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Original Study
Exploring Variation in Rates of Polypharmacy Across Long Term Care Homes

https://doi.org/10.1016/j.jamda.2011.07.001Get rights and content

Abstract

Objective

Use of multiple, concurrent drug therapies, often referred to as polypharmacy, is a concern in the long term care (LTC) setting, where frail older adults are particularly at risk for adverse events. We quantified the scope of this practice by exploring variation in the use of nine or more drug therapies across LTC homes.

Design

Cross-sectional analysis of LTC home census data.

Setting

All LTC homes in Ontario, Canada.

Participants

A total of 64,394 LTC residents aged 66 years and older residing in 589 LTC homes in the fall of 2005.

Measurements

Facility-level rates of polypharmacy were compared with rates of use of Beers criteria and antipsychotic drug therapies. Multivariate logistic regression models were used to assess predictors of polypharmacy across residents and LTC homes.

Results

Nine or more drug therapies were dispensed concurrently to 10,007 (15.5%) of LTC home residents. Compared with those dispensed fewer drugs, residents receiving 9 or more drug therapies were more likely to have multiple comorbidities. There was threefold variation in polypharmacy rates across homes (26.2% versus 7.9%) and facility-level rates of polypharmacy were modestly correlated with rates of use of Beers criteria drugs (r = 0.27, P < .001) and antipsychotic drug therapies (r = 0.16, P < .001). Controlling for resident factors, those living in LTC homes with high polypharmacy rates were more likely to receive 9 or more drug therapies (odds ratio 1.9, 95% confidence interval 1.7–2.0).

Conclusion

Residents in Ontario LTC homes commonly received nine or more concurrent drug therapies, particularly residents with multiple chronic conditions. The threefold variation in rate across homes suggests a role for this measure in guiding drug review at the facility level.

Section snippets

Setting

In Ontario, publically funded residential LTC is available for individuals who require access to 24-hour nursing care and supervision within a secure setting.20 The provincial government sets standards for care, inspects homes annually, and sets the rules governing eligibility through a centralized admission process. Payments are based on a resident needs-based formula and cover nursing and personal care, quality of life programs, food, and accommodation costs. Residents also pay a fixed

Results

In our cohort, 10,007 (15.5%) of prevalent LTC residents were concurrently dispensed nine or more drug therapies and, among these individuals, 1294 (2.0% of all residents) received 13 or more drug therapies. Few residents (1835 or 2.9%) received no drug therapy and the remaining 52,552 (81.6%) were dispensed between one and eight drugs. Table 1 highlights the most commonly dispensed drug therapies by subclass. Among LTC residents with at least one drug claim, diuretics (37.7%), antipsychotic

Discussion

Our population-based study found that 15% of long term care home residents were dispensed nine or more drug therapies concurrently. Although drug therapies used to treat chronic conditions (such as diuretics, proton pump inhibitors, and angiotensin-converting enzyme inhibitors) were most prevalent in this subgroup of residents, psychoactive drug subclasses (such as benzodiazepine derivatives and antipsychotic agents) were also common. There was considerable variation in the rate of polypharmacy

Conclusion

Residents in Ontario LTC homes commonly received 9 or more drug therapies concurrently. Although the practice of polypharmacy at the resident level is likely appropriately concentrated in individuals with multiple chronic conditions, the high rate of polypharmacy in certain facilities, the threefold variation in use across provincial LTC homes, and the correlation with other measures of inappropriate prescribing suggest a role for this measure in guiding drug review at the facility level.

Acknowledgments

The authors acknowledge Ping Li for her assistance with data management and analysis. They also thank Brogan Incorporated, Ottawa, for use of their Drug Product and Therapeutic Class Database.

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    An earlier version of this study was accepted for poster presentation at the AcademyHealth Annual Research Meeting, June 28–30, 2009, in Chicago, IL and at the Ontario Long-Term Care Association Applied Research Education Day, November 27, 2009.

    This research was funded by the Canadian Institutes of Health Research (CIHR) through an operating grant (Prescribing quality in long-term care homes: correlation between overuse, underuse & misuse – MOP-93642), an Interdisciplinary Capacity Enhancement grant (HOA-80075) and a Team grant (OTG-88591) through the Institute of Nutrition, Metabolism, and Diabetes. S.E.B. is supported by a New Investigator Award in the Area of Aging from CIHR, S.S.G. is supported by a New Investigator Award from CIHR, and C.M.B. is supported by a Chair in Patient Safety and Continuity of Care from CIHR and the Canadian Patient Safety Institute.

    This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the MOHLTC is intended or should be inferred.

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