Canadians take pride in having a universal health care system, but there are always differences in the way health care is delivered to each person. You can see these variations in every part of the health system: After-hours access to a family doctor varies by province, Caesarian section rates vary by hospital, and wait times for nursing homes vary by region in Ontario.
Some of this variation in health care is expected, acceptable and even desirable. Each patient is an individual with unique needs. But how much variation is too much? At what point does it become unwarranted? And if you do uncover unwarranted variation, how do you fix it?
These questions jump to mind with the release of a new report by Health Quality Ontario on antipsychotic medication use in Ontario nursing homes. The report, Looking for Balance, shows that the percentage of long-term care home residents who are using antipsychotic medications varies from zero per cent in some of the province's homes to 67 per cent in others. That's a striking amount of variation.
While it's true that some long-term care homes specialize in treating people with severe mental illness or advanced dementia, it is unlikely this factor alone explains the breadth of the difference between none and more than two-thirds across more than 600 homes.
Although antipsychotic medications can play an important role in managing psychosis as well as behavioural symptoms related to dementia, such as agitation and aggression, they should only be prescribed when needed. They are powerful drugs that have risks of side effects, including an increased risk of falls, sedation and possibly a slight increased risk of death.
Overall, the report also showed that over four years there was a small decline in the use of antipsychotic medications in long-term care homes, to just under 29 per cent of residents in 2013 from 32 per cent in 2010. But the variation across long-term care homes raises some important questions, such as:
- Are there people using antipsychotic medications who shouldn't be?
- Should patients who have dementia be using these medications?
- If someone has been using these medications for a long time, can they be re-evaluated?
- Are there other ways to treat symptoms of agitation and aggression that are not drug-based?
Across Ontario, long-term care homes are working to find different ways of caring for residents without using antipsychotic medications. Our report highlights several of these stories. However, as a physician, I'm well aware that we don't always work in a world of perfect knowledge. Every patient is different and responds to medications or non-medical interventions differently. Furthermore, agitation and confusion can be very distressing and lead to situations where people harm themselves or others.
As with any medication use, particularly among those who are elderly and frail, we need to strive for the right balance of risk and benefits. And as with any activity in health care, we need to learn from each other, ask hard questions, involve patients and ensure that variation in care is about safer and better care.
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