Borson S, Doane K
Department of Psychiatry and Behavioral Sciences, University of Washington Medical Center, Seattle, Washington 98195, USA.
Psychiatr Serv. 1997 Oct;48(10):1289-96. doi: 10.1176/ps.48.10.1289.
This study examined the impact of regulations established by the Omnibus Budget Reconciliation Act of 1987 (OBRA-87) on prescriptions for psychotropic drugs, and on research on their use in nursing homes.
Data were collected on drugs prescribed for residents of 39 skilled nursing facilities over the four-year period from 1989 to 1992, bracketing the implementation of OBRA-87 in the fall of 1990. Changes in prescribing patterns were analyzed by drug class, specific target medications and doses, number of drugs prescribed, and multidrug combinations. To determine the effect of OBRA-87 on research, peer-reviewed journals were searched for the number and content of publications on psychotropic drug use in skilled nursing facilities between 1980 and 1996.
The number of prescriptions for antipsychotics, sedative antihistamines, and sedative-hypnotics decreased significantly, while prescribing of anxiolytics increased. Qualitative, but not quantitative, shifts occurred in prescriptions for antidepressant drugs, the most frequently used psychotropic medications in all years. Rates of psychotropic polypharmacy remained stable. The number of data-based publications on psychotropic drug use in nursing homes increased after implementation of OBRA-87, but few were related to the effectiveness of drug treatment.
Implementation of OBRA-87's nursing home regulations was associated with reductions in use of drugs specifically targeted by this legislation and was a potent stimulus to research, an unanticipated benefit of legislative action. Increased use of anxiolytics, persistent prescribing of anticholinergic antidepressants, enthusiastic adoption of new agents despite a limited research database involving frail patients, and the paucity of new studies reporting data on clinical effectiveness suggest a need for targeted research on treatment outcomes to improve the care of this population.
本研究考察了1987年综合预算协调法案（OBRA - 87）所制定的法规对精神药物处方以及疗养院中精神药物使用研究的影响。
收集了1989年至1992年这四年间39家专业护理机构中居民所开药物的数据，这一时间段涵盖了1990年秋季OBRA - 87的实施。按药物类别、特定目标药物及剂量、所开药物数量和多药联用情况分析了处方模式的变化。为确定OBRA - 87对研究的影响，检索了1980年至1996年间同行评审期刊中关于专业护理机构中精神药物使用的出版物数量及内容。
抗精神病药、镇静性抗组胺药和镇静催眠药的处方数量显著减少，而抗焦虑药的处方量增加。在所有年份中最常用的精神药物——抗抑郁药的处方发生了定性而非定量的变化。精神药物联合用药率保持稳定。OBRA - 87实施后，疗养院中基于数据的精神药物使用出版物数量有所增加，但很少与药物治疗效果相关。
OBRA - 87疗养院法规的实施与该立法所针对的药物使用减少有关，并且是研究的有力刺激因素，这是立法行动带来的意外益处。抗焦虑药使用增加、抗胆碱能抗抑郁药持续处方、尽管涉及体弱患者的研究数据库有限但新药物仍被积极采用，以及新研究报告临床疗效数据的匮乏表明需要针对治疗结果进行有针对性的研究，以改善这一人群的护理。
