Education, Reminders Reduce Risky Prescriptions for Elders

Laird Harrison

May 21, 2016

LONG BEACH, California — Systematic education and reminders can reduce prescriptions in emergency departments that can be inappropriate for older patients, researchers say.

A program that implemented such measures in four Veterans Affairs emergency departments "had significant reductions in potentially inappropriate medications," said Melissa Stevens, MD, from Emory University School of Medicine in Atlanta.

About 60% of older patients receive at least one new drug when they are discharged from an emergency department, Dr Stevens reported. And they are not always appropriate.

In fact, one study showed that 11.6% of elderly veterans discharged from the Veterans Affairs Medical Center in Durham, North Carolina, were prescribed a drug that should be avoided in older patients (J Am Geriatr Soc. 2008;56:875-880). And those who received the inappropriate drugs suffered adverse events sooner than those who received no drugs or only appropriate drugs.

To address this problem, Dr Stevens and her colleagues implemented the EQUiPPED program — Enhancing Quality of Prescribing Practices for Older Veterans Discharged From the Emergency Department — in Veterans Affairs emergency departments in Birmingham, Alabama; Durham; the Bronx, New York; and Atlanta.

She presented the findings here at the American Geriatrics Society 2016 Annual Scientific Meeting.

EQUiPPED Program

The EQUiPPED team included geriatricians, gerontologists, geriatric pharmacy specialists, emergency department providers, quality improvement nurses, clinical informatics specialists, clinical application coordinators, and data analysts.

The goal of the program was to reduce, to 5% or less, the proportion of potentially inappropriate medications prescribed to veterans 65 years and older at discharge from the emergency department.

To achieve that reduction, the team provided didactic instruction and held one-on-one meetings with providers to inform them about medications that could be risky for older patients. They gave providers information on whether they were prescribing potentially inappropriate medications and how their prescribing patterns compared with those of their peers. And they created discharge medication order sets and drug alerts in electronic health records.

The researchers tracked the number of patients older than 64 years treated by each provider involved in the program, the number of prescriptions they wrote, and the number of medications they prescribed that met the Beers criteria for inappropriate medication. The team used these data to calculate the percentage of prescriptions that were potentially inappropriate attributed to each provider.

Not all the sites had order sets when the project began, and when they did, the order sets did not distinguish between older and younger patients.

"Providers typically used order sets for all patients because they thought they improved efficiency when prescribing discharge medications, despite the fact that these order sets were not tailored to older patients, and might, in fact, lead providers to inadvertently choose medications or doses of medications that were inappropriate for older patients," Dr Stevens explained.

When the EQUiPPED team encountered these, they modified the order sets to work for older people.

For example, if providers clicked on a geriatrics link and then a pain prescribing link, they might get a warning to "avoid Toradol (ketorolac) and indomethacin." They might also get a tip to "consider coprescribing PPI with NSAIDs if the patient is not already taking and there is no contraindication," and be given a list of the maximum daily doses of 4 g acetaminophen for all dosage forms. In addition, they could get a list of drugs for constipation (a common adverse effect of opioids) and helpful references.

"Alert fatigue was a common complaint, and providers unanimously said they hate popup drug warnings," said Dr Stevens, eliciting chuckles from the audience. Nevertheless, the EQUiPPED program included such alerts.

The impact of the intervention varied from one center to another, but made a difference at all of them.

Table. Potentially Inappropriate Medication Prescriptions

Site Before EQUiPPED, % After EQUiPPED, % P Value
Atlanta 11.8 5.3 <.0001
Birmingham 8.9 6.3 .0025
Bronx 7.4 5.6 .04
Durham 8.3 4.5 <.0001


The four emergency departments are working to sustain the benefits of the intervention by including geriatric order sets in provider orientation, giving continuous performance feedback to providers, and offering monthly education to residents.

For example, each emergency department now posts cards listing the top 5 potentially inappropriate medications prescribed in that department to people 65 years and older at discharge.

After two years, Atlanta continues to have potentially inappropriate prescribing rates of about 5%.

This is not rocket science. It's harder.

The EQUiPPED program is now being used in eight Veterans Affairs medical centers, and the team is helping other emergency departments and non-VA hospitals to implement the program.

After the presentation, a member of the audience asked Dr Stevens about data she reported that showed slight upticks in potentially inappropriate prescriptions 2 years after the program was implemented in Atlanta and 1 year after it was implemented in Birmingham.

Dr Stevens explained that providers come and go at all sites, and said that the team is working to educate new providers about prescribing practices for older patients.

Another audience member wanted to know if there was an increase in hospital admissions after the EQUiPPED program was implemented. "My theory is that if the prescriber doesn't have enough medications to manage these conditions, they may be inclined to admit the patients," he said.

Dr Stevens said that the researchers are still analyzing outcomes data, including hospital admissions. However, she explained, the order sets do not restrict what medications can be prescribed, they simply offer a default option of drugs and doses considered safe.

The results are impressive, said session moderator Ellen Flaherty, PhD, from the Dartmouth Centers for Health and Aging in Lebanon, New Hampshire.

"This is not rocket science. It's harder," she told Medscape Medical News. "A lot of this seems like common sense, but healthcare is a messy world."

This study was funded by the Veterans Health Administration. Dr Stevens and Dr Flaherty have disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2016 Annual Scientific Meeting: Abstract P1. Presented May 19, 2016.


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