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J Am Med Dir Assoc. 2019 Sep 23. pii: S1525-8610(19)30585-7. doi: 10.1016/j.jamda.2019.07.025. [Epub ahead of print]

Optimizing Prescribing of Antipsychotics in Long-Term Care (OPAL): A Stepped-Wedge Trial.

Author information

1
Division of Geriatric Psychiatry, Queen's University, Kingston, Ontario, Canada. Electronic address: kirkhamj@providencecare.ca.
2
School of Pharmacy and Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada.
3
Division of Geriatric Psychiatry, Queen's University, Kingston, Ontario, Canada.

Abstract

BACKGROUND:

Inappropriate antipsychotic prescribing is a key quality indicator by which clinical outcomes might be monitored and improved in long-term care (LTC), but limited evidence exists on the most effective strategies for reducing inappropriate antipsychotic use.

OBJECTIVES:

The objective of the study was to evaluate a multicomponent approach to reduce inappropriate prescribing of antipsychotics in LTC.

DESIGN:

A prospective, stepped-wedge study design was used to evaluate the effect of the intervention.

SETTINGS AND PARTICIPANTS:

Interdisciplinary staff at 10 Canadian LTC facilities.

METHODS:

The intervention consisted of an educational in-service, provision of evidence-based tools to assess and monitor neuropsychiatric symptoms (NPS) in dementia, and monthly interprofessional team meetings. The primary outcome was the proportion of residents receiving an antipsychotic without a diagnosis of psychosis using a standardized antipsychotic quality indicator.

RESULTS:

The weighted mean change in inappropriate antipsychotic prescribing rate from baseline to 12-month follow-up was -4.6% [standard deviation (SD) = 2.8%, P < .0001], representing a 16.1% (SD = 17.0) relative reduction. After adjusting for site, the odds ratio for the inappropriate antipsychotic prescribing quality indicator at 12 months compared to baseline was 0.73 (95% confidence interval = 0.48-0.94; chi-square = 6.59; P = .01). There were no significant changes in related quality indicators, including falls, restraint use, or behavioral symptoms.

CONCLUSIONS AND IMPLICATIONS:

This multicomponent intervention was effective in reducing inappropriate antipsychotic prescribing in LTC without adversely affecting other domains related to quality of care, and offers a practical means by which to improve the care of older adults with dementia in LTC.

KEYWORDS:

Antipsychotic; dementia; long-term care

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