Sometimes I worry that we are not making progress in our goal of improving the health of older Americans. Sometimes, the process of incremental change with its two steps forward, one step back seems more like going nowhere.
As I wrote in a recent post, the Foundation has been working on problems in medication prescribing and use among older people for 30 years. Occasionally we have rejoiced at what might have seemed impressive changes, such as the passage of the Omnibus Budget Reconciliation Act of 1987 (known affectionately as OBRA '87), which addressed medication problems in nursing homes. It specifically targeted dangerous uses of medications aimed at controlling "behavioral problems" of long-term care residents through drugs. But recently I saw two things that made me question even this progress. I’ll talk about the first one today.
First, in the New York Times's “New Old Age” column there was a fine piece describing a nursing home that had radically reduced its use of anti-psychotic and anti-anxiety medications by using behavioral interventions (like redirection and distraction). Staff found that when they reduced or eliminated medication "the mental fog" cleared among residents. After they instituted proper pain control, residents’ quality of life seemed to improve.
Great stuff. But this is 2011. Why are we still fixing things that OBRA 87 was intended to fix—nearly 25 years ago? The law and subsequent regulation requires that use of psychotropic medications be kept to the minimum necessary, specifically to prevent the use of "chemical straight-jackets" in facilities that find it easier to administer drugs than to provide high quality care. Dr. Mark Lachs, former Beeson Scholar, and long-time friend of the foundation is quoted in the New Old Age piece, “If a place is understaffed, if it takes particularly unruly patients, you can see how it happens . . . Behavioral interventions are far more time-consuming than giving a pill.”
Yes, of course, that is the tension and trade-off in nursing home care. We see similar trade-offs throughout health care where services reimbursed at low rates are done less and less well (see "Wrongness Baked Right In"). But under OBRA '87, the Centers for Medicare and Medicaid Services requires a monthly review of prescriptions for nursing home residents by a pharmacist to identify any problems and issues. (See below; the best part is the explicit point that not only must irregularities be reported but that "these reports must be acted upon." CMS must have been expecting indifference—with good reason, apparently.)
F428 https://www.cms.gov/transmittals/downloads/R22SOMA.pdf, p. 508.
§483.60(c) Drug Regimen Review
(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.
(2) The pharmacist must report any irregularities to the attending physician, and the director of nursing, and these reports must be acted upon.
In 2006, CMS updated the rules with additional clarification:
(Rev. 22, Issued: 12-15-06, Effective/Implementation: 12-18-06)
INTENT (F428) 42 CFR 483.60(c)(1)(2) Medication Regimen Review
The intent of this requirement is that the facility maintains the resident’s highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing:
• A licensed pharmacist’s review of each resident’s regimen of medications at least monthly; or
• A more frequent review of the regimen depending upon the resident’s condition and the risks or adverse consequences related to current medication(s);
I’d like to think things are finally getting better. Despite the lingering problems in the long-term care system, I still have hope that things can improve. The new Annual Wellness Visit (see “New for 2011”), for example, includes regulations calling for medication reviews and a full listing of providers participating in a patient’s care. If done right, this could be the next best thing to a brown bag medication review. But if nursing home overuse of medications is any example, is there really any reason for hope? On Thursday, I’ll discuss another article that makes me uneasy about our progress on reducing inappropriate medication use in nursing homes.