Optimising Drug Utilisation in Long Term Care
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Providing quality long term care for the elderly while containing costs is presenting major challenges for governments and policy makers. Although international variability exists with respect to the number of medications and other factors influencing suboptimal pharmacotherapy, suboptimal pharmacotherapy among elderly persons is common. This international problem requires a creative and multifaceted approach to improve and rationalise prescribing.
We outline the non-regulatory efforts and regulatory means to approaching this problem. The recent introduction of a prospective payment system for long-term care in the US has underscored the importance of a regulatory approach to counter-balance the cost containment efforts which bundle the cost of medications into a prospectively set per diem rate. An examination of how US regulatory bodies are considering improving prescribing is provided. Considering the case of coronary heart disease, we provide data regarding the performance of a quality indicator aimed at stimulating quality prescribing for this medical condition. Although the use of regulatory approaches can improve prescribing, it is also recognised that a more holistic approach involving multidisciplinary teams and greater focus on the patient is the ultimate aspiration. This is particularly the case with the elderly in whom appropriate drug therapy can have a major impact on outcomes.
A major cultural shift in the way society views and treats the elderly may be required in order to produce dramatic improvements in long term care for older people.
The impetus for this paper stemmed from numerous lively conversations between the two authors while Dr. Hughes was a Harkness Fellow in Healthcare Policy 1998 to 1999. Dr Lapane is attempting to implement some of the ideas for improving pharmacotherapy in long term care in part by a contract (#500-95-0622) ‘Development and Validation of Quality Indicators’ from the Health Care Financing Administration (HCFA), to the Abt Associates with a subcontract to Brown University in Providence, Rhode Island, USA. Fellowship funding for Dr Hughes was provided by The Commonwealth Fund, a New York City-based private independent foundation. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or the HCFA, its directors, officers or staff. Dr Hughes is currently being supported by a National Primary Care Career Scientist Award from the Research and Development Office (Northern Ireland). The preliminary ideas presented here for the policy approach have been expanded by the team members of the Drug Team of this contract consisting of: Anne Hume, PharmD, Norma Owens, PharmD, David Gifford, MD, Steve Levenson, MD, Helen Deere-Powell, and Vince Mor PhD. We also acknowledge the hard work of two diligent graduate students Claudio Pedone, MD, MPH and Brian Quilliam, RPh., PhD, who assisted in the development and testing of the coronary heart disease quality indicator.
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