Computerized System Can Reduce Inappropriate Medication in Hospitalized Seniors

Fran Lowry

August 09, 2010

August 9, 2010 — A computerized provider order entry (CPOE) system that uses alerts to warn when the wrong medication has been prescribed can reduce the prescription of potentially inappropriate medications (PIMs) in hospitalized older patients, according to the results of a new prospective study published in the August 9/23 issue of the Archives of Internal Medicine.

"Older people admitted to the hospital are especially vulnerable to adverse drug events (ADEs), which occur in up to 40% of hospital admissions," write Melissa L.P. Mattison, MD, from Beth Israel Deaconess Medical Center, Boston, Massachusetts, and colleagues. "Some medications may predispose vulnerable older patients to ADEs." Based on the consensus of a panel of geriatric medicine experts, a proposed list was made up of drugs were identified as medications that should be avoided in older persons. Despite the publication of this list, known as "Beers medications," "the prescription of [PIMs] to elderly patients remains common," the authors explain.

The aim of this study was to determine whether a computerized provider order entry drug warning system could decrease the number of orders for PIMs in such a population.

The authors used a prospective before-and-after design among patients aged 65 years or older admitted to their medical center from June 1, 2004, through November 29, 2004 — before the addition of the warning system — and from March 17, 2005, through August 30, 2008 — after the warning system was added.

The investigators studied the ordering patterns for 3 groups of drugs: a larger group of drugs included those on the original Beers medications list that were flagged as not to be used, a second group of Beers medications that were flagged to be used at reduced doses, and a third group of Beers medications that were not flagged.

After the warning system was deployed, there was an immediate and sustained decrease in the rate of orders for the medications that were flagged not to be used, the authors report. The mean (SE) rate of prescribing not-recommended medications dropped from 11.56 (0.36) to 9.94 (0.12) orders per day (difference, 1.62 [SE, 0.33] orders per day; P < .001). There was no evidence that this effect waned over time, the authors write.

They also found a modest decrease in the use of unflagged medications, and no change in the rate of prescriptions of medications flagged to be used at reduced doses.

Before the start of the warning system, the most commonly prescribed inappropriate drug was diphenhydramine. This accounted for about one third of all prescriptions, the authors note.

"Both its use and the use of other targeted medications dropped markedly after implementation of the warning system, although we had insufficient power to examine other medications individually," the authors write.

They also note other limitations in their data. One is the inability to determine the dose of lorazepam and ferrous sulfate — 2 drugs that were flagged to be prescribed at a reduced dose. As a result, it was not possible to know with certainty whether the targeted dose reductions were achieved with these drugs. In addition, the drug warning system was used at an academic center that uses medical trainees and physician extenders to order most medications. Therefore, whether similar results would be seen in centers where attending physicians place most of the orders or in institutions that do not use a CPOE system is unknown. Finally, the data do not show whether adverse drug events were prevented by the warning system, and whether the medications that were ordered were, in fact, clinically required.

The authors suggest that an important area of future study would be to improve understanding of scenarios in which it is clinically appropriate and reasonable to prescribe the medications on the Beers list, "even to older adults."

They conclude that a CPOE system with specific, targeted, and straightforward warnings "can dramatically yet selectively reduce the prescriptions of PIMs in vulnerable hospitalized older patients," and add that such systems "may represent a tool for improving the safety of hospitalized older adults."

The study was supported by a grant from the Harvard Clinical and Translational Science Center, from the National Center for Research Resources The authors have disclosed no relevant financial relationships.

Arch Intern Med. 2010;170:1331-1336.

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