Clinical Geriatrics

Oversight of long-term care (LTC) prescribing is getting a little more difficult because, on top of the restrictions on access imposed on prescribers as a result of Medicare Part D, there are now additional pressures being applied by LTC state surveyors. These new surveyor pressures are the results of the revised survey guidelines concerning pharmacy services and unnecessary medications that were introduced on December 18, 2006. In addition to these factors, it appears likely that legislative changes planned for Medicare Part D may place even greater restrictions on prescribing.

The Need for Prescribing Guidance
The perceived need for restrictions on prescribing comes from our current clinical, economic, and political environment. On the clinical side, there continue to be reports of failure to follow evidence-based guidelines such as the Beers Criteria.¹ Dr. Steven Handler in The American Journal of Geriatric Pharmacotherapy concluded that medication-related adverse events are common in the nursing home setting.² A recent study published in The New England Journal of Medicine caught national headlines in concluding that adverse effects of atypical antipsychotic drugs overall offset any advantages in their efficacy in the treatment of psychosis, aggression, or agitation in patients with Alzheimer’s disease.³

On the economic side, with increasing demand for prescription drugs for a growing number of elderly persons, as well as enhanced availability of innovative products, payors are looking to apply greater guidance to assure that utilization is controlled. This is especially severe in LTC, where nursing home residents take an average of 8.8 medications per day, and 32% take 9 or more medications.⁴ But of course it is not only the direct cost of the medications that is an issue but also the costs associated with medication-related adverse events, which was estimated to be $4 billion per year in a 1997 study.⁵

These economic pressures are especially acute given that the federal government is now the primary payor for the vast majority of medications for the elderly. These forces are coming together to cause regulations and other restrictions to guide prescription access to what is considered appropriate. All too often, however, the determination of appropriate access may be directed by non-clinicians.

Medication Therapy Management
One way that the prescription guidance has historically been applied in LTC is through medication regimen review. The State Operating Manual (SOM) F428—Medication Regimen Review (MRR) requires that the drug regimen of each resident must be reviewed at least once per month by a licensed pharmacist. The pharmacist must report any irregularities to the attending physician and the director of nursing; these reports must then be acted upon. This is not to say that this report must be accepted, but attending physicians are obligated to acknowledge recommendations. The acknowledgement of these recommendations must include clear documentation of acceptance or clinical reasoning as to why the recommendations were not followed.

The goal of MRR is to promote positive outcomes and minimize adverse consequences associated with medications. This review includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities and collaborating with other members of the interdisciplinary team. The consultant pharmacist reviews are targeted to eliminate medication-related problems that arise from the use of a medication without adequate indication for use, or identifiable evidence that safer alternatives or more clinically appropriate medications have been considered.