Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Securing care
- Mark D Oliver (15 March 2003)
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More questions raised for research findings
- Ann M Elkins (16 March 2003)
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Is different care worse care?
- David A de Berker (16 March 2003)
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A Patient Experience
- Name and address supplied (17 March 2003)
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Good news on antipsychotics
- Giovanni Gambassi, Rossella Liperoti, Claudio Pedone, Roberto Bernabei (18 March 2003)
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Damned if we do....?
- Jon Gurr (19 March 2003)
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A true comparison?
- Martin S Wolfson (20 March 2003)
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Author's response
- Tom Fahey, Alan A Montgomery, James Barnes, Jo Protheroe (7 April 2003)
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Equality of care exists through Ambulatory Services
- Robert Boland-Freitas, Katrina Chau and Nicholas Collins (10 April 2003)
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Neuroleptic and falls in nursing homes
- John R Harper, Marion E.T.McMurdo (7 May 2003)
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Mark D Oliver, GP principal Stafford ST16 3AT
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The best way to secure care compatible to normal general practitioners patients would be to get the nursing homes to bring these patients to surgery for their care.It is difficult to deliver structured care on a reactive nursing home call oput, of which there are very many. Perhaps a charge to the home for GP visits with a subsidy for arranging appropriate transport would solve the problem.Ironically they can currently only obtain transport to take them to outptients, a historic anachronism given the shedding of work to general practice. Competing interests: A busy GP |
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Ann M Elkins, Manager 185 Cooper St Epping VIC 3076 Australia
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Re your paper, “Quality of Care for elderly residents in nursing homes and elderly people living at home: controlled observational study” . I found this to be a very interesting article, as much for the issues researched as further quality issues identified which require further study. The article highlights gaps in the quality of service which a particular group in society can expect to be provided with. As the population continues to age, this is particularly relevant to all of us. Quality healthcare should be an expectation that does not depend on age, sex or race. Inappropriate medication prescribing can add to the healthcare budget significantly. Kohn refers to a study in which two teaching hospitals were found to a preventable adverse drug reaction for 2 out of every 100 admissions or about 2.8 million annually for a 700 bed teaching hospital. This leads to wondering about medication services provided by Outpatient services, physician offices, clinics, retail pharmacies and Nursing Homes. The increasing cost of healthcare may be cited as a reason why quality improvement cannot be undertaken, however it can also lead to significant cost savings once new systems are implemented and the related adverse events are prevented. In Australia there is a growing emphasis on the importance of appropriate medication with a number of projects receiving funding to focus on this. There is an increase in the numbers requiring a residential bed, and an increase in the numbers of older people with complex needs living at home. The over and under prescribing of appropriate medications is one area in which further research is obviously required – however it also raises the question about other differences which may be available to this group and the importance of also understanding them. Competing interests: None declared |
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David A de Berker, Consultant Dermatologist Bristol Dermatology Centre, Bristol Royal Infirmary, Bristol, BS2 8HW
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Tom Fahey's paper is interesting, but appears to take a position on nursing home care at the outset. I would generally agree that care in nursing homes is often not as good as we would wish, but I doubt that this paper can be used as evidence of this. There is no explicit description of the 2 groups of patients and so we are denied the ability to look at age, mobility (think of constipation), ability to consent (think of vaccination), number of hospital admissions (think of medications in general) and range of other diseases that might influence patient state and care. There is equally no recognition of the fact that if elderly people are at home this often reflects close involvement of relatives and this is a significant factor in maintaining effective interaction with healthcare services. A further factor is data collection - can the authors be sure that GPs and district nurses visiting nursing homes enter data on their computer systems as effectively after such visits for all those encountered as they do during consultations in the practice? Although the authors employed logistic regression, this is no substitute for clear data on 2 very different populations of patients. Where there are no clinical assessments it is of concern that the major issue of appropriate prescribing is judged according to statistical norms rather than in terms of the needs of individual patients. To conclude from this limited data that "elderly people in one UK city receive inadequate care when judged against explicit quality indicators" is the kind of snappy media comment that is stepping beyond the scope of this paper. Competing interests: None declared |
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Name and address supplied
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Those of us in receipt of care (either from relatives or in a nursing home) must thank Tom Fahey and his colleagues for their concerns. But before the medical profession embarks on measures to provide better treatment, I believe basic care of the elderly needs to be improved. I recently sent this account of my first stay in a nursing home to my MP. As an individual with savings, this nursing home care cost more than my sister's "respite" holiday. The key points are these:- 1. A stench of stale urine. I spent 32 days, 24 hours a day, in a bed where the previous incumbent had clearly been incontinent. And the bed was at least 40 years old, it had an "old-fashioned" wire mattress that sagged. 2. There was no supervision of other patients. A mentally disturbed man regularly came into my room at night thinking it was the toilet. He would urinate against the wall. I was fearful that he might urinate over me and wondered whether this explained the appalling state of the bed. Assistance took many minutes to arrive, and never any apology, just the comment "John has done it again". 3. Sometimes, a meal was "missed"; I was told they had forgotten me! And food was totally inadequate - an evening "meal" of one and a half rounds of bread with a little spread of some sort is not sufficient: never any fresh fruit or vegetables. Three meals were crammed into the time between 9.0am and 4.30pm, so that night staff had no meals to prepare; sleepless, hungry nights are not fun for someone in pain! 4. Patients are isolated. I saw someone only when food was brought. 5. A bedridden patient has to provide their own TV, radio etc - there is no access to newspapers or books. How many simply stare at a blank ceiling? How can a patient complain? It was impossible to make a telephone call because a bedridden patient could not access the fixed payphone. In addition, at that time I was unable to write. (I write this with voice activated computing). I cannot begin to explain how vulnerable the patient feels; a complaint might have repercussions. I would wish to erase this experience from my mind. Thankfully, I since found a "better" nursing home for more recent "holidays" and I now take a mobile phone along with my TV, radio, books and magazines. I can also now "talk" to my computer and hope that one day a radio link may allow access to an Internet Service Provider. Why should a bedridden patient be subject to worse conditions than a prisoner? The whole provision of nursing care needs thorough investigation. Competing interests: None declared |
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Giovanni Gambassi, Associate Professor of Medicine Università Cattolica, 00168 Rome, Italy, Rossella Liperoti, Claudio Pedone, Roberto Bernabei
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The use of antipsychotics in general and more so in nursing homes has been a concern for many years. Reported high rates have been considered indicative of poor care or malpractice. In the United States, a highly regulatory system has had an impact on the prescribing of antipsychotics in nursing homes.(1) The results of a recent study analyzing data from 1999 and 2000 show than overall no more than 15% of elderly residents receive antipsychotics.(2) This estimate is consistent with a previous estimate of 17-18% using aggregate data from all the nursing homes in the contiguous US in 1997.(3) In general, the pattern of antipsychotic drugs use seems indicative of good practice. We observed a 3:2 ratio between atypical and conventional agents with a consistent trend for atypical to replace conventional antipsychotics. The prescription is restricted to psychiatric patients (7 out of 10 treated) or to patients with cognitive impairment who display behavioral and/or psychological disturbances (1 out of 4 patients treated). The inappropriate use of antipsychotics appears to be negligible (<1%). Daily doses and modality of use are in accordance with FDA recommendations. However, the enthusiasm is a little attenuated by the evidence of large differences among nursing homes. All in all, good news on antipsychotics! 1. Hughes CM, Lapane KL, Mor V, et al. The impact of legislation on psychotropic drug use in nursing homes: a cross-national perspective: J Am Geriatr Soc 2000;48:931-7 2. Liperoti R, Mor V, Lapane KL, et al. The use of antipsychotics in nursing homes: how is it atypical? J Clin Psychiatry (in press) 3. Hughes CM, Lapane KL, Mor V. Influence of facility characteristics on use of antipsychotic medications in nursing homes. Med Care 2000;38:1164- 73 Competing interests: None declared |
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Jon Gurr, GP Partner Huddersfield HD5 8XW
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Shortly before reading about this article on the BBC News Website, my partner had described to me her visit, the previous day, to one of the nursing homes we cover. We have been getting a very large number of requests from this home for night sedation and similar drugs, and she commented that she had thought that the staff were going to barricade the doors to prevent her leaving until she had prescribed the requested items. A receptionist has also told me that a staff member from the home had hinted that they would complain to the PCT if I did not prescribe as asked. It seems that GPs cannot win here, and refusals are met by much wailing and gnashing of teeth and heart-rending tales of vulnerable insomniac residents. On a wider scale, however, I wonder why it is worthy of comment that patients who require nursing home care are on more medication than their peers who are managing a more independant existence, and why this fact should be taken as a sign of inadequate care. It was not even clear whether we GPs are over-or-under prescribing. I am sure there are up-to- date figures for the proportion of Care-of-Elderly admissions which are iatrogenic, and if you wanted to draw up a rogues gallery of responsible drugs, I am sure that beta-blockers and aspirin would not be left out. I attempt, with very limited time, and against often competing interests, to tailor my care to the individual circumstances of my patients, and to resist the pressure to reduce them to a list of tick- boxes. To take another swipe, it appears that if I wish to increase, or even maintain my income if the New Contract does come in, that I will face ever more such pressure. Competing interests: GP struggling with Nursing Home demands |
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Martin S Wolfson, GP Claremont Med Centre, Surbiton, Surrey KT6 6BS
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Patients in nursing homes are more likely than patients of the same age living in the community to be suffering from, multiple pathologies, immobility, psychological problems, poor diet & limited life expectancy. They are therefore more likely to need psychoactive medication & laxatives as well as it being more often inappropriate for them to receive life prolonging medication such as beta blockers. Likewise the need for biological measurements. We should be careful to ensure we are comparing like with like. Competing interests: None declared |
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Tom Fahey, Prof of Primary Care Medicine Tayside Centre for General Practice, Kirsty Semple Way, Dundee DD2 4AD, Alan A Montgomery, James Barnes, Jo Protheroe
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Editor, We thank the contributors for interest in our paper. We wish to clarify some issues that they raise: There is explicit description of the characteristics of the two groups- nursing home residents and people living at home with regard to age, sex, number of current diagnoses and number of current medications in Table 1 of the full version of our paper. Furthermore, odds ratios for all comparisons concerning quality of care were adjusted for age, sex, practice, total number of diagnoses and total number of drugs prescribed. We agree that the care given by relatives is important; however medical care should not be dependent on this issue. Elderly patients should receive high quality care irrespective of their family support. Data collection was by means of both the written and computerized record. Most of the indicators related to prescribed medication or laboratory investigations. Suggesting that blood pressure readings may have been taken but not recorded in the patient’s notes rather misses the point. If a GP is to make a treatment decision based on previous readings, then these readings must be available in the medical record. We feel that our conclusions are justified. We took care to generate quality indicators prior to the start of the study that were well recognized and validated. We ensured that participating GPs agreed with the quality indicators prior to the start of the study- if we did not have unanimous agreement the quality indicator was removed. We found that for several indicators nursing homes residents fared less well than their controls- hence the conclusion of our study. We feel further investigation is required into the care elderly patients receive in terms of poly- pharmacy, nutrition, wound and nursing care. Lastly, we feel that several commentators highlight the need to have the necessary organizational structure in place to ensure that GPs and nurses have the time and resources to provide co-ordinated, ongoing care to this vulnerable group of patients. Competing interests: None declared |
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Robert Boland-Freitas, 4th Year Medical Student Macarthur Health Service, P O Box 149, Campbelltown NSW 2560, Katrina Chau and Nicholas Collins
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Fahey et al.,(1) have suggested that future studies on the health care that elderly patients receive focus on access to and quality of care. This is particularly important with the expansion of the elderly population in Western nations, such as the UK and Australia. Hospital in the Home (HITH), or Ambulatory Care services, provide an avenue for maintaining equal access to quality care for all elderly patients, regardless of residence, in managing acute medical problems and exacerbations of chronic disease. These services offer patients the opportunity to access multidisciplinary hospital-type treatment in a familiar environment. There are advantages of this approach, which include fewer complications, such as nosocomial infections, confusion, and bowel and urinary problems compared with admission to a hospital ward (2). There are also elevated levels of satisfaction with care in the patient, their carers and GP’s, relative to inpatient care. (2),(3),(4) Furthermore, studies have shown that HITH services may be a cost- effective alternative (4). The multidisciplinary approach provided by HITH and Ambulatory Care services cultivates good channels of communication with General Practitioners, carers and nursing home staff (5). This further enhances the important role that ambulatory services can provide when elderly patients require access to appropriate health care. (1) Fahey T, Montgomery AA, Barnes J, Protheroe J. Quality of care for elderly residents in nursing homes and elderly people living at home: controlled observational study. BMJ 2003:326:580-584. (2) Caplan GA, Ward JA, Brennan NJ, Coconis J, Board N, Brown A. Hospital in the home: a randomised controlled trial. MJA 1999; 170:156- 170. (3) Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care. The Cochrane Library (4):2002. (4) Jester R, Hicks C. Using cost-effectiveness analysis to compare hospital at home and in-patient intervention. Journal of Clinical Nursing 2003:12(1):13-27. (5) Montalto M. Hospital in the nursing home. Australian Family Physician 2001:30(10):1010-1012. Competing interests: None declared |
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John R Harper, Clinical Lecturer Ageing & Health, Department of Medicine, Ninewells Hospital and Medical School, Dundee, DD1 9SY., Marion E.T.McMurdo
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Editor, Professor Fahey’s paper found that over a quarter (28%) of elderly residents of nursing homes were prescribed neuroleptics1. The level is similar to that found in a study of 28 nursing homes in Glasgow (24%), reported in 19962. In most cases these drugs are prescribed in nursing homes for behavioural disturbances in the context of dementia. This occurs despite the lack of convincing evidence for their efficacy in this setting. A meta-analysis of the use of neuroleptics for agitation associated with dementia found that less than one in five of treated patients could be expected to show symptomatic benefit.3 The widespread use of neuroleptics in institutionalised older people is of particular importance when falls are considered. Incidence rates of falls in nursing homes are almost three times those for community-dwelling older people, due to the frailty and co-morbidity of many residents4. There is a clear link between falls and the use of neuroleptics in older people. In a meta-analysis neuroleptics conferred a higher risk of falls (Odds Ratio 1.66) than benzodiazepines, and an equal risk to antidepressants, when psychiatric inpatients were excluded from the analysis5.The inappropriate use of neuroleptics represents one risk factor for falls in nursing homes that can realistically be addressed. Trials have shown that neuroleptics can be successfully withdrawn, by gradual dose reduction, in the majority of institutionalised older people on long term prescriptions5. An educational programme encouraging, although not mandating, trials of drug withdrawal resulted in a discontinuation of neuroleptics in a third of nursing home residents6 Neuroleptics undoubtedly have a role in specific situations such as psychosis and controlling dangerous behaviour, but they have been used indiscriminately for too long in many institutionalised older people. The growing recognition of the importance of falls in older people, and a widening evidence-base for falls’ risk factors, should act as a further incentive to reduce the use of neuroleptics in institutionalised older people. Dr John R. Harper, Prof. Marion E.T. McMurdo
Reference List 1. Fahey T, Montgomery AA, Barnes J, Protheroe J. Quality of care for elderly residents in nursing homes and elderly people living at home: controlled observational study. BMJ 2003;326:580. 2. McGrath AM,.Jackson GA. Survey of neuroleptic prescribing in residents of nursing homes in Glasgow. BMJ 1996;312:611-2. 3. Schneider LS, Pollock VE, Lyness SA. A metaanalysis of controlled trials of neuroleptic treatment in dementia. J.Am.Geriatr.Soc. 1990;38:553 -63. 4. Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann.Intern.Med. 1994;121:442-51. 5. Cohen-Mansfield J, Lipson S, Werner P, Billig N, Taylor L, Woosley R. Withdrawal of haloperidol, thioridazine, and lorazepam in the nursing home: a controlled, double-blind study. Arch.Intern.Med. 1999;159:1733-40. 6. Meador KG, Taylor JA, Thapa PB, Fought RL, Ray WA. Predictors of antipsychotic withdrawal or dose reduction in a randomized controlled trial of provider education. J.Am.Geriatr.Soc. 1997;45:207-10. Competing interests: None declared |
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