An Evaluation of the Impact of Physician Education on Prescribing for Hypertension in a Nursing Home

Abstract

Background: Nursing home residents are a frail population with multiple co-morbidities, and at risk for polypharmacy and its associated adverse events. Nevertheless, most clinical practice guidelines (CPGs) do not consider the significance of frailty when making treatment recommendations and there is little information to guide prescribing practices for the frail elderly. To deal with this issue, new treatment recommendations for hypertension, specific to the frail elderly, have been developed by local experts in Halifax, Nova Scotia through the Dalhousie Academic Detailing Service (ADS) and PATH (Palliative and Therapeutic Harmonization) programs. Objectives: To determine the effect of an educational intervention on appropriateness of prescribing medications for hypertension in a nursing home setting, from baseline to 7 months post-intervention, by measuring adherence to four key messages within the ADS/PATH treatment recommendations. Methodology: Observational, before and after study in a single nursing home in Halifax, Nova Scotia. Chart Review of 138 nursing home residents from September 2012 to May 2013. Results: The percentage of residents taking one or more medication affecting blood pressure decreased from 60.2% prior to the intervention to 51.9% in the post-intervention population (p=0.003) The proportion of residents prescribed 2 or more medications affecting blood pressure decreased from 36.4% pre-intervention to 23.1% post intervention (p=0.002). At least one medication affecting blood pressure was discontinued in 25% of residents during the study period. Median monthly cost for medications affecting blood pressure was $4.18 pre-intervention and decreased to $1.05 post-intervention (p<0.001). Proportion of residents with at least one fall decreased from 50% in the 6 months prior to the educational intervention to 34% post-intervention (p=0.028). There was no change in mean blood pressure between time points (123/67 pre- vs 119/68 post-intervention). Conclusion: Nursing home residents were generally over-treated with medications that affect blood pressure. A multi-faceted educational intervention based on treatment recommendations specific to the frail elderly can decrease the use of medications affecting blood pressure in a frail population. Decreasing the use of medications that lower blood pressure decreased the proportion of residents with a fall and lowered medication costs.