Hans Wouters, PhD; Jessica Scheper, MD; Hedi Koning, MSc; Chris Brouwer, MSc; Jos W. Twisk, PhD; Helene van der Meer, MSc; Froukje Boersma, MD, PhD; Sytse U. Zuidema, MD, PhD; Katja Taxis, PhD
Acknowledgment: The authors thank the nursing home residents, their family members, and the health professionals involved in the study for their contributions. They also thank Dr. Roel Grol and Dr. Simon Horsburgh for commenting on earlier versions of the manuscript.
Grant Support: By the Netherlands Organisation for Health Research and Development (grant 80-83600-98-10176).
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-2729.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: See the Supplement and reference 20 . Statistical code and data set: Available from Prof. Taxis (e-mail, email@example.com).
Requests for Single Reprints: Hans Wouters, PhD, Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, Oostersingel, Building 50, PO Box 196, 9700 AD Groningen, the Netherlands; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Wouters and Boersma and Prof. Zuidema: Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, Oostersingel, Building 50, PO Box 196, 9700 AD Groningen, the Netherlands.
Dr. Scheper, Ms. Koning, Mr. Brouwer, Ms. van der Meer, and Prof. Taxis: Department of PharmacoTherapy, Epidemiology & Economics (PTEE), Groningen Research Institute of Pharmacy, Faculty of Science and Engineering, University of Groningen, A. Deusinglaan 1, 9713 AV Groningen, the Netherlands.
Prof. Twisk: Professor in Biostatistics, Department of Epidemiology and Biostatistics, VU University Medical Center, De Boelelaan 1089a, Amsterdam, the Netherlands.
Author Contributions: Conception and design: H. Wouters, H. van der Meer, F. Boersma, S.U. Zuidema, K. Taxis.
Analysis and interpretation of the data: H. Wouters, J. Scheper, H. Koning, C. Brouwer, J.W. Twisk, H. van der Meer, F. Boersma, S.U. Zuidema, K. Taxis.
Drafting of the article: H. Wouters, S.U. Zuidema, K. Taxis.
Critical revision of the article for important intellectual content: J. Scheper, J.W. Twisk, H. van der Meer, F. Boersma, S.U. Zuidema, K. Taxis.
Final approval of the article: H. Wouters, J. Scheper, H. Koning, C. Brouwer, J.W. Twisk, H. van der Meer, F. Boersma, S.U. Zuidema, K. Taxis.
Provision of study materials or patients: J. Scheper, H. Koning, H. van der Meer, S.U. Zuidema.
Statistical expertise: J.W. Twisk.
Obtaining of funding: S.U. Zuidema, K. Taxis.
Administrative, technical, or logistic support: H. Wouters, J. Scheper, H. Koning, C. Brouwer, H. van der Meer.
Collection and assembly of data: J. Scheper, H. Koning, C. Brouwer.
Inappropriate prescribing is a well-known clinical problem in nursing home residents, but few interventions have focused on reducing inappropriate medication use.
To examine successful discontinuation of inappropriate medication use and to improve prescribing in nursing home residents.
Pragmatic cluster randomized controlled trial, with clustering by elder care physicians and their wards. (ClinicalTrials.gov: NCT01876095)
59 Dutch nursing home wards for long-term care.
Residents with a life expectancy greater than 4 weeks who consented to treatment with medication.
Multidisciplinary Multistep Medication Review (3MR) consisting of an assessment of the patient perspective, medical history, critical appraisal of medications, a meeting between the treating elder care physician and the pharmacist, and implementation of medication changes.
Successful discontinuation of use of at least 1 inappropriate drug (that is, without relapse or severe withdrawal symptoms) and clinical outcomes (neuropsychiatric symptoms, cognitive function, and quality of life) after 4 months of follow-up.
Nineteen elder care physicians (33 wards) performed the 3MR, and 16 elder care physicians (26 wards) followed standard procedures. A total of 426 nursing home residents (233 in the intervention group and 193 in the control group) were followed for an average of 144 days (SD, 21). In an analysis of all participants, use of at least 1 inappropriate medication was successfully discontinued for 91 (39.1%) residents in the intervention group versus 57 (29.5%) in the control group (adjusted relative risk, 1.37 [95% CI, 1.02 to 1.75]). Clinical outcomes did not deteriorate between baseline and follow-up.
The 3MR was done only once. Some withdrawal symptoms or relapses may have been missed.
The 3MR is effective in discontinuing inappropriate medication use in frail nursing home residents without a decline in their well-being.
Netherlands Organisation for Health Research and Development.
Wouters H, Scheper J, Koning H, Brouwer C, Twisk JW, van der Meer H, et al. Discontinuing Inappropriate Medication Use in Nursing Home Residents: A Cluster Randomized Controlled Trial. Ann Intern Med. [Epub ahead of print 10 October 2017]167:609–617. doi: 10.7326/M16-2729
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Published: Ann Intern Med. 2017;167(9):609-617.
Published at www.annals.org on 10 October 2017
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