013). Compounding matter is how little we know about the changes in pharmacokinetics and pharmacodynamics that occur as people age, as there have been few studies on the subject (Kwan & Farrell, 2013).

The most common medications were analgesics, followed by psycholeptics (antipsychotics, anxiolytics, hypnotics and sedatives (CSAH, 2014). Studies have shown that medication-related problems are common. Yet, they are often preventable, with as many as 42% of adverse drug events being preventable at the ordering and monitoring stages of care. For health care providers, adverse drug events are costly, time-consuming and needless put the patient at risk. (CSAH, 2014).

Because of the problems associated with polypharmacy, there has been an effort in recent years to reduce its incidence, particularly in long-term care. There are, for example algorithms that have been adopted in countries like Israel and Australia that have been shown to reduce polypharmacy significantly. However, reducing polypharmacy is something that is viewed as a "fundamental change in our philosophy of medicinal care." (UBC, 2014). The current study will allow for the state of polypharmacy in New Brunswick to be evaluated, to better understand what changes need to be made.

Research Methodology and Design

A survey will be used. The survey will draw from the experience of managers at long-term care facilities in New Brunswick. The survey methodology will require the managers to answer multiple different questions. The first set of questions will be to ascertain the practices that these facilities use. The second set of question will pertain to the outcomes. The rationale for the two sets is that there may be explanatory factors in the first set that can explain differences in the second set. There were be both open-ended and closed-ended questions, and the outcomes section in particular will be designed to deliver quantitative results. This design will allow for the exploratory nature of the research to be conducted. The end result will be an overview of the practices used in these facilities and their outcomes.

Alignment with MSSU Goals and Objectives

The ARTC Awards have the stated goal of "supporting patient-oriented health service research and decision-making in the Maritime provinces," according to the ARTC website. My research aligns closely with these goals. First, the research is patient-focused, because it speaks to patient outcomes that result from polypharmacy. Second this is a good example of applied health care research. I come from a pharmacy background, therefore I understand drugs and the dangers of mixing drugs.

However, I also know that many patients must mix different drugs, sometimes in a manner that increases the risk to the patient. To improve patient care in New Brunswick's long-term care facilities, it is important to understand how those facilities are handling polypharmacy. Understanding the checks that they do, the amount of prescriptions they do that increase patient risk, and having reliable figures about patient outcomes all contribute to an environment where we can baseline facility performance, and then take the needed steps to improve patient outcomes.

Decision-making in these facilities is based on what we know about the risks of prescribing multiple drugs to people. This study will help build the body of knowledge with respect to what we know, and in turn that will provide health care professionals with better information about how to manage polypharmacy in the future. There are many studies with respect to specific drug pairings with contraindications, but this will provide an overview of the issue, identify potential areas of weakness and in that way will be able to assist with health care professionals to improve the decision-making processes by which they prescribe and administer multiple drugs to patients in the long-term care facility setting in New Brunswick.

One of the things that often stands in the way of improving the quality of health care is a lack of data. It is difficult to follow the principles of evidence-based practice when there is no evidence. This study will help to build the body of evidence that can help guide better policy, in particular better decision-making with respect to drugs in this particular environment. There is great value in having this information available to health care practitioners so that they can improve and so that patient outcomes can also improve.

The study also contributes to the interdisciplinary approach promoted by the ARTC. This study not only has a patient focus, but also involves physicians, pharmacists and nurses, along with health care administrators. All of these different components of the health care system contribute to the health outcomes of those seniors who are living in long-term care facilities.

How the Research Qualifies as Patient-Oriented

The end outcome for this study is to find ways to improve patient outcomes. Ultimately, it is the patient that bears the risk of multiple drugs working in their system at the same time. By better understanding the checks and balances that exist in the health care system, it will be easier to adapt the system to improve patient outcomes. IF there are no adverse outcomes, then that will confirm that the system need not improve.

But if there are gaps in performance, and these are leading to adverse patient outcomes in terms of morbidity and mortality, then the study will play an important role in quality control in these types of facilities. For the patient, this is of utmost importance, because anything that can be done to decrease negative outcomes naturally will benefit the patient. While the study will focus on both the operational aspects at the long-term care facilities and patient outcomes, it must be remembered that all of the effort ties back to the patient, and whether or not the facility is improving the health outcomes of the patient.

There is nothing more important that improving patient outcomes. This is the goal of any pharmacist. But the task is not always easy, and sometimes decisions need to be made that balance different risks to the patient. Understanding what these decisions are, how common they are, and how the decision-making paradigms that are used contribute to patient outcomes is a worthy venture, one that can make a significant contribution to understating risks and to improving patient outcomes, making it an inherently patient-focused study.