By Dr. David Kaplan and Anna Greenberg
Since 2015, Ontario family physicians who provide medical care to residents of long-term-care homes have been able to receive confidential, personalized reports on how to improve their practice.
To date these quarterly reports – known as MyPractice: Long-Term Care reports and produced by Health Quality Ontario – have focused on the priority area of optimizing the use of antipsychotic medications and benzodiazepines and addressing the particular risks associated with some of the medications (e.g. falls). Health Quality Ontario collaborated with Public Health Ontario in the development of antibiotic prescribing indicators and ideas on how physicians can improve their practises. In addition, the reports contain contextual data on resident demographics, behavioural characteristics, and chronic conditions.
Health Quality Ontario will soon expand the scope of the reports to include antibiotic prescribing data. These much-anticipated indicators will allow long-term care physicians to see how many of their residents have been started on antibiotics and how often their prescription duration is longer than seven days – which may not be necessary for common uncomplicated infections found among LTC residents.
Appropriate prescribing of antipsychotics and antibiotics in long-term care homes have been singled out by the Choosing Wisely Canada initiative as one means of reducing unnecessary tests and treatments among long-term care home residents. However, there is also a recognition that there are times when these medications are needed. The My Practice reports are meant to optimize care, not just reduce the medications.
The reports also allow physicians to compare their prescribing practices with their peers at the regional and provincial level and they provide tools and topic-specific resources for improving quality care.
So far, more than 400 physicians have signed up to receive the MyPractice Long-Term Care reports. In Ontario, there are approximately 800 physicians with a substantial LTC practice.
To demonstrate the value of the reports, Health Quality Ontario quotes the case of Dr. Julie Auger, Medical Director of Golden Manor Home for the Aged in Timmins, Ontario, Medical Director of Continuing Care Rehabilitation Programs at Timmins and District Hospital, and Board Member of the not-for-profit organization Ontario Long Term Care Clinicians.
From her MyPractice: Long-Term Care reports, Dr. Auger saw that 178-bed Golden Manor averaged an overall antipsychotic prescribing rate of 40% in 2015, which was much higher than she had expected. Motivated to set an example for the sector, she was determined to make some changes.
After reviewing all of her residents’ files and confirming each of their diagnoses, Dr. Auger realized that there was quite a bit of misclassification (mislabelled drugs or indications, incorrect diagnoses) in her patients’ charts and the nursing home’s coding database. After cleaning up files and educating staff at the home on the importance of accurate documentation, by the fall of 2015 Dr. Auger found that her overall rate of antipsychotic use was 35%: with 15% being deemed to be appropriate while the remainder involved “inappropriate” prescribing.
As Dr. Auger described, “I must admit, it was easy to generate all sorts of excuses as to why my numbers were justifiably high. But when I really started digging into it … one of the biggest barriers in getting them down had been my own inertia and just lack of time and energy to focus on it.”
After making changes to improve the process of prescribing, Dr. Auger found the rate of “inappropriate” antipsychotic prescriptions dropped to about 10% in a year.
MyPractice: Long-Term Care reports were developed by Health Quality Ontario with the support of ICES and in partnership with the Ontario Medical Association, Ontario Long Term Care Clinicians, Ontario Long Term Care Association, AdvantAge Ontario, the Nurse Practitioners’ Association of Ontario, the Ontario Pharmacists Association and Public Health Ontario. The reports are also developed with ongoing input from family physicians who work in long-term care.
Dr. David Kaplan is Chief Clinical Quality and Anna Greenberg is Interim President and CEO of Health Quality Ontario.