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A Controlled Trial of Provider Education

Wayne A. Ray, PhD; Jo A. Taylor, RN, MPH; Keith G. Meador, MD, MPH; Michael J. Lichtenstein, MD, MS; Marie R. Griffin, MD, MPH; Randy Fought; Margaret L. Adams, RN; Dan G. Blazer, MD, PhD

Arch Intern Med. 1993;153(6):713-721.

Abstract
Objective
In the United States, 20% or more of nursing home residents receive antipsychotic drugs, primarily for the behavioral manifestations of dementia. This high level of use of drugs with substantial toxicity has engendered a strong and persistent controversy and recently has led to explicit regulatory measures to curtail use (Omnibus Budget Reconciliation Act of 1987). We developed and tested a comprehensive program to reduce antipsychotic use through education of physicians, nurses, and other nursing home staff. The primary elements of the program were instruction in use of behavioral techniques to manage behavior problems and encouragement of a trial of gradual antipsychotic withdrawal.

Design
In a nonrandomized controlled trial, the program was implemented (beginning in August 1990) in two rural Tennessee community nursing homes with elevated antipsychotic use; two other comparable homes were selected as concurrent controls.

Patients
Throughout the study 194 residents were in the education homes and 184 were in the control homes. Residents in both groups of homes had comparable demographic characteristics and functional status, and each group had a baseline rate of 29 days of antipsychotic use per 100 days of nursing home residence.

Main Outcome Measures
The primary end points were postintervention changes in administration of antipsychotics and other psychotropic drugs, use of physical restraints, and frequency of behavior problems.

Results
Days of antipsychotic use decreased by 72% in the education homes vs 13% in the control homes (P<.001). No significant changes were noted in the use of other psychotropic drugs in either group. Days of physical restraint use decreased 36% in the education homes vs 5% in the control homes (P<.001). Behavior problem frequency did not increase in either group, even among the 48% of baseline antipsychotic users in the education homes who had antipsychotic drug regimens discontinued for 3 or more months.

Conclusions
The educational program led to a substantial reduction in antipsychotic use with no increase in the frequency of behavior problems. This suggests that for many antipsychotic drug users benefits may be marginal and that programs to reduce such drug use among the 250 000 US nursing home residents receiving these drugs should have high priority.

(Arch Intern Med. 1993;153:713-721)

Author Affiliations
From the Department of Preventive Medicine (Drs Ray and Griffin, Mss Taylor and Adams, and Mr Fought) and Psychiatry (Dr Meador), Vanderbilt University School of Medicine, Nashville, Tenn; the University of Texas Health Science Center and the Geriatrics Research Education and Clinical Center, Audie L. Murphy Memorial Veterans Hospital, San Antonio (Dr Lichtenstein); and the Department of Psychiatry, Duke University Medical Center, Durham, NC (Dr Blazer).

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