A Systematic Review of Interventions to Improve Analgesic Use and Appropriateness in Long-Term Care Facilities.

Laura A Dowd, Amanda J Cross, Felicity Veal, Choon Ean Ooi, J Simon Bell

Journal of the American Medical Directors Association 2022 Jan

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To systematically review the effectiveness of interventions to improve analgesic use and appropriateness in long-term care facilities (LTCFs). Systematic review. MEDLINE, Embase, PsycINFO, and CINAHL Plus were searched from inception to June 2021. Randomized controlled trials (RCTs), controlled and uncontrolled prospective interventions that included analgesic optimization, and reported postintervention change in analgesic use or appropriateness in LTCFs were included. Screening, data extraction, and quality assessment were performed independently by 2 review authors. Eight cluster RCTs, 2 controlled, and 6 uncontrolled studies comprising 9056 residents across 9 countries were included. The 16 interventions included education (n = 13), decision support (n = 7), system modifications (n = 6), and/or medication review (n = 3). Six interventions changed analgesic use or appropriateness, all of which included prescribers, 5 involved multidisciplinary collaboration, and 5 included a component of education. Education alone changed analgesic use and appropriateness in 1 study. Decision support was effective when combined with education in 3 interventions. Overall, 13 studies reported analgesic optimization as part of pain management interventions and 3 studies focused on medication optimization. Two pain management interventions reduced the percentage of residents reporting pain not receiving analgesics by 50% to 60% (P = .03 and P < .001, respectively), and 1 improved analgesic appropriateness (P = .03). One reduced nonsteroidal anti-inflammatory drugs (NSAIDs) (P < .001) and another resulted in 3-fold higher odds of opioid prescription in advanced dementia [95% confidence interval (CI) 1.1-8.7]. One medication optimization intervention reduced NSAID prescription (P = .036), and another reduced as-needed opioid (95% CI 8.6-13.8) and NSAID prescription (95% CI 1.6-4.2). Interventions involving prescribers and enhanced roles for pharmacists and nurses, with a component of education, are most effective at changing analgesic use or appropriateness. Interventions combining education and decision support are also promising. Medication review interventions can change analgesic prescription, although there is currently minimal evidence in relation to possible corresponding improvements in resident-related outcomes. Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

Citation

Laura A Dowd, Amanda J Cross, Felicity Veal, Choon Ean Ooi, J Simon Bell. A Systematic Review of Interventions to Improve Analgesic Use and Appropriateness in Long-Term Care Facilities. Journal of the American Medical Directors Association. 2022 Jan;23(1):33-43.e3