resident characteristics and organizational factors influencing the quality of drug use in swedish...

RESIDENT CHARACTERISTICS AND ORGANIZATIONAL

FACTORS INFLUENCING THE QUALITY OF DRUG USE

IN SWEDISH NURSING HOMES

INGRID SCHMIDT,1,4* CECILIA B. CLAESSON,2 BARBRO WESTERHOLM3 andBONNIE L. SVARSTAD4

1Apoteket AB, S-13188 Stockholm, Sweden, 2National Board of Health and Welfare, Stockholm,Sweden, 3NEPI foundation, S-10514 Stockholm, Sweden and 4School of Pharmacy, University of

Wisconsin-Madison, 425 No. Charter, Madison, WI 53705, U.S.A.

AbstractÐAppropriateness of drug use is an important indicator of the quality of care in nursinghomes. In this study, we analyzed the in¯uence of resident characteristics and selected organizationalfactors on the appropriateness of psychotropic drug use in 33 Swedish nursing homes. Speci®c criteriabased on published guidelines and recommendations were developed to measure appropriateness. Resi-dents diagnosed with a psychiatric disorder and younger residents had more deviations from the cri-teria; however, resident mix did not explain variations in appropriateness of drug use at the facilitylevel. Facilities with better nurse sta�ng and drug intervention teams had fewer deviations from the cri-teria, but only 15±20% of the variation in drug prescribing was explained by these predictors. # 1998Elsevier Science Ltd. All rights reserved

Key wordsÐpsychotropics, drug utilization, quality of care, nursing homes, quality criteria

INTRODUCTION

Many studies have documented the inappropriateand excessive use of psychotropic drugs among nur-sing home residents in the U.S. and other countries

(Beers et al., 1988; Gulmann, 1993; Snowdon et al.,1995; McGrath and Jackson, 1996; Schmidt et al.,

1997). However, few studies have scienti®callyexplored the resident and organizational factors

that in¯uence the appropriateness of psychotropicdrug use in this population (Harrington et al.,

1992). This research is needed for several reasons.First, studies have found dramatic di�erences in

psychotropic drug use from one nursing home toanother (Ray et al., 1980; Garrard et al., 1991).

While stricter nursing home regulations and otherinterventions have reduced the overall use of anti-psychotic drugs in recent years, reform e�orts have

not eliminated these facility di�erences. Forexample, Rovner et al. (1992) reported an overall

reduction of 36% in antipsychotic drug use in theirsample of 17 Baltimore nursing homes after im-

plementation of the 1987 Omnibus BudgetReconciliation Act (OBRA), but found substantial,

unexplained variation in the magnitude of decreaseacross facilities. Shorr et al. (1994) found a decline

of 27% in antipsychotic drug use among Tennesseenursing home residents; however, they also noted

considerable variation across facilities after OBRAimplementation.

Second, appropriateness of psychotropic drug use

remains an important nursing home quality indi-

cator or measure of performance (Zimmerman et

al., 1995). In addition to increased risk of side

e�ects due to the higher sensitivity to drugs among

the elderly, drugs with anticholinergic side e�ects

can worsen and even induce dementia (Starr and

Whalley, 1994). A consistent body of clinical litera-

ture therefore emphasizes careful monitoring of all

drugs, minimizing the use of drugs with anticholi-

nergic e�ects (especially antipsychotics and tricyclic

antidepressants), and avoiding long-acting benzo-

diazepines for anxiety or sleep (Lindley et al., 1992;

Avorn and Gurwitz, 1995). Despite recommen-

dations, one in every ten nursing home residents in

the U.S. still receives an anxiolytic agent and there

has been little change in the level of anxiolytic use

since implementation of OBRA 1987 (Shorr et al.,

1994; Garrard, 1995). Studies examining the organ-

izational determinants of inappropriate drug use

would help us understand why these patterns of

drug use appear resistant to change.

A third reason for studying organizational factors

is that residents' clinical and demographic charac-

teristics apparently explain only a small proportion

of the variance in the level or appropriateness of

psychotropic drug use. Younger residents and resi-

dents with a psychiatric disorder or diagnosis of

dementia have a higher probability of receiving an

antipsychotic drug (Beers et al., 1988; Buck, 1988)

and a higher probability of inappropriate antipsy-

Soc. Sci. Med. Vol. 47, No. 7, pp. 961±971, 1998# 1998 Elsevier Science Ltd. All rights reserved

Printed in Great Britain0277-9536/98 $19.00+0.00

PII: S0277-9536(98)00169-5

*Author for correspondence.

961

chotic and anxiolytic drug use (Svarstad and

Mount, 1991), possibly because these resident sub-groups have more severe behavioral problems.However, previous work (Buck, 1988) suggests that

resident diagnostic and demographic predictorsjointly explain only 10% of the variance in the ad-ministration of antipsychotic medication (drug ver-

sus no drug) and less than 10% of the variance inthe administration of sedative/hypnotics and antian-

xiety agents.A few studies have found that nursing home pre-

scribing practices are related to physician factors

such as the number of residents per physician (Rayet al., 1980), frequency of physician contact withresidents and individual characteristics such as

physician age, gender and years of experience(Beers et al., 1993).

Finally, there is some evidence that organiz-ational factors can have a signi®cant impact onboth the quantity and quality of psychotropic drug

use in nursing homes; however, the relationshipsare complex and poorly understood. A few studies®nd higher rates of drug use in larger facilities and

for-pro®t facilities, but other studies ®nd that facil-ity size and ownership have no e�ect ( Ray et al.,

1980; Buck, 1988; Garrard et al., 1991; Garrard,1995). Perhaps the most common hypothesis is thatbetter sta�ng and other resources will result in

lower rates of drug use and fewer deviations fromtreatment guidelines. Again, the ®ndings are mixed.Of ®ve studies examining this important issue, three

found a weak or nonsigni®cant relationship betweenfacility sta�ng and psychotropic drug use (Ray

et al., 1980; Buck, 1988; Garrard, 1995).Unfortunately, these studies relied on somewhatcrude measures of sta�ng and lacked information

about appropriateness of drug use. Several studiesalso excluded private-pay residents and more ``elite''facilities that do not accept Medicaid recipients

and, in one case (Buck, 1988), 41% of the residentswere excluded because their facilities were unable toprovide complete cost and sta� data. As Mount

(1992) has suggested, these methodological pro-blems can cause the richest and poorest facilities to

be underrepresented, seriously compromising theanalysis of sta�ng and resource variables.Shorr et al. (1994) avoided some of these pro-

blems by employing more re®ned measures of sta�-ing and indeed found more extensive antipsychotic

drug use in those Tennessee facilities with poorerthird-shift sta�ng. Svarstad and Mount (1991) alsoused a more re®ned measure of facility sta�ng in

their study of private- and public-pay residents inWisconsin facilities. As predicted, residents in facili-ties with less adequate nurse sta�ng and resources

were more likely to have an order for an antipsy-chotic or anxiolytic medication, more likely toreceive such medications, and more likely to have

inappropriate use Ð even after controlling for resi-dents' clinical and demographic characteristics.

Unfortunately, the Wisconsin researchers studied

only seven facilities and therefore had to use theresident as the unit of analysis, making it di�cultto interpret the e�ects of facility-level variables. The

Tennessee researchers had a larger sample and usedthe facility as the unit of analysis but did not con-trol for residents' clinical characteristics, raising

other questions. Whether the results of theWisconsin and Tennessee studies can be generalized

to other states (or countries) also remains to beseen.A few studies have described the problematic

nature of psychotropic drug use in Swedish nursinghomes (Andersson, 1989), but little is known aboutthe determinants of inappropriate drug use and

there have been no regulatory e�orts to bring aboutchanges in prescribing practices. Since 1992, most

Swedish nursing homes are operated by the munici-palities in which they are located and a supervisorynurse is responsible for the quality of resident care.

However, the availability of nurse sta�ng and fre-quency with which physicians visit the nursinghome can vary, as happens in other countries.

There also is evidence that the level of drug use inSwedish nursing homes may have increased in

recent years. In the late 1980s, those living inSwedish nursing homes and sheltered accommo-dations were prescribed an average of 4 to 5 drugs

each, most to be used on a regular basis(Andersson, 1989). In a recent study, the averagenumber of drugs per resident was 7.7, with 80%

used on a scheduled basis (National Board ofHealth and Welfare, 1996).

In March 1994, the Medical Products Agency inSweden (SMPA), together with the NorwegianMedicines Control Authority (Medical Products

Agency and The Norwegian Medicines ControlAuthority, 1995), arranged a meeting where expertsdiscussed the treatment of mental conditions in per-

sons with dementia. The recommendations formu-lated at the meeting were published and distributedduring the summer of 1994 to all practising phys-

icians in Sweden and Norway. The recommen-dations (hereafter referred to as SMPA guidelines)

emphasized the need to minimize the use of drugsthat can cause confusion and impaired memory andincluded two lists, one including drugs that can

cause impaired memory and confusion due to theiranticholinergic properties (referred to as list 1) andone including drugs that can cause confusion

through other mechanisms (referred to as list 2).In this paper, we extend previous work by exam-

ining the appropriateness of psychotropic drug usein 33 Swedish nursing homes using data collectedapproximately one year after Swedish physicians

received the new treatment recommendations onpsychotropic drug use in persons with dementia.We considered several approaches to the de®nition

of ``inappropriate drug use''. Many studies in thepast have examined the number of doses in each

I. Schmidt et al.962

drug class and assumed that a lower number was

more appropriate. A second approach has been tocreate a local ``expert panel'' or small group ofexperts who evaluate appropriateness of drug use in

each patient or resident using a semi-structuredassessment tool and implicit criteria based on cur-rent knowledge and information as well as their

own expert judgments (Burns and Kamerow, 1988;Lipton et al., 1992; Schmader et al., 1994). In a

third approach, researchers create explicit criteriabased on the literature and seek feedback fromnationally or internationally recognized experts

identi®ed by the researchers (Beers et al., 1993).Researchers also have rated appropriateness of druguse using regulatory guidelines such as the guide-

lines developed by the Health Care FinancingAdministration (HCFA) and mandated by the U.S.Congress as part of OBRA 1987 (Garrard et al.,

1991). A ®fth approach is to develop an assessmenttool based on explicit criteria published by a nation-

ally or internationally recognized consensus panelor expert groups appointed by professional associ-ations such as the American Psychiatric Association

(Mount and Svarstad, 1991; Svarstad and Mount,1991).

After considering these options, we developed anassessment tool that incorporates the new rec-ommendations distributed by SMPA, recommen-

dations from the Swedish drug formulary (FASS),and published criteria used in other nursing homestudies (Svarstad and Mount, 1991). The goals of

the present study were: (1) to describe the appropri-ateness of psychotropic drug use in the nursinghomes using this new assessment tool and (2) to

determine the in¯uence of selected resident andfacility characteristics on three di�erent types of

inappropriate psychotropic drug use. We refer tothese types of inappropriate use as: deviations of in-itiation or documentation (e.g. prescription of a

drug without a documented diagnosis), deviationsof selection (e.g. selecting an inappropriate drug)and deviations of excess (e.g. using a larger dose or

number of drugs than is appropriate).For each type of inappropriate drug use, we test

a series of hypotheses which possibly account forvariations in the appropriateness of drug use acrossnursing homes. They include: the need hypothesis,

the demographic hypothesis, the resource hypoth-esis, the communication hypothesis and the size hy-pothesis. The resident need and demographic

hypotheses suggest that variations in drug useacross facilities are due largely to resident mix, with

inappropriate use being more common in facilitieswith younger residents and a larger proportion ofresidents with psychiatric disorder or dementia. The

remaining hypotheses suggest that facility di�er-ences in drug use are due largely to organizationalfactors such as: resource availability and demand

(low/high nurse sta�ng; low/high resident function-ing); caregiver communication (presence/absence of

intervention team meetings); and facility size (small/large number of beds; re¯ecting a measure of insti-

tutional environment).

METHOD

Data were obtained from a larger study examin-

ing drug use in 33 Swedish nursing homes beforeand after an intervention designed to reduce inap-propriate drug use through improved multidisciplin-

ary communication and teamwork. Detailedinformation about the intervention and its e�ectshave been presented elsewhere (Schmidt et al.,1997). Brie¯y, study sta� who were employed by

the National Corporation of Swedish Pharmaciesrandomly selected 18 pharmacy regions to partici-pate in the study. Each regional pharmacy director

then selected two facilities in his or her region usingfour criteria: (1) resident and sta� characteristicsshould be similar, (2) homes should be supervised

by di�erent physicians and geographically separ-ated, (3) supervising physicians should not be geria-tric specialists and (4) homes should be typical forthe region. Researchers randomly assigned one

home in each pair to receive the intervention. Threeof the 18 experimental facilities were unable to meetstudy requirements and were dropped from the

study, yielding a ®nal sample of 15 experimentalhomes and 18 control homes. The interventioninvolved training a regional pharmacist to help

establish and maintain a multidisciplinary team forpurposes of reviewing and improving drug therapyin the region's experimental facility. Each team con-

sisted of a physician, pharmacist, and selectednurses and nurses' aides who usually met once amonth to discuss the needs of individual residentsin their facility. Emphasis was placed on residents

with dementia and the SMPA guidelines were usedas a basis for discussion. No other educational oradministrative interventions were attempted.

Since we are interested in the resident and organ-izational determinants of inappropriate drug useafter e�orts to improve drug use, the present study

examined data from the post-intervention periodonly. Two levels of analysis were performed. Theresident analysis examines the appropriateness ofdrug use in 1823 residents and identi®es those resi-

dent characteristics associated with various types ofinappropriate drug use. The facility analysisdescribes the variability in appropriateness of drug

use among 33 facilities and assesses the relative im-portance of resident mix and other organizationaldeterminants of inappropriate drug use.

Data collection

Drug use. Drug use data were obtained from each

resident's medication list. Data from the controlhomes covered drug use during the entire month of1 March to 1 April of 1995, and data from theintervention homes covered drug use during the

Drug use in nursing homes 963

®nal month of the 12 month intervention in 1995.This means that data from all homes not were col-

lected at the same point in time since interventiondates varied. We have no reason to believe that thisa�ected the results in any way. Available infor-

mation included drug name, strength, route, dosageregimen and changes and the number of days eachdrug was used in the index month. Trained coders,

supervised by pharmacists, classi®ed and coded allscheduled and pro re nata (PRN) orders. Drugswere classi®ed using the Anatomical Classi®cation

System recommended by the World Health Organ-ization, Europe.Resident characteristics. Resident demographic

characteristics were obtained from the medication

administration list. In addition, the head nurse ineach ward was asked to note whether or not a resi-dent had a documented or known diagnosis of

dementia and to record any other diagnoses listedin the medical records. This information was sentto study sta� who then classi®ed all diagnoses

according to the presence or absence of any demen-tia, the presence or absence of any depression andthe presence or absence of any other psychiatric dis-

orders or symptoms (e.g. schizophrenia, hallucina-tions, anxiety).Facility characteristics. Data on nursing home

size, number of wards, sta�ng, and proportion of

residents with selected activity of daily living func-tions (ADL) were collected by means of two ques-tionnaires. The questionnaires were distributed to

municipality nurses by the National Board ofHealth and Welfare. Municipality nurses are thenurses responsible for medical standards in all of

the nursing homes within each municipality. Thenurses were asked to distribute the questionnaire tothe manager of the each nursing home who thencompleted the form and sent it back to the

National Board of Health and Welfare.

De®ning and measuring inappropriate drug use

A list of thirteen drug use criteria was developedto measure appropriateness in the present study.The criteria were based on SMPA guidelines, the

Swedish drug formulary (FASS), and other toolsfor measuring excessive use of psychotropic druguse in the elderly (e.g. Svarstad and Mount, 1991).

A score of ``0'' or ``1'' was assigned for each cri-terion, with 1 indicating deviation from rec-ommended drug practice. Individual resident scores

could range from 0 to 11. The list re¯ected threecomponents or dimensions of inappropriateness:

Deviation from criteria regarding drug initiation and

documentation

This component indicates drug prescribing that is

not consistent with the reported diagnosis or poordocumentation of the indication for use. It is poss-ible that some residents may have experiencedsymptoms requiring temporary use of drugs such as

antipsychotics; however, information on residents'symptoms was not available to researchers.

Deviation from criteria regarding drug selection

This component re¯ects questionable choice orselection of drug, as de®ned by SMPA guidelines.Tricyclic antidepressants and long-acting benzo-

diazepines generally are regarded as inappropriatein the elderly, especially those with dementia. Theselection criteria also include the prescription of

other drugs with strong anticholinergic e�ects andvarious drug interactions. The classi®cation of druginteractions was based on a recently developed

Swedish interaction classi®cation system included inFASS. A drug interaction classi®ed as C means``caution'' (e.g. could require adjustment of doses)and D means ``combination should be avoided''

due to risk for adverse e�ects. It is important tonote that the potential interaction e�ects includepsychotropic drugs as well as other prescribed

drugs.

Deviation from criteria regarding excess use

This component re¯ects an excessive number ofdrugs, inappropriate therapeutic duplication, or un-

necessary polymedicine as de®ned by SMPA guide-lines and other published criteria (Svarstad andMount, 1991). It also incorporates the general rec-

ommendation in Sweden that elderly patientsshould be prescribed one half the normal adultdosage for psychotropic drugs. Since all psychotro-pics appear on either List 1 or List 2 of the SMPA

guidelines, there may be some overlap in the scoringof these criteria.

Measuring resident and facility characteristics

Residents were classi®ed into three diagnostic

groups for the resident analysis. The groupsincluded: residents with a psychiatric disorder (psy-chotic disorder, depression or any other reported

psychiatric impairment), with or without dementia(PD), those with dementia (including diagnoseddementia and a report of likely dementia) (D) and

those with no report of psychiatric disorder ordementia (NO PD). Due to the small number ofresidents with documented psychiatric disorders, welater collapsed the diagnostic measure into two cat-

egories: residents with diagnosed dementia or likelydementia and those without dementia. The facilityanalysis was performed using percentage of resi-

dents with dementia as an independent variable.Resident age was coded as a dichotomous vari-

able over or under 85 y, in the resident analysis and

a continuous variable (mean age) in the facilityanalysis. Resident gender also was coded as adichotomous variable in the resident analysis and as

a continuous variable (% female) in the facility ana-lyses.The mean level of functional disability for each

facility was calculated using seven facility measures


(% wheelchair dependent, % incontinent, % withcatheter, % requiring bedtime assistance, % requir-

ing toilet assistance, % requiring washing assist-ance, % requiring meal assistance). The medianscore was determined and each nursing home was

coded as above below median. The facility's level offunctional disability was considered a proxymeasure for workload, a factor that might in¯uence

the use of drugs. Facility size was measured by thetotal number of beds and the level of sta�ng wasmeasured by the number of full-time equivalent

nurses and nurses' aides per resident. Finally, wecreated a dummy variable to re¯ect the presence orabsence of multidisciplinary teams.

Statistical analysis

After describing the resident and facility sample,we assessed the proportion of residents with devi-ation from drug criteria and variation across the 33

study facilities. We then examined the bivariate re-lationships between selected resident and facilitycharacteristics and our measures of deviation from

drug use criteria (any deviation and number of de-viations from criteria of initiation/documentation,drug selection, and excessive use). These analyses

were performed using the resident as the unit ofanalysis. Signi®cance levels for the w2 are presented.The ®nal steps involved an examination of Pearson

product-moment correlations and multiple re-gression results using the three deviation scores asthe dependent variables and the facility as the unitof analysis. Included in the regression analyses were

any resident or organizational variables that wererelated signi®cantly to one or more measures of

deviation in the bivariate analyses. Backward elim-ination procedures were used to delete nonsigni®-cant terms.

RESULTS

Drug use data were available for 1823 residentsin 33 study facilities. A summary of resident andfacility characteristics is provided in Table 1.

Approximately 70% of the residents were female,and 49% were 85 y or older (mean age = 83 years).Nurse informants reported that 44% of the resi-

dents had diagnosed dementia or likely dementiaand 8% had a psychiatric disorder. Psychotropicprescribing was extremely common, with the mostfrequently prescribed drugs being the anxiolytics

(42%), hypnotics (38%) and antipsychotics (34%).The residents' functional status was low: 64% werewheelchair dependent, 68% were incontinent and

56% required meal time assistance.While the study facilities were similar in many

respects, they di�ered in several notable ways. For

example, the proportion of residents with dementiaranged from 13% to 77% and number of sta� perresident ranged from 0.70 to 1.44 (mean = 0.91).

Facility size ranged from 22 to 226 beds, with amean of 75 beds. Some facilities had extremely lowrates of psychotropic drug use, whereas, others hadvery high levels of drug use. For example, rates of

Table 1. Selected resident and facility characteristics

Resident characteristics Residents n= 1823 Facilities n = 33

mean range

Female (%) 70 68 47±87Age (mean years) 83 84 77±87.+age 85 (%) 49 49 25±67>age 85 (%) 51 51 33±76

Diagnoses (%)*Dementia 44 46 13±77Psychiatric disorder** 8 9 0±20

Psychotropic drugs (%)Antipsychotics 34 34 7±53Hypnotics 38 37 3±53Anxiolytics 42 41 20±64Antidepressants 24 23 7±44

Functional status (%)Wheelchair dependent 64 64 26±98Incontinent 68 71 44±100Catheter 8 8 2±20Bedtime assistance 90 91 55±100Toilet training 27 26 0±63Washing assistance 95 97 55±100Meal time assistance 56 56 25±88Facility characteristics ÿNumber of beds ÿ 75 22±226Sta� per resident ÿ 0.91 0.70±1.44Nurse per resident ÿ 0.13 0.04±0.31

*Numbers include residents with positive and likely diagnoses.**Includes depression (4%) and other psychotic disorders (4%).


antipsychotic drug use ranged from 7% to 53%

and hypnotic use ranged from 3% to 53%.

Table 2 summarizes the proportion of residents

with deviation from the various criteria used to

measure appropriateness. The SMPA guidelines, inaccordance with international literature and rec-

ommendations, suggest minimal use of all neurolep-

tics. However, 532 residents were prescribedneuroleptics without any report of psychotic dis-

order, while 16 residents were reported to su�er

from a psychotic disorder but were not prescribed

any antipsychotic drugs. In this sample, 367 resi-dents were prescribed an antidepressant without

diagnosis of depression, while 26 residents su�ered

from depression but were not prescribed any

antidepressants. This ®nding could re¯ect poordocumentation of depression and/or use of anti-

depressants for reasons other than depression.

Approximately 45% of residents were prescribed

either a nonrecommended anxiolytic or hypnoticdrug and 5.9%, a tricyclic antidepressant. Eighty-

one (4.4%) residents were prescribed other drugs

with anticholinergic e�ects from list 1 in the guide-

lines and 458 residents were prescribed drugs withan interaction classi®cation of C or D (6% had an

interaction of type D). 40% (n = 737) were pre-

scribed a psychotropic drug in a dose higher thanone half the normal adult dose, and 26% had three

or more psychotropic drugs prescribed concur-

rently. Over 23% had two or more drugs from thesame therapeutic group.

We found wide variability in the appropriatenessof drug use among the 33 homes as re¯ected inrange of means displayed in Table 2. For example,

the percentage of residents prescribed 3 or moredrugs varied between 7% and 53% among the 33homes, therapeutic duplication varied between 4%

and 42% and neuroleptic use without a documenteddiagnosis varied between 4% and 47%. The totalaverage deviation score was 2.6 in the resident

sample, with a range of 1.0 to 3.5 among the 33nursing homes. Three homes had an average scoreof 1 per resident and three homes had an averagescore of 3.5 per resident. Over 100 residents had a

score of 6 or higher.

Resident analysis

Table 3 shows the bivariate relationships betweenselected resident and facility characteristics and de-

viation from drug use criteria using the resident asthe unit of analysis. As expected, resident diagnosiswas related signi®cantly to the probability of anydeviation and number of deviations in ®ve of the

six tests of this hypothesis ( p< 0.001). Residentswith a psychiatric disorder tended to have more de-viations from the criteria of selection and criteria of

excess, whereas, residents with dementia tended tohave more deviations from the criteria of initiation/documentation. The low prevalence of documented

psychiatric disorders precluded a more detailedanalysis or breakdown of data. However, we sus-pect that residents with depression have a higher

likelihood of deviations from criteria of selectionand excess because they often express multiplesymptoms (depressive symptoms, anxiety andinsomnia) which are treated symptomatically with

hypnotics and anxiolytics, increasing their exposureto polymedicine.As hypothesized, age was a signi®cant predictor

of deviation from the selection and excess criteria:younger residents had signi®cantly more deviationsfrom these di�erent criteria. Interestingly enough,

age was unrelated to deviations of initiation/docu-mentation and there were no signi®cant di�erencesby resident gender. We also see that none of the or-ganizational factors predicted deviation from cri-

teria of initiation/documentation at the residentlevel and only one organizational factor predicteddeviations of selection at the resident level. As pre-

dicted, residents in experimental facilities with amultidisciplinary intervention team were less likelyto have any deviation of selection ( p < 0.001) and

had a lower number of deviations in this area( p < 0.001). This is not surprising since the inter-vention emphasized the SMPA guidelines which

provided explicit lists of recommended and nonre-commended drugs in this population.In contrast, three of four organizational factors

were associated with one or more measures of

Table 2. Percentage of residents with deviation from drug criteriaand variation among nursing homes

Drug use measure

% of allresidents(n = 1823)

Variationamong nursing

homes(mean %)(n = 33)

Deviation of initiation/documentationNeuroleptic prescribed; psychoticdiagnosis absent

29.2 (532) 4±47

Psychotic diagnosis present; noneuroleptic prescribed

0.9 (16) 0±7

Antidepressant (any) prescribed;depression diagnosis absent

20.1 (367) 0±44

Depression diagnosis present; noantidepressant prescribed

1.4 (26) 0±8

Deviations of selectionAny tricyclic 5.9 (107) 0±20Any non recommended hypnoticdrug

22.1 (402) 2±36

Any non recommendedanxiolytic drug

22.2 (405) 4±47

Any other drug from list 1 4.4 (81) 0±14Interaction class C or D 25.1 (458) 0±43

Deviations of excessr3 psychotropic drugs 26.4 (482) 7±53r3 drugs from list 1 or 2 39.6 (722) 7±61r2 drugs from same class 23.5 (429) 4±42over one half adult dosage, anypsychotropic

40.4 (737) 7±60

Mean total score per resident(max score: 11):

2.6 (0±9) 1.0±3.5

No. residentsrscore 4: 189 ÿNo. residentsrscore 6: 111 ÿNo. residentsrscore 8: 30 ÿ


excessive use. While the level of functional disability

in the facility had no e�ect on excessive use, level of

sta�ng and number of beds signi®cantly in¯uenced

deviations of excess. As predicted, smaller nursing

homes and nursing homes with better sta�ng had

signi®cantly fewer deviations of excess ( p < 0.05).

Finally, as hypothesized, experimental nursing

homes with a multidisciplinary team had signi®-

cantly fewer deviations of excessive use at the resi-

dent level ( p< 0.01).

Facility analysis

Table 4 displays the Pearson product-moment

correlations for various resident, organizational,

and deviation measures using the facility as the unit

of analysis. While resident age and diagnosis pre-

dicted appropriateness of drug use at the individual

level, neither the proportion of residents with

dementia nor the proportion of younger residents

was correlated with any of the deviation scores at

Table 4. Bivariate correlation of nursing home variables (n= 33)

Variables 1 2 3 4 5 6 7 8 9

(1) Dementia (%) ÿ(2) Ager85 (%) ÿ0.18 ÿ(3) Female (%) 0.27 0.46** ÿ(4) Sta� level ÿ0.20 ÿ0.20 ÿ0.29 ÿ(5) Disabilities (0,1) 0.20 ÿ0.07 0.36* ÿ0.03 ÿ(6) Size (number of beds) ÿ0.37* ÿ0.23 0.10 0.00 ÿ0.15 ÿ(7) Regular team interventions (0,1) 0.03 ÿ0.07 0.01 0.32 0.28 0.17 ÿ(8) Initiation criteria score ÿ0.07 ÿ0.02 0.15 ÿ0.18 ÿ0.11 ÿ0.16 ÿ0.18 ÿ(9) Selection criteria score ÿ0.24 ÿ0.05 0.03 0.08 ÿ0.01 0.17 ÿ0.47** 0.28 ÿ(10) Excess criteria score 0.07 ÿ0.26 0.02 ÿ0.42* ÿ0.02 0.12 ÿ0.31 0.66** 0.56**

*Correlation is signi®cant at the 0.05 level (2-tailed).**Correlation is signi®cant at the 0.01 level (2-tailed).

Table 3. Bivariate analysis of deviation from drug use criteria using resident as level of analysis (n= 1823)

Drug use predictor Any deviation from documentation/initiation criteria

Any deviation fromselection criteria

Any deviation fromexcess criteria

% Mean score(max = 2)

% mean score(max = 5)

% mean score(max = 4)

All residents(n = 1823)

45.0 0.52 57.7 0.80 61.3 1.30

Diagnostic group (1)PD 38.4 0.42 65.8 1.03 78.8 2.00Dementia only 52.1 0.61 50.7 0.69 57.0 1.22No PD 40.0*** 0.45*** 61.7*** 0.85*** 62.2*** 1.26***

Resident ager85 43.6 0.49 53.3 0.71 54.8 1.12<85 46.4 0.55 61.7*** 0.89*** 68.2*** 1.49***

Resident sexFemale 44.9 0.54 57.3 0.79 60.0 1.28Male 45.3 0.51 57.7 0.81 64.4 1.34

Facility characteristics

Level of sta�Below median 45.5 0.52 57.2 0.77 63.0 1.37Above median 44.2 0.51 57.7 0.83 59.0* 1.20*

Level of residents with functional disabilitiesBelow median 44.7 0.51 57.6 0.80 61.4 1.25Above median 45.4 0.53 57.0 0.79 61.3 1.37

Number of bedsBelow median 46.5 0.54 54.6 0.79 58.5 1.31Above median 44.0 0.51 59.0 0.78 63.0* 1.34

Intervention teamYes 45.1 0.51 49.4 0.66 56.0 1.18No 44.9 0.52 61.0*** 0.86*** 63.6* 1.35**

P level for w2: *P < 0.05, **P < 0.01, ***P < 0.001.(1) PD: psychiatric disorder including depression, psychosis and serious symptoms, with or without dementia. Dementia only: resident

with reported dementia only, or likely dementia. No PD: No report of psychiatric diagnosis or dementia.


the facility level. The proportion of female residentsalso was unrelated to deviation scores. Consistent

with ®ndings at the individual level, none of the or-ganizational characteristics was associated with de-viations of initiation/documentation and only one

organizational factor predicted deviation from selec-tion criteria. As expected, experimental facilitieswith an intervention team had fewer deviations of

selection (p < 0.01). Level of sta�ng was the onlyfactor that was correlated signi®cantly with devi-ations of excessive use at the facility level. As pre-

dicted, facilities with better sta�ng had fewerdeviations of excess (r=ÿ 0.42, p < 0.05). Neitherfacility size nor the presence of an interventionteam was correlated with excessive use at the facility

level.Linear regression analysis was performed using

the three deviation scores as dependent variables

and the nursing home as the unit of analysis(n= 33) (Table 5). Consistent with bivariate corre-lations, higher sta�ng level remained signi®cant

predictor for fewer deviations from excessive criteriaeven after controlling for resident mix experimentalgroup, age and size. the drug criteria. Nursing

homes with team interventions had the fewer devi-ations from selection criteria, but had no impact onthe other criteria. Neither age or proportion of resi-dents with dementia remained signi®cant predictors

in the ®nal models.

DISCUSSION

This is the ®rst study scienti®cally examining thein¯uence of both residents' characteristics and or-ganizational factors on drug prescribing practices in

Swedish nursing homes. It also is one of the ®rststudies outside the United States to examine appro-priateness of psychotropic drug use in nursing

homes using explicit criteria based on publishedguidelines and recommendations. We managed tomitigate several limitations that have hampered pre-

vious studies by using more re®ned measures ofinappropriateness, incorporating three di�erenttypes of deviation from drug use criteria. It is im-

portant to distinguish among these di�erent types

of deviation, because the determinants of inap-

propriate use vary from one type of deviation to

another. Given a sample of 33 nursing homes, we

were able to perform statistical analyses using with

the nursing home as the unit of analysis. This dis-

tinction also proved to be quite important, because

the factors a�ecting the appropriateness of drug use

at the individual level are not necessarily the same

as those factors a�ecting variation from one facility

to another. It is important to recognize these com-

plexities in future studies of this kind.

The ®ndings of this study raise serious concerns

about the quality of drug prescribing practices in

Swedish nursing homes. Over 25% of the residents

were prescribed three or more psychotropic drugs

and almost 25% were prescribed two or more drugs

from the same drug class. A majority of the resi-

dents had deviations from one or more of the drug

use criteria, with the mean score per resident at 2.6.

We also found extraordinary variation in the qual-

ity of drug use from one facility to another and

were able to identify only a few factors that might

explain for these facility di�erences. Taken together,

the predictors included in the ®nal regression

models explained only 15±20% of the variance in

deviation at the facility level. This ®nding in itself

calls for further research in the nursing home set-

ting. American researchers exploring the causes of

poor quality drug use and care in nursing homes

have pointed to the problems that can occur when

certain facilities have for-pro®t ownership or must

rely solely on Medicaid reimbursement (Svarstad

and Mount, 1991; Zinn et al., 1993). However,

these factors cannot explain the high level of psy-

chotropic drug use or the extraordinary variation

in drug use in this Swedish study. In the sample

all nursing homes were nonpro®t and operated by

public municipalities and there is no functional

di�erence in ®nancial status among the residents-all

are covered by the Swedish universal health care

insurance plan. This makes the ®nding from the

Swedish study even more intriguing. What accounts

for these ®ndings? No doubt, the nursing home

Table 5. Final regression models of drug criteria scores using nursing home aslevel of analysis (n = 33)

Initiation criteriascore

Selection criteriascore

Excess criteriascore

Dementia (%) NS ÿ0.251 NSAger85 (%) NS ÿ0.128 ÿ0.119Sta�ng level ÿ0.153 NS ÿ0.384*Size (number of beds) ÿ0.179 NS NSIntervention teams ÿ0.087 ÿ0.466** ÿ0.201Intercept 4.532 1.163 2.309Adjusted R2 ÿ0.031 0.211 0.149F-ratio 0.683 3.847* 2.866*

aTable shows standardized b-coe�cients.bNS = non signi®cant terms omitted in ®nal model.c*P < 0.05, **P < 0.01.


facility provides a complex environment with exten-

sive medical, social, and psychological needs forboth residents and sta�. The study highlights thecomplexity of this problem and the need for com-

parative studies in other health care systems.As expected (and consistent with previous

research), diagnostic group and age were signi®cant

predictors of deviation from drug use criteria at theindividual level of analysis. Residents with a psy-

chiatric disorder generally were prescribed moremedications and therefore had a greater likelihoodof inappropriate drug use. Younger residents also

had more deviations from the criteria. However,residents' clinical and demographic characteristicsdid not account for variations from one facility to

another, suggesting that facility di�erences are notdue simply to resident mix. The study con®rmed

the expected positive e�ect of multidisciplinaryintervention teams in improving the selection ofpsychotropic drugs (Schmidt et al., 1997). However,

further research is needed to determine whether thisteam e�ect will persist and whether these teamseventually will be able to improve drug use in other

areas.Our ®ndings also con®rm that sta�ng levels can

have a signi®cant in¯uence on deviations from cri-teria regarding concurrent drug use and dosage rec-ommendations. This is consistent with several

studies conducted in the U.S. (Svarstad and Mount,1991; Shorr et al., 1994) and reinforces the need formore detailed studies to determine whether and

how nurse sta�ng actually shapes the drug use pro-cess. Future studies also are need to clarify why

facility size is signi®cant in some studies and notothers and whether other features of the nursinghome have a positive or negative impact on the

quality of drug use. For example, future studiesmight consider the potential in¯uence of facility de-sign, access to a private room and personal a�ects,

the presence or absence of meaningful social andrecreational activities, and the availability of plea-sant recreational facilities.

While these data provide evidence suggestingthe inappropriate use of psychotropic drugs, our

study approach had several drawbacks. First, themethod of measuring appropriateness has limi-tations. The criteria developed in this analysis are

based on various guidelines and recommendations,but they do not take into consideration the clinical

condition of individual residents. Certainly, the useof some drugs classi®ed here as inappropriate mayin fact be highly appropriate for some residents,

especially those experiencing serious psychiatricsymptoms for which there are no alternative treat-ments. Nursing home residents frequently su�er

from sleep disorders, anxiety, and other conditionswhich can be alleviated through drug therapy.However, polymedicine and harmful combinations

must be reduced. We also need to determinewhether and how residents' symptoms and beha-

viors are a�ected by the institutional environment

itself. If some symptoms are the result of the insti-tutional environment, then environmental changesmight provide as much or more relief than psycho-

active drug therapy.A second limitation of the study is the limited

amount and quality of data regarding the residents'

clinical status and diagnosis. As mentioned earlier,the head nurse in each ward was asked to note on

the medication list any known diagnosis, as well aswhether the resident was demented or not. We werenot able to determine the accuracy of these diagnos-

tic reports. As a result, we may have overestimatedor underestimated the appropriateness of drugtherapy due to inaccurate or incomplete diagnostic

information. In any case, our ®ndings draw atten-tion to the lack of documented diagnoses or indi-

cations for use in a larger proportion of Swedishnursing home residents.A third set of limitations relates to sampling pro-

cedures. We recognize the potential di�culties as-sociated with sampling residents through pharmacyregions and nursing homes within a region.

However, it was not feasible to sample residentsindependently. Studying a few individuals within a

larger number of facilities also would haveincreased the risk of an ``observer e�ect'', becausepractitioners might feel compelled to give more

attention to the selected residents.Several kinds of studies would provide new

insights into the problems described in this paper.

First, it would be useful to understand how phys-icians, nurses, nurses' aides and pharmacists com-

municate with each other about residents' drugtherapy needs. In this analysis, we found that multi-disciplinary teamwork can improve drug practices.

While these teams held regular meetings to discussdrug therapy and appeared to have a signi®cantimpact on the choice of drugs, further studies are

needed to understand the dynamics of team success(and failure).

Second, studies are needed to understand bettersta� attitudes toward psychotropic drugs. Sta� atti-tudes toward the elderly have been studied exten-

sively and a handful of studies have also exploredthe attitudes of nursing sta� and managers towardpsychotropic drugs (Glasspoole and Aman, 1988;

Mort et al., 1993). Nurses in both studies expresseda preference for non-drug interventions in managing

behavioral symptoms. However, their views ofassessment seem to underestimate the role of socialand emotional factors. Svarstad (1992) also has

found wide variability in long-term care nurses'beliefs regarding the assessment and management ofsleep problems: nurses with a more holistic treat-

ment ideology believed that nurses should take amore active role in assessing residents' sleep pro-

blems, favored the use of non-drug interventions,and actually administered fewer doses of anxiolytic/hypnotic medication to their residents.


Increasingly, health care providers are acknowl-edging that organizational culture is crucial to

understanding and managing the complex demandsof a health care organization. The de®nition of or-ganizational culture may include the social climate,

quality of communication among sta�, and infor-mal values, norms, beliefs and attitudes shared bymembers of the organization. Recent work has

shown that an organizational culture based on ateamwork approach (as opposed to a traditionalhierarchy of authority) can signi®cantly improve

patient outcomes (Shortell et al., 1995). We are notaware of any published studies testing this modelon the quality of care in nursing homes, but wouldsuggest that it is a promising direction for future

research.Finally, studies are needed to understand the fac-

tors in¯uencing physician prescribing habits. Becker

et al. (1972) examined physician interaction withthe drug industry and its e�ect on prescribing prac-tices and demonstrated that a high level of inter-

action with the drug industry predicted lessappropriate prescribing habits. However, surpris-ingly few studies have addressed the questions

raised by this study. Given the last decade's explo-sive development of the drug industry in both theUnited States and Europe, research activities andcommercial interactions with physicians probably

have increased substantially. From a public healthperspective, it is of utmost importance to determinewhich sources of information most e�ectively and

e�ciently improves the appropriateness and qualityof drug-related decisions by physicians and otherproviders.

Drug use is an important indicator of quality ofcare in nursing homes. This study clearly suggeststhat much remains to be done when it comes toimproving the quality of drug use for the frail

elderly population in these facilities. The proportionof elderly persons is increasing and health caremanagers and policy-makers need to make import-

ant decisions based on current research concerninghow care for elderly might best be provided inorder to meet their medical, human and social

needs.

AcknowledgementsÐThe authors want to acknowledgeSune Pettersson, Stefan Gustavsson, Linda Dalin, pharma-cists and sta� in the nursing home for their inspiring col-laboration. The research was supported by the NationalCorporation of Swedish Pharmacies and the SwedishPharmaceutical Society.

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