Telemedication Reviews to Optimize Medication Prescription for Older People in Nursing Homes

Abstract

Introduction:

Older people living in nursing homes (NH) are at a higher risk of preventable drug-related adverse events because of age-related physiological changes, polypathology, and polypharmacy. NH residents are particularly exposed to potentially inappropriate medications (PIMs). Many strategies have been developed to improve the quality and the safety of drug prescription in NH, including medication reviews (MRs).

Methods:

In the context of the application of telemedicine, we developed and are currently implementing a novel hospital expert-based MRs through tele-expertise (or “telemedication review,” telemedication reviews hereafter [TMR]) in French NH residents. The impact of these TMR on unplanned hospitalizations 3 months after implementation is assessed. TMR consider all available sociodemographic, clinical, biological, and pharmaceutical data pertaining to the patient and are performed in accordance with their health care objectives.

Results:

The preliminary results for the 39 TMRs performed to date (September 2021) showed that a total of 402 PIMs were detected, and all residents had at least one PIM. We also present the feasibility and the usefulness of this novel TMR for NH, illustrating these preliminary results with two concrete TMR experiences. Among the 39 TMR performed, the average acceptance rate of expert recommendations made to general practitioners (GP) working in NH was ∼33%.

Discussion and Conclusions:

The success of this novel TMR depends on how the proposed prescription adjustments made by the hospital expert team are subsequently integrated into health care practices. The low acceptance rate by GP highlights the need to actively involve these professionals in the process of developing TMR, with a view to encouraging them to act on proposed adjustments.

Introduction

As in most developed countries, the population in France is aging. By 2050, an expected 2 billion people will be 65 years of age and older worldwide, and 434 million people will be 80 years of age and older.¹ One consequence of this is an increasing number of people with loss of autonomy living in nursing homes (NH).² Given residents' advanced age and the fact that that polypathology frequently leads to polypharmacy,³ NH face the constant risk of drug iatrogenesis. In France, NH residents have an average of eight comorbidities for which they take an average of seven medications per day.⁴ This is in line with other developed countries, as shown in a systematic review which found that 74% of NH residents take 10 or more medications per day.³

This iatrogenesis is partly the result of potentially inappropriate prescriptions, including overuse (e.g., prescription of medications not indicated for a specific illness), misuse (e.g., choice of molecules, inappropriate doses, and unintentional duplicate prescription), and underuse (omission of indicated drugs).⁵ Two French multicenter studies highlighted that approximately two-thirds of NH residents had at least one potentially inappropriate medication (PIM) in their prescription.^6,7 Furthermore, a systematic review showed that almost half of NH residents were exposed to PIMs.⁸

Effective interventions to optimize drug prescribing in NH are needed, including pharmacists' systematic medication reviews (MRs), multidisciplinary team strategies, staff training, and the use of information technology support systems for MRs, and the number of international studies exploring these options is growing.^9

–13

MRs are the most frequently used method to improve prescribing practices. Indeed, 10 of the 12 studies investigated in Alldred et al.'s review of randomized controlled trials evaluating interventions aimed at optimizing prescribing for older people living in NH, included MRs as a component.¹²

Any systematic MR requires the patient's treatment to be put into perspective, in terms of their comorbidities, possible geriatric syndromes, their illness-related wishes, and available pharmacological evaluation tools.^14,15 For the elderly, MRs must also be performed in accordance with health care objectives centered on patients and their autonomy, especially in terms of their age and the possibility of multiple comorbidities (Charlson index).¹⁶ The main goal of an MR is to optimize drug prescribing all the while, ensuring that this optimization does not cause more harm than good.

To ensure multidisciplinary collaboration in a structured MR and to guarantee coordinated care, e-Health tools (e.g., telemedicine and tele-expertise) are becoming increasingly essential today, especially given the current COVID-19 health care context. The specific aim of employing these tools is to facilitate health care professionals' (HP) requests for expert medical opinions, by using a dedicated software package or a secure e-mail system.¹⁷ Over the last decade, tele-expertise has developed in several medical areas in France.^18

–22 A recent systematic review reported that, while the availability of tele-expertise services has expanded significantly both internationally and in terms of the specialty services offered, the benefits in terms of population health (e.g., patient safety, morbidity, and mortality) and associated savings are still limited and need further development.²¹

Data on the use of tele-expertise to perform MRs (or telemedication reviews [TMRs] hereafter) are scarce, particularly in the context of NH.^22,23 Our team is currently conducting the first study in France aimed at evaluating the impact of a novel hospital expert-based TMR intervention for NH residents (called TEM-EHPAD) on the rate of unplanned hospitalizations in the 3 months following study randomization (NCT03640845).²⁴ In this article, we present the feasibility of this novel TMR using real-world examples from TEM-EHPAD, as well as problems of acceptance of recommendations made during TMR by general practitioners (GP) working in the study's participating NH.

Methods

The TMRs are performed by a hospital-based team comprising a clinical pharmacist and an internal medicine specialist trained in geriatrics. Each TMR considers all available sociodemographic, clinical, biological, and pharmaceutical data pertaining to the patient. TMRs are based on established therapeutic objectives, which take into account life expectancy, patient priorities, and quality of life. In accordance with the French National Authority for Health guidelines, TMR always start with medication reconciliation.²⁵ Each prescribed drug is assessed based on the patient's history and comorbidities and requires consideration of the risk/benefit balance. Medication databases are consulted to exclude drugs with unproven efficacy and inappropriate medications.

Where necessary, adjustments are then made to a patient's prescribed list of drugs using explicit STOPP/START.v2 criteria¹⁴ coupled with implicit approaches (e.g., the drug burden index [DBI]¹⁵), all the while taking into consideration existing therapeutic recommendations. Furthermore, the galenic form of each prescribed drug is checked to ensure it is suitable for older patients.

All proposed changes to a patient's therapeutic management are highlighted in the TMR and are summarized in a written report, which is signed by both experts, and then transmitted to the NH health care professionals. The next step is to track what happens in practice in the NH for each of the proposed changes to the drug prescription. The GP can either accept or reject the proposed changes. GP acceptance rate is calculated 3 months after the TMR.

We present results and real-world examples from the TEM-EHPAD study, which was approved by an Institutional Review Board before data collection (Comité de protection des personnes Sud Est II n° 2018–48).

Results

To date (September 2021), 39 NH residents have had a TMR. The mean age of those involved was 86.5 ± 8.3 years old, and 26 (67%) were women. At medication reconciliation, the mean number of medications per resident was 12.7. A total of 402 PIMs were detected by the TMR and all 39 residents had at least one PIM (Table 1). More specifically, 263 (65.4%) prescribed medications did not comply with current therapeutic strategies, 106 (26.3%) were prescribed without any valid indication, 21 (5.2%) were pharmacologically redundant, 6 (1.5%) were contraindicated, and 6 (1.5%) led to drug-drug interactions (DDI). Using the pharmacological evaluation tools STOPP/START.v2 criteria and DBI, at baseline (i.e., before the TMR), we identified a mean of 1.8 ± 1.1 START criteria and 4.2 ± 2.4 STOPP criteria per resident, and a mean DBI score of 0.95 ± 0.7.

Table 1.

Distribution of Potentially Inappropriate Medication ( n = 402) and Telemedication Reviews Hereafter Recommendations

PIM categories, n (%)
Not in accordance with current therapeutic strategies	263 (65.4)
No indication	106 (26.3)
Duplication	21 (5.2)
Drug-drug interaction	6 (1.5)
TMRs recommendations to the GP, n (%)
Stopping a medication	127 (30.8)
Therapy monitoring	36 (8.7)
Optimizing administration	111 (26.9)
Modifying galenic form	22 (5.3)
Adapting medication schedules	7 (1.7)
Starting a medication	54 (13.1)
Adjusting dosage	48 (11.6)
Substituting a medication	7 (1.7)

GP, general practitioners; PIM, potentially inappropriate medication; TMRs, telemedication reviews.

Each TMR led to several types of recommendations being made to the residents' GPs (n, %) as follows: stopping a medication (127, 30.8%), therapy monitoring (111, 26.9%), starting a medication (54, 13.1%), adjusting dosage (48, 11.6%), substituting a medication (36, 8.7%), optimizing administration (22, 5.3%), modifying galenic form (7, 1.7%), and adapting medication schedules (7, 1.7%). The TMRs led to a mean of 0.6 ± 0.9 START criteria (p < 0.001) and 1.7 ± 1.3 STOPP criteria (p < 0.001) per resident, and a mean DBI score of 0.7 ± 0.7 (p = 0.11). The mean number of drugs per resident was also significantly reduced (9.7/resident p < 0.01). Among the 39 TMRs performed, the average acceptance rate by GPs of all the recommendations was ∼33%.

To illustrate these results, we present 2 of the 39 TMRs in detail.

PATIENT NO. 1

Mrs. M, 86 years old, was being monitored for depression and psychosis with extrapyramidal symptoms. Her Charlson index was 4. She had limited autonomy. Her vaccinations were up to date. There was no recent biological monitoring. The analysis of her eight lines of therapy (Table 2) revealed three medications not in accordance with current therapeutic strategies, one with possibly clinically significant DDI, and one with no indication for her pathologies. At baseline, her DBI score was 2.23 and 4 STOPP criteria (D5, K1, K2,andK4) were identified.

Table 2.

Summary of Drug Prescription Problems Detected at Baseline and Medication Recommendations Made for Mrs. M, 86 Years Old

TREATMENT BEFORE TMR (I.E., BASELINE)					INAPPROPRIATE DRUG PRESCRIPTIONS IDENTIFIED	TMR RECOMMENDATIONS
MOLECULE	DOSAGE	MORNING	MIDDAY	EVENING	INAPPROPRIATE DRUG PRESCRIPTIONS IDENTIFIED	TMR RECOMMENDATIONS
Oxazepam	10 mg	1	1	1		Interrupt evening dose and take daytime doses only if necessary
Venlafaxine LA	75 mg	2		1	Nonconformity to recommendationsToo high a dosage	Switch to vortioxetine
Zopiclone	7.5 mg			1
Acetaminophen (if needed)	500 mg	2	2	2
Levodopa/Benserazide	50 mg/12.5 mg	1	1		Not indicated	Interrupt
Haloperidol	2 mg/mL			40 drops	Drug-drug interactionDrug inappropriate for older people	Switch to risperidone
Econazole	1%	1		1
Influenza and pneumococcal vaccinations performed

LA, long acting; TMR, telemedication review.

First of all, the TMR highlighted an excessively high daily dosage of venlafaxine at 225 mg, especially given the patient's age. Dosages above 150 mg per day have shown a less positive benefit-risk balance.²⁶ The prolonged-release form is taken as a single daily dose, usually in the morning because sleep disturbances are frequently reported.²⁷ Mrs. M was also prescribed haloperidol.

However, the concomitant use of venlafaxine and haloperidol is strongly discouraged due to the risk of QT interval prolongation and/or ventricular arrhythmia, the latter being associated with increased higher plasma concentrations of haloperidol as a result of the venlafaxine-reducing enzyme activity of cytochrome CYP2D6. DDI between antipsychotics and antidepressants are frequently detected in NH residents. Liperoti et al. showed that this association significantly decreased residents' survival rates at 12 months of follow-up.²⁸ As Mrs. M's depression continued despite having initiated venlafaxine more than 6 months previously, a change to vortioxetine was recommended. This choice was justified by vortioxetine's better cardiac tolerance and because it does not interact with haloperidol.²⁹

Haloperidol is not recommended in older people because of its high anticholinergic burden. The TMR recommended replacing it with risperidone at a minimum effective dose over a limited period. Risperdone is also associated with a lower risk of extrapyramidal symptoms. Furthermore, Mrs. M was x taking levodopa/benserazide. The TMR recommended that its use should be re-evaluated because of potential trembling induced by venlafaxine, and its lack of effectiveness on pseudoparkinsonism syndrome induced by neuroleptics. In addition, the high DBI score of Mrs. M's list of prescribed medications was associated with an increased risk of falls.³⁰ To limit this risk, the TMR recommended reducing both anticholinergic drugs and the use of benzodiazepines, especially in the evening.

Finally, it recommended a complete set of blood tests, in particular because hepatic disturbances may be caused by haloperidol and because there is an increased torsadogenic risk when hypokalemia is present.

Following the TMR, the number of STOPP/START criteria remained unchanged. However, the DBI score decreased (1.58) as a result of switching venlafaxine to vortioxetine. The only recommendations from the TMR implemented by the patient's GP were blood tests.

PATIENT NO. 2

Mrs. M, 95 years old, had chronic kidney disease (CKD), type 2 diabetes, gout, and osteoarthritis-related pain. Her Charlson index was 9. She was still autonomous. Her most recent blood pressure was 153/65 mmHg. The most recent blood test showed a hemoglobin concentration of 10.2 g/dL and an HbA1c level of 5.8%. A creatinine clearance of 19.6 mL/min was estimated 3 months previously. An older assessment revealed folate deficiency. Her vitamin B12 level and iron status were normal.

At baseline, she was taking 14 medicines (Table 3). Her DBI score was at 1.1. Two STOPP criteria (E6, L2) and two START criteria (H2, I2) were identified. The TMR highlighted that nine prescribed drugs were not in accordance with current therapeutic strategies, one was contraindicated, and two were prescribed with no indication for her pathologies.

Table 3.

Summary of Drug Prescription Problems Detected at Baseline and Medication Recommendations Made for Mrs. M, 95 Years Old.

TREATMENT BEFORE TMR (I.E., BASELINE)					INAPPROPRIATE DRUG PRESCRIPTIONS IDENTIFIED	TMR RECOMMENDATIONS
MOLECULE	DOSAGE	MORNING	MIDDAY	EVENING	INAPPROPRIATE DRUG PRESCRIPTIONS IDENTIFIED	TMR RECOMMENDATIONS
Metformin	1,000 mg		1	1	Unintentional duplicate prescriptionContraindication for severe CKD	Interrupt
Metformin	1,000 mg		1	1		Interrupt
Sitagliptin/metformin	50 mg/1,000 mg	1			Contraindication for severe CKD	InterruptSwitch to repaglinide
Colchicine	1 mg	1			Contraindication for severe CKD	Interrupt
Epoetin alfa—route IV	30 000 UI	Every 2 weeks and if Hb >12 g/dL 1 week out of 3			Unintentional duplicate prescriptionInappropriate administration routes	Interrupt one line of therapySwitch to subcutaneous administration route
Epoetin alfa—route IV	30 000 UI	Every 2 weeks and if Hb >12 g/dL 1 week out of 3
Citalopram	20 mg	1			Contraindication for severe CKDNot indicated	InterruptReassessment of indication and choice of molecule
Furosemide	20 mg	1
Ferrous sulfate	80 mg	1			Not indicated	Interrupt
Folic acid	5 mg	1				Reassessment of the folic acid supplement
Vitamin D3/colecalciferol	100 000 UI	One vial/month				Calcium phosphate evaluation
Allopurinol	100 mg	½			Dosage inconsistent with renal function	One tablet 100 mg every other day
Tramadol/acetaminophen	37,5 mg/325 mg	1	1	1	Inappropriate medication for older people (tramadol)	Switch to only acetaminophen
Enalapril/HCTZ	20 mg/12.5 mg	1			HCTZ: Contraindication for severe CKDEnalapril: High dosage	HCTZ: InterruptEnalapril: Reduce dosage to 2.5 mgAdd a calcium channel blocker
Influenza vaccination performed						Pneumococcal vaccination

CKD, chronic kidney disease; HCTZ, hydrochlorothiazide; TMR, telemedication review; UI, unit.

The TMR also highlighted two unintentional duplicate prescriptions (erythropoietin and metformin), which needed to be corrected to avoid double administration. Moreover, intravenous administration had been prescribed for erythropoietin, despite the fact that subcutaneous administration is the preferred route.

Mrs. M was prescribed citalopram. However, this drug is contraindicated in people with severe CKD. The TMR highlighted that if the reason it was prescribed was because Mrs. M had depression, then the choice and the dosage of the antidepressant needed to be reconsidered to take into account the patient's renal function.^31,32 The TMR also recommended a dosage adjustment of prescribed allopurinol. With regard to diabetes management, Mrs. M's HbA1c level was very low. In older people with severe CKD, the goal is to achieve an HbA1c level ≤8% because of the higher risk of hypoglycemia and therefore of falling in this population.³³ Accordingly, interruption of antidiabetic drugs was recommended, especially given the fact that metformin and sitagliptin were contraindicated because of the patient's CKD. The TMR noted that repaglinide could be prescribed if necessary.³³

Given Mrs. M's elevated blood pressure levels and the context of diabetes and severe CKD, the TMR recommended continued prescription of enalapril, but at a lower dose because of the patient's renal failure. The use of furosemide with hydrochlorothiazide for hypertension management was not recommended as hydrochlorothiazide was contraindicated, again because of renal failure. The TMR suggested combining furosemide with enalapril and if needed, to add a calcium channel blocker.³⁴ The findings for Mrs. M in terms of renal failure and inappropriate prescriptions reflect Gheewala et al., who found that 16% of the 48% of NH residents with CKD had inappropriate drug prescription for renal elimination.³⁵

With respect to pain management, Mrs. M was prescribed tramadol. However, this drug is poorly tolerated in older people. The TMR suggested acetaminophen alone at a maximum dosage of three grams per day and if this was insufficient, then an acetaminophen/opium combination could be considered.

With regard to anemia, the TMR suggested that the prescribed iron be stopped, and the folate level controlled, given that the patient had been taking vitamin B9 supplements for several months. A calcium phosphate and vitamin D evaluation were also highlighted to evaluate whether continued supplementary vitamin D3/colecalciferol was necessary. The prescription of iron and/or vitamin supplements over a long period with no revaluation is often reported in the literature.⁸ The TMR strongly recommended anti-pneumococcal vaccination.

Following the TMR, the number of medications was reduced to 11 and no STOPP/START criteria were identified. There was no longer any anticholinergic drug burden. Ten of the 13 recommendations made (77%) were accepted by the patient's GP.

Discussion

Over the last decade, the development of telemedicine has greatly expanded and could be considered a new opportunity to assist and provide care for older people living in NH.³⁶ Tele-expertise in NH has the major advantage of making multidisciplinary expertise available to the GP within a short period of time. Furthermore, it helps to improve the efficiency and coordination of health care.

The objective of TMRs in NH is to improve the quality and safety of drug prescriptions. The purpose of MRs is to establish a complete list of medications taken by the patient, verify that each drug is associated with a specific diagnosis, and ensure that current recommendations are being followed. Assessing the benefit-risk balance of each drug prescription, avoiding PIM use, and adapting galenic form are essential. MRs also help to ensure that therapeutic objectives can be optimized by considering the following patient-related data: autonomy, life expectancy, quality of life, and patient preferences.

Published studies on TMRs in NH contexts are scarce. Two studies conducted in Germany highlighted multidisciplinary collaborative MRs through online communication platforms. In both studies, primary outcomes were assessed, studying the proportion of NH residents with PIMs or using the Medication Appropriateness Index.^37,38 However, to our knowledge, no study to date has evaluated the impact of a hospital expert-based TMR intervention on unplanned hospitalizations of NH residents. The preliminary results of this novel TMR intervention in our TEM-EPHAD study are promising both in terms of establishing an efficient care management strategy for NH residents and optimizing drug prescription.

The feasibility of implementing the TMR described is based on an expert internist/clinical pharmacist team trained in geriatrics, who work together on a daily basis to perform MRs. Given NH residents' mobility problems and the limited resources available for mobile geriatric care units to visit all NH, this novel TMR intervention would appear to be a necessary and essential tool. More generally, the benefit of a structured MR of geriatric patients' prescriptions conducted by hospital-based geriatricians and clinical pharmacists has already been demonstrated elsewhere in hospitalized older patients.³⁹ TEM-EHPAD was implemented at the request by several NH who saw it as an opportunity to obtain specific recommendations, while guaranteeing the same conventional health care requirements in terms of quality and safety of care.

In this study, the average acceptance rate by GPs of the recommendations made 3 months after the intervention was ∼33%. This rate is lower than other—although very heterogeneous—values described in the literature. Indeed, a recent review showed that the overall acceptance rate by GPs of pharmaceutical interventions in NH, including MRs, varied between 31% and 100% (mean 70%).⁴⁰ The study by Robert et al., which aimed at evaluating the impact of a clinical pharmacy program, including MRs in 52 NH, reported a GP acceptance rate of 39%.⁴¹ This low GP acceptance rate could be explained by the absence of direct contact between the expert team and GPs in the participating NH.

While Robert et al.'s team was notified when the TMR recommendations had been received by the GP, no feedback about whether the latter had read it or not was provided. As highlighted by Verrue et al., the lack of direct contact with GP can reduce the impact of tele-expertise and decrease their acceptance of recommendations.¹¹ However, Foubert et al. found a GP acceptance rate of 45%, despite a face-to-face GP/pharmacist meeting to discuss the latter's recommendations. The GP's perception of the different medications already prescribed as necessary and/or beneficial. The main reason for nonacceptance was that GPs saw the different medications already prescribed as being necessary.⁴²

Finally, other issues related to GP nonacceptance of our TMR recommendations were reported by GPs and other HPs in a qualitative study about acceptability of TMRs, which was conducted by our team before the beginning of TEM-EHPAD study.⁴³

In that study and others,^44,45 HPs reported that NH residents and/or their families were often reluctant to change treatment. Furthermore, in the qualitative study, some GPs also expressed fears about loss of control over their prescription writing and reported that they associated TMR interventions with a loss of professional worth, and felt that TMRs put their autonomy and professional value into question.⁴³ Providing advice to GP without limiting their prescription autonomy is a key issue when a third party performs an MR. Accordingly, and especially given the reluctance of some GP to the development of telemedicine,^43,46 involving GP in the development of the TMR by implementing an education and information component concurrently with a tele-expertise program⁴⁷ may increase their acceptability. Above all, in parallel with the establishment of tele-expertise, clear communication with the GP seems paramount.

Conclusions

These preliminary results attest to the feasibility and relevance of implementing our novel hospital expert-based TMR for residents of NH. The 39 TMRs performed to date have certainly led to safer drug use. However, the overall success of these TMRs will depend on how they are perceived by GP and how the proposed prescription adjustments made by the TMR team are subsequently integrated into GPs' health care practices. The low acceptance rate by GPs to date highlights the need to implement strategies that actively involve these professionals in the process of developing and implementing TMRs, to encourage them to act on the proposed adjustments.

Footnotes

Acknowledgments

The authors of this article thank the residents, health care workers, and administrators in the participating NH for their participation. It was a true privilege for our hospital to collaborate with these NH. We especially thank the coordinating physicians (Drsc Roux, Labarièrre, San José, Manes, and Mayan).

Authors' Contributions

A.D. and F.C. initiated and designed the project, with contributions from M.M. and C.B. C.B. and T.D.M. extracted the data from the database. C.B., A.D., and F.C. were responsible for data interpretation, with contributions from P.V., S.H., and A.L.C. C.B., A.D., and F.C. drafted the article, with contributions from A.L.C. P.V., and S.H. reviewed the article for important intellectual content. All authors read and approved the final version of the article.

Authorship Confirmation Statement

All authors meet the criteria for authorship stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (ICMJE).

Disclosure Statement

A.L.C. reports personal fees from BMS, Ferring, and Nutricia outside the submitted work. F.C. reports personal fees from Novartis, BMS, AstraZeneca, and Pierre Fabre outside the submitted work. All other authors report no conflict of interests.

Funding Information

TEM-EHPAD is supported by the French Ministry of Health through institutional grants from the French 2017 National Programme for Clinical Research (Programme de Recherche sur la Performance du Système de Soins PREPS-2017-0574). The Assistance Publique-Hôpitaux de Marseille is the study promoter. The trial is registered at ClinicalTrials.gov under the number NCT03640845.

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