Gurwitz J H, Soumerai S B, Avorn J
Program for the Analysis of Clinical Strategies, Beth Israel Hospital, Boston, Massachusetts 02115.
J Am Geriatr Soc. 1990 May;38(5):542-52. doi: 10.1111/j.1532-5415.1990.tb02406.x.
There is ample and compelling evidence to suggest that medications are frequently used inappropriately in the nursing home. The occurrence of avoidable adverse drug reactions is the most serious consequence of inappropriate prescribing; economic implications are also of interest. With increasing concern over the quality of care in nursing homes, and with the revision of regulations governing such care by the Health Care Financing Administration, it is important to consider the experience thus far in monitoring and improving drug use in nursing homes. A number of studies have investigated approaches designed to reduce inappropriate prescribing and drug utilization in this setting. In contrast to the wide range of approaches that have been evaluated and implemented in the hospital setting, interventions in the nursing home have centered primarily around consultant-pharmacist activities. Although these activities are now federally mandated in all nursing homes, there is little evidence from adequately controlled studies to document their impact or cost-effectiveness. By contrast, face-to-face educational interventions directed at physicians ("academic detailing") have been shown to be effective in improving prescribing for some medications. The prominent role played by the nursing staff in the utilization of many medications in the nursing home implies that an educational intervention excluding nursing staff would be insufficient to influence drug utilization positively in many situations (eg, psychoactive medications and laxatives). Future research efforts must pay greater attention to adequate study design considerations as well as to the clinical outcomes of such interventions and their cost-effectiveness.
有充分且令人信服的证据表明，疗养院中药物的使用常常存在不当之处。可避免的药物不良反应的发生是不当开药最严重的后果；经济影响也备受关注。随着对疗养院护理质量的日益关注，以及医疗保健财务管理局对这类护理相关规定的修订，考量迄今为止在监测和改善疗养院药物使用方面的经验十分重要。一些研究调查了旨在减少这种情况下不当开药和药物使用的方法。与在医院环境中已评估和实施的广泛方法形成对比的是，疗养院的干预措施主要围绕药师的活动展开。尽管现在所有疗养院都有联邦规定要求开展这些活动，但充分对照研究几乎没有证据能证明其影响或成本效益。相比之下，针对医生的面对面教育干预（“学术详述”）已被证明在改善某些药物的开药情况方面是有效的。护理人员在疗养院许多药物的使用中发挥着重要作用，这意味着在许多情况下（如精神活性药物和泻药），不包括护理人员的教育干预不足以对药物使用产生积极影响。未来的研究工作必须更加关注充分的研究设计考量以及此类干预的临床结果及其成本效益。
