mission on Accreditation of Hospitals requires regular ongoing review ... eases/Epidemiology of the College of Physicians and Surgeons of ... a grant from Smith-Kline French Laboratories/Fujisawasa-Smith-Kline at Orlando, FL, September 7- .... Since no precise technical guidelines about medication errors are included.
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ANTIBIOTIC USE IN NURSING HOMES: PREVALENCE, COST AND UTILIZATION REVIEW* KENT CROSSLEY, M.D., KEITH HENRY, M.D., PATRICK IRVINE, M.D., AND KAREN WILLENBRING Department of Medicine St. Paul-Ramsey Medical Center St. Paul, Minnesota
M/[ EDICAL practice in nursing home environments is not fully regulated. Activities in acute care hospitals are carefully scrutinized by the medical staff through committees established to facilitate physician involvement and supervision. Although there are organizational similarities in nursing homes, policies and regulations in these institutions usually are developed without major participation by physicians. Because most physicians spend limited time in nursing homes, their involvement with the institution is much less than with acute care hospitals. I Use of drugs-and antibiotics in particular-illustrates these issues. In most hospitals, a limited number of drugs are included in the formulary, and information about drug cost is usually available to physicians. The Joint Commission on Accreditation of Hospitals requires regular ongoing review and efforts to improve antibiotic use. In nursing homes formularies are the exception. The costs and financing of drugs for nursing home residents are not well understood. Although medication review is required by federal regulation and by the Joint Commission Long Term Care Standards, the impact of this process on physicians' prescribing patterns in nursing homes is not clear.2 This paper undertakes to define some aspects of antibiotic usage in longterm-care institutions. We shall summarize information about antibiotic use in nursing homes in Minneapolis-St. Paul, discuss costs and sources of these drugs for nursing home residents, and examine the drug utilization review process required in these institutions. *Presented as part of the Fourth Annual SK & F/FSK Anti-Infective Conference, Controversies in Diagnosis and Management of Infectious Disease, held by the Division of Infectious Diseases/Epidemiology of the College of Physicians and Surgeons of Columbia University and funded by a grant from Smith-Kline French Laboratories/Fujisawasa-Smith-Kline at Orlando, FL, September 79, 1986.
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During the early 1980s we conducted studies that led to an interest in drug use in nursing homes. One study found that 27 % of nursing home residents were admitted to our hospital because of infection.3 In two other studies conducted in St. Paul nursing homes, we found that the prevalence of antibiotic usage was between 15 and 20%.4 These data suggested that although antibiotics are extensively used in nursing homes, many residents develop serious infections and require transfer to acute care hospitals. Infections are important causes of morbidity and mortality in nursing home residents. Since care in acute care hospitals typically costs five to 10 times as much per day as in nursing homes, the economic impact of infection among residents is also of major importance. We recently reported a prevalence study of antibiotic use in a group of 16 nursing homes in Minneapolis-St. Paul.5 Of the 2,434 residents in the homes when these studies were conducted, 404 (16.6%) were receiving antibiotics. Although most residents got only a single antibiotic (353/404; 87.4%), a few received two (46/404;11.4%) or three (5/404;1.2%) antimicrobials. Most antibiotics were given by mouth (170/460; 37.0%) or by topical administration (156/404;33.9%). Conjunctival instillation accounted for 65 (14.1 %) courses of therapy. The remaining antibiotic courses were administered by gastrostomy (11 instances) or were used as irrigants (in two residents). When these data were collected in 1985, no intravenous or intramuscular drugs were administered in the 16 study homes. As a result of this study, we identified two areas of antibiotic usage that seemed both important and problematic. First, trimethoprim-sulfamethoxazole was extensively used for treatment or prophylaxis of urinary tract infection, and was the most commonly prescribed antibiotic in this series of patients. It was also often given for long periods of time; the median duration of administration among nearly 100 patients receiving this drug was 114.5 days. Evidence is now mounting that antibiotic therapy to prevent urinary tract infection in elderly individuals (whether or not they have an indwelling urinary catheter) is unlikely to be successful.&S For this reason, we believe the use of trimethoprim-sulfamethoxazole to manage urinary tract infections in nursing home residents is appropriate only for acute asymptomatic infections. The second area for concern was the frequent use of topical antimicrobials for minor cutaneous lesions. Even though many of the orders for these drugs were pro re nata (p.r.n), institutions virtually always purchase drugs for paVol. 63, No. 6, July-August 1987
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tients when prescribed in this manner. Reduction in the frequency of p.r.n orders, use of less expensive topical preparations (e.g., iodophors or corn starch), and institution of automatic stop orders might reduce the cost of these agents for residents of long-term-care facilities. SUPPLIERS AND COSTS OF ANTIBIOTICS IN NURSING HOMES IN MINNEAPOLIS-ST. PAUL As a result of these studies, we became interested in how antibiotics are supplied to nursing homes in Minneapolis-St. Paul. We were aware that in Minnesota a nursing home resident is free to select any pharmacy but, for convenience, relatively few firms supply most nursing homes in our communities. We conducted telephone interviews with the director of nursing in all 137 licensed nursing homes in the seven-county metropolitan area. Of this group, 117 agreed to share information about the sources of drugs for their residents. Six pharmacies were named as primary suppliers of pharmaceuticals by 75 of the 117 homes. In the remaining nursing homes, most residents received drugs from a neighborhood retail pharmacy. The bed size of the nursing home did not correlate with the source of the drug supply; larger homes were not more likely to use a major nursing home supplier than small homes (Table I). We next compared the prices of commonly prescribed oral antibiotics in community pharmacies with the prices of those firms which supplied a large number of nursing homes. We randomly selected seven retail pharmacies in Minneapolis-St. Paul as a control group and obtained their prices for 10 commonly used oral antibiotics. We asked the six major suppliers of Twin Cities nursing homes for the same information; four agreed to cooperate. Table II summarizes the average price of these agents for a 10-day course from the seven retail pharmacies and the four firms which are principally nursing home suppliers. Except for one discount firm, all of the retail pharmacies offered charge accounts or accepted bank credit cards and provided free delivery. Two of the four firms that principally supply nursing homes did not extend charge accounts to individuals; all four provided free delivery. Although data suggest that pharmacies with a large nursing home business charge more than community pharmacies, the comparison may be misleading for a number of reasons. First, many pharmacies with extensive nursing home involvement also provide the institution with a computerized system to manage and implement physician orders. Second, consultative medicaBull. N.Y. Acad. Med.
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TABLE I. SOURCES OF PHARMACEUTICALS REPORTED BY 117 NURSING HOMES IN MINNEAPOLIS-ST. PAUL Proportion of homes Pharmacy supplied Mean bed size A 20.5% 143 B 10.3% 104 C 9.4% 130 D 11.1% 134 E 7.7% 137 F 5.1% 138 G 3.4% 121 All other pharmacies 32.5% 148
tion review is often provided by the firm at little or no charge to the nursing home. The cost of these services may be borne indirectly by payment for prescription drugs and supplies. The comparisons are further complicated because the price paid for drugs is clearly influenced by the source of payment. The third column in Table II lists the amount which Minnesota's Medicaid program will reimburse for prescriptions for the indicated antibiotics. Charges are based on the average wholesale price plus a markup of $4.30 per drug per month. Since well over half of residents of long-term-care facilities are supported by Medicaid, the apparent differences between those firms which supply nursing homes and the retail pharmacies are probably relatively unimportant.9 Payment under the Medicaid program is identical for all providers. DRUG UTILIZATION REVIEW IN NURSING HOMES
These data and other published information suggest that antibiotics are both expensive and commonly used in nursing homes.'0 For this reason we decided next to review the drug utilization review process in nursing homes. Since the government buys a substantial proportion of pharmaceuticals used in nursing homes, one might expect pharmacy services in nursing homes to be carefully regulated. Ambiguities in relevant federal and state statutes and the absence of extensive guidelines for antibiotic utilization review suggest that the present pharmacy review process may be less than optimal. In addition, because nursing homes have not been as affected by prospective payment programs as acute care facilities, studies of nursing home pharmacy practices have been concerned primarily with quality rather than cost. Medication usage has been Vol. 63, No. 6, July-August 1987
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suggested as a key indicator of quality of care in an important recent report from the National Academy of Sciences."I. The study notes that "excessive use of tranquilizers and antipsychotic drugs, medication errors and adverse drug reactions are evidence of poor quality in nursing homes." The current system of nursing home drug review evolved from the Federal Medicare (Title XVIII) and Medicaid (Title XIX) regulations as revised in 1974. In skilled nursing facilities, a pharmacist performs a monthly review of drugs prescribed for each resident.'2 In intermedicate care facilities these reviews may be carried out by a pharmacist or registered nurse.'3 The regulations further state that drugs may be obtained from outside pharmacists or stocked by the nursing home itself in accordance with federal, state, and local laws. Any irregularities discovered are to be reported to the medical director and administrator. There is also a requirement that each nursing home establish a pharmaceutical services committee responsible for policies regarding proper drug use. In Minnesota the only additional state statutes pertain to automatic stop orders, detailing of medication errors, and review of drug treatment by the charge nurse and attending physician every three months.'4 The drug review regulations thus focus entirely on issues perceived as important to quality control rather than to cost containment. Detailed guidelines for drug use and penalties for noncompliance are not included in these regulations. Research examining the drug review process in nursing homes has focused on the pharmacist's role in providing quality control. Most reports are published in the pharmacy literature and include studies of medication errors in nursing homes, the benefit of consulting clinical pharmacists or a centralized pharmacy service, polypharmacy, the impact of automatic stop orders and the acceptance of pharmacists' recommendations by physicians and nurses. Several studies have examined the medication error rate in nursing homes. Barker studied 58 nursing homes from a national sample.'5 He found a medication error rate (defined as errors/opportunity for errors) of 12.2% with a range of 0 to 59% per facility. When errors based on out-of-date or unsigned orders were excluded, the error rate was still 8%. Only 31 % of nursing homes had a rate of 6% or less. Since no precise technical guidelines about medication errors are included in federal drug review regulations, in 1980 the Department of Health and Human Services developed a list of indicators to assist in assessing compliance with the drug review requirement.'6 A study by Shannon et al. examined the benefit of these indicators in a study of Wisconsin nursing homes Vol. 63, No. 6, July-August 1987
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and found fewer drug administration irregularities per 100 residents in homes where these indicators were applied than in homes that did not apply them. 17 Witte et al.'8 studied the benefit of a consulting clinical pharmacist in 10 skilled nursing facilities as documented in 13,081 charts. Of those charts, 978 (7.1 %) indicated real or potential drug therapy problems. This study suggested there were eight potential drug therapy problems per 10 nursing home beds each year. The major problems identified were a lack of documented indication for the drug and a lack of monitoring for drug effectiveness (60% of the problems identified). Another study (19) evaluated the potential cost savings for nursing homes when comprehensive central pharmaceutical services were utilized. For the years 1970-1977 a 42.8% decline in the number of drugs per patient was seen (P
