MRNH (Medication Review in Nursing homes) implémentation

The aging population is a challenge for healthcare systems, as many people suffer from multiple diseases requiring polymedications. Polypharmacy, the use of five or more medications, can cause Drug Related Problems (DRPs) including the use of potentially inappropriate medications (PIMs), i.e. drugs with a possible negative benefit-risk balance. Many services, such as clinical decision support systems or medication reviews, have been initiated to address DRPs or PIMs, but their implementation in practice remains challenging and not frequently reported. 

Objectives

In 2021, we led an implementation and impact study in ten pilot Swiss nursing homes (NH), with the aim of performing medication reviews in ten percent of their residents. The main objectives of the study were:

1. To evaluate the implementation of medication reviews in terms of reach, adoption, fidelity, acceptability, feasibility and maintenance, and to describe implementation processes and strategies
2. To assess the impact of medication reviews on the proportion of resolved DRPs at follow-up (four months )

Methods 

This observational study was a type 2 hybrid implementation design and used a mixed-method approach. Relevant implementation outcomes have been defined through the FISpH and RE-AIM frameworks. Data were collected through questionnaires, focus groups and administrative records. DRPs at baseline and follow up were collected based on treatment modifications plans and coded according to the PCNE classification for Drug-Related Problems V9.1. 

Results 

The ten pilot NHs involved 19 physicians, 18 nurses and 12 pharmacists. Eight NHs have completed the ten percent objective, with a total of 58 medication reviews completed between March and September 2021. Data from 43 medication reviews were transmitted to the research team. The mean number of DRPs detected by pharmacist per resident was 5.2 SD 2.1, of which 42% related to safety issues, 29% were related to effectiveness issues and 29% related to other issues. As a result of the interprofessional team discussion, 147 treatment modifications issued from the 229 propositions to resolve DRPs made by pharmacists were decided, 128 implemented and 122 maintained at follow-up (4 months). The main reasons for non-implementation were patients’ refusal or death, and reintroduction of medication due to recurrence of symptoms. 

Conclusion 

A preliminary analysis of the questionnaires and focus groups shows that medication reviews are feasible, acceptable and recommendable by healthcare providers. This supported the decision of the regional health department to extend the service to more nursing homes in 2022.