Hughes Carmel M, Lapane Kate L
School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland.
Drugs Aging. 2005;22(4):339-51. doi: 10.2165/00002512-200522040-00006.
The quality of nursing home care has been subject to intense investigation and scrutiny, particularly in the US. In particular, there has long been concern about the extensive use of psychotropic agents, notably antipsychotics, hypnotics and anxiolytics, in this setting. These drugs have been described as 'chemical restraints', in that they were used to sedate and subdue patients, partly to compensate for poor staffing levels and to minimise staff contact with patients. However, following a damning Institute of Medicine report to the US Congress, use of such drugs became regulated under a unique administrative initiative: the Nursing Home Reform Act, embedded within the Omnibus Budget Reconciliation Act 1987 (OBRA 87). Research has indicated that psychotropic drug use in nursing homes has declined markedly following the implementation of this regulation. In addition, explicit criteria for potentially inappropriate medication use were incorporated within the guidelines for nursing home inspectors from 1 July 1999. Because regulations have targeted poor prescribing, rather than promoting the use of effective drugs in older residents, it has been difficult to determine whether outcomes have improved for nursing home residents as a result. However, US government agencies have responded to continuing concerns about nursing home care through the implementation of quality indicators which are used to guide and plan inspections of such facilities and to compare nursing homes within the same state. Although there are a limited number of quality indicators relating to prescribing, this represents a move away from adversarial regulation, which focuses on poor practice, and attempts to improve quality of care. An important role for educational initiatives and interventions has been advocated by some commentators and these have proved to be successful in the nursing home environment. Other countries have not implemented such restrictive prescribing regulation in nursing homes. Exemplars of innovative prescribing models, involving pharmacists and encouraging resident-centred care, may offer a more palatable approach to improving drug use in this vulnerable population.
养老院护理质量一直受到深入调查和严格审查，尤其是在美国。特别是长期以来，人们一直关注在这种环境下精神药物的广泛使用，尤其是抗精神病药、催眠药和抗焦虑药。这些药物被称为“化学约束”，因为它们被用于使患者镇静和制服患者，部分原因是为了弥补人员配备不足，并尽量减少工作人员与患者的接触。然而，在医学研究所向美国国会提交了一份严厉的报告之后，此类药物的使用通过一项独特的行政举措得到了规范：《养老院改革法案》，该法案包含在1987年的《综合预算协调法案》（OBRA 87）中。研究表明，该法规实施后，养老院中精神药物的使用显著下降。此外，自1999年7月1日起，养老院检查员指南中纳入了潜在不适当用药的明确标准。由于法规针对的是不当处方，而不是促进老年居民使用有效药物，因此很难确定养老院居民的结局是否因此得到改善。然而，美国政府机构通过实施质量指标来回应人们对养老院护理的持续关注，这些指标用于指导和规划此类设施的检查，并在同一州内比较不同的养老院。尽管与处方相关的质量指标数量有限，但这代表了从侧重于不良做法的对抗性监管向试图提高护理质量的转变。一些评论家主张教育举措和干预措施发挥重要作用，并且这些措施在养老院环境中已被证明是成功的。其他国家尚未在养老院实施如此严格的处方规定。涉及药剂师并鼓励以居民为中心的护理的创新处方模式范例，可能为改善这一弱势群体的药物使用提供一种更易接受的方法。
