White Paper on Quality Pharmaceutical Care in Long Term Care
Introduction
Medication errors and adverse drug events have been addressed in many clinical
trials, research studies, and review articles over the years. However, rarely does this
data focus on elderly patients in long term care settings. Long term care medical directors
and attending physicians--working with the interdisciplinary team--have attempted
to address the complex issue of medication management within their facilities. Yet the
reality is that medication errors and adverse drug events continue to occur.
In November 1997, the Office of the Inspector General (OIG) released a series of
reports on "Prescription Drug Use in Nursing Homes," which concluded that "the
intent of the provisions of the OBRA Acts concerning prescription drug usage are being
clearly fulfilled." While the scientific merit of the reports was called into question,
they nonetheless triggered a great deal of talk about inappropriate drug prescribing and
usage in long term care. It became clear that, while individual practitioners and/or
facilities were making strong efforts to reduce medication errors, there were no national,
interdisciplinary initiatives directed toward encouraging widespread change specific
to long term care.
Like many other groups, the American Medical Directors Association (AMDA) was
concerned about the objectivity and validity of the data in the OIG reports. Nonetheless,
AMDA took a proactive response to the reports and saw them as a springboard to
creating a catalyst for change. In 1998, AMDA established the National Forum on Quality
Pharmaceutical Care in Long Term Care with the ultimate aim of continuous
improvement of quality patient care. The goals of the Forum are to create a proactive
solution, rather than a reactive list of inappropriate medications or problem drugs;
define the ideal process; identify key outcomes and indicators; and identify specific
areas of opportunity to improve the current process.
AMDA convened leaders in long term care as the National
Forum on Quality Pharmaceutical Care Advisory Committee on September 13, 1998, in
Bethesda, MD. The group, which included physicians and other practitioners, administrators, and
pharmaceutical industry representatives, developed specific goals, objectives, and plans
for an invitational consensus conference, set for November
5-7, 1998. The results of the November conference are a cornerstone for the Forum's efforts
to address issues related to medication prescribing, usage, and monitoring throughout the
long term care continuum.
Phase one of this initiative revolved around the November conference and aimed at
reaching consensus on issues including the roles of physicians and other
interdisciplinary team members in assuring quality pharmaceutical care and identifying
root causes of medication prescribing and usage errors. This meeting brought together
medical directors, physicians, and other practitioners with industry leaders, government
officials, providers, and nationally recognized experts. Future phases could involve
the development and dissemination of educational programs and materials, research
data, guidelines, and other tools.
During the Advisory Committee meeting, AMDA Board members and Advisory
Committee co-chairs Jacob Dimant, MD, CMD, and Cheryl Phillips, MD, CMD, worked
with the group to determine topics and tasks to be addressed at the November
conference and identify invited participants and speakers.
"The OIG report on drug prescribing in long term care facilities triggered a great
deal of talk about inappropriate drug prescribing and usage in long term care," Dr.
Phillips told the group. "And while the report's scientific merit has been called into
question, it is clear that there are problems relating to medication prescribing, usage,
and monitoring that need to be addressed," she said, adding, "This Forum represents
a rational approach to solutions."
Dr. Dimant noted, "The idea for this Forum preceded the OIG report. But until now,
we've never had a comprehensive approach." "We want this to be a true partnership of
all stakeholders, including medical directors, attending physicians, nurses, pharmacists,
administrators, vendor pharmacies, and all others playing active roles," he added.
This white paper is based on the results of the consensus conference and examines
a number of questions addressed during the meeting. This paper includes the following:
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