Communication and teamwork : Studies of the impact on quality of drug use in swedish nursing homes

Sammanfattning: This thesis examines factors that affect the quality of drug-use practices in Swedish nursing homes.The analysis comprises six consecutive studies. Data from the first four studies come from a randomizedcontrolled trial conducted in 1994-1995 with the primary aim of assessing the impact of regularmultidisciplinary team interventions on the quantity and quality of drug prescribing in 36 nursing homes. Facilities in the experimental group participated in an outreach program designed to influence drug use through improved teamwork among physicians, pharmacists, nurses, and nurse's assistants. The data for the last two studies come from a follow-up study in the same sample of nursing homes.Baseline results showed extensive psychotropic drug prescribing, with the most commonly prescribeddrugs being hypnotics (40%), anxiolytics (40%), and antipsychotics (38%). After 12 months of team meetings in nursing homes in the experimental group, there was a significant decrease in the prescribing of inappropriate drugs, as defined by recommendations from the Swedish Medical Product Agency.Pharmacists documented the nature of drug-related problems discussed during the meetings, as well as staff member assessments of resident outcomes. The most common drug-related problems were unclear indications and the appropriate choice of drugs. Nineteen percent of changes in drug therapy had a beneficial effect on the resident's reported clinical status while 47% of changes resulted in no observable changes in clinical outcome. Eight percent of the changes were considered to have had a negative effect on the resident. In these situations, the previous therapy was restored. The remaining 26% were too complicated to evaluate; it was not possible for nursing staff to assess whether a behavioral change was a result of the change in drug therapy.Quality indicators based on published guidelines and recommendations were developed to measure quality of drug use. Using the facility as the unit of analysis, there was a great variation among facilities in the quality of drug use. Resident characteristics (age, sex, diagnosis) did not contribute to variation among facilities in the 1995 study; rather, facilities with multidisciplinary teams and/or a staff: resident ratio above the median, were found to have higher quality of drug use.To assess the long-term effects of the multidisciplinary team intervention, a follow-up study on druguse was conducted in 1998. In addition, nurses in the study's 36 nursing homes were interviewed regarding the quality of their communication with physicians.Three factors accounted for the major part of the variation in the quality of drug use in the follow-upstudy: Whether or not the homes received the experimental intervention; the perceived quality of nursephysician communication; and the proportion of residents with behavioral symptoms.In summary, this thesis provides convincing evidence that the level of drug use in Swedish nursinghomes is high, and the choice of drugs for use in the nursing home population is often inappropriate. Further, clinical characteristics of residents-explain some, but not all, of the large variation in the quality of drug use among facilities. Factors associated with higher quality of drug use include higher perceived quality of nurse-physician communication, and exposure to the structured multidisciplinary team intervention.