Effect of a multimethod quality improvement intervention on antipsychotic medication use among residents of long-term care

Abstract

Background: Antipsychotic medications are used to address neuropsychiatric symptoms associated with dementia. Evidence suggests that among older adults with dementia, their harms outweigh their benefits. A quality improvement initiative was conducted to address inappropriate antipsychotic medication use in long-term care (LTC) in the province of Alberta.

Methods: We conducted a multimethod evaluation of the provincial implementation of the project in 170 LTC sites over a 3-year project period incorporating a quasi-experimental before-after design. Using a three-component intervention of education and audit and feedback delivered in a learning workshop innovation collaborative format, local LTC teams were supported to reduce the number of residents receiving antipsychotic medications in the absence of a documented indication. Project resources were preferentially allocated to supporting sites with the highest baseline antipsychotic medication use. Changes in antipsychotic medication use, associated clinical and economic outcomes, and the effects of the project on LTC staff, physicians, leaders and administrators, and family members of LTC residents were assessed at the conclusion of the implementation phase.

Results: The province-wide initiative was delivered with a 75% implementation fidelity. Inappropriate antipsychotic medication use declined from 26.8% to 21.1%. The decrease was achieved without unintended consequences in other outcomes including physical restraint use or aggressive behaviours. The project was more expensive but resulted in less inappropriate use of antipsychotics than the pre-project period (incremental cost per inappropriate antipsychotic avoided of $5 678.71). Accounts from family, organisational leaders, and LTC staff were supportive of the project activities and outcomes.

Conclusion: This quality improvement initiative was successfully delivered across an entire delivery arm of the continuing care sector. Quality of care in LTC was improved.

Keywords: PDSA; breakthrough groups; collaborative; nursing homes; performance measures; quality improvement.

Figure 1

The risk-adjusted quality indicator (QI) for the per cent of LTC residents on antipsychotics without a diagnosis of psychosis (DRG01) at the project baseline (FY2011–2012 Q4) and follow-up (FY2014–2015 Q4) time points and the associated per cent of spread of the intervention to LTC sites during project implementation. *For sites participating in the learning workshop series, the intervention spread reflects the quarter in which the first learning workshop was delivered. LTC, long-term care.

Figure 2

LTC resident outcomes at baseline and follow-up, reported as the per cent of residents experiencing the outcome. (A) The risk-adjusted quality indicator (QI) for LTC residents with symptoms of delirium and who fell in the last 30 days. (B) The risk-adjusted QI for LTC residents with pain and in daily physical restraints. LTC, long-term care.