The medical office of the 21st century (MOXXI): effectiveness of computerized decision-making support in reducing inappropriate prescribing in primary care (original) (raw)
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The American Journal of Geriatric Pharmacotherapy, 2008
Older adults take multiple medications and are at high risk for adverse drug effects. This systematic review was conducted to describe the impact of computer decision support (CDS) interventions designed to improve the quality of medication prescribing in older adults. PubMed and EMBASE databases were searched from January 1980 through July 2007 (English-language only); studies were eligible if they described a CDS intervention intended to improve medication prescribing in adults aged > or =60 years. Studies were retained if they were observational or experimental in design and reported > or =1 process or clinical outcome measurement related to medication prescribing. In the main analysis, study characteristics and major outcome results were extracted. A combination of searches was performed using relevant medical subject headings: aged; drug therapy, computer-assisted; medication errors; medication errors/prevention and control; decision making, computer-assisted; decision support systems, clinical; and clinical pharmacy information systems. After review of study abstracts, 10 articles met the eligibility criteria. Of those 10 studies testing CDS interventions, 8 showed at least modest improvements (median number needed to treat, 33) in prescribing, as measured by minimizing drugs to avoid, optimizing drug dosage, or more generally improving prescribing choices in older adults (according to each study's intervention protocols). Findings for the impact of CDS interventions on clinical outcomes were mixed and were reported for only 2 studies. Various types of CDS interventions may be effective in improving medication prescribing in older adults, but few studies reported clinical outcomes related to changes in medication prescribing. Data from this study should help to guide refinement and testing of future CDS interventions that specifically target older adult populations that are taking multiple medications.
Journal of Medical Internet Research, 2019
Background: Older adults are more vulnerable to polypharmacy and prescriptions of potentially inappropriate medications. There are several ways to address polypharmacy to prevent its occurrence. We focused on computerized decision support tools. Objective: The available literature was reviewed to understand whether computerized decision support tools reduce potentially inappropriate prescriptions or potentially inappropriate medications in older adult patients and affect health outcomes. Methods: Our systematic review was conducted by searching the literature in the MEDLINE, CENTRAL, EMBASE, and Web of Science databases for interventional studies published through February 2018 to assess the impact of computerized decision support tools on potentially inappropriate medications and potentially inappropriate prescriptions in people aged 65 years and older. Results: A total of 3756 articles were identified, and 16 were included. More than half (n=10) of the studies were randomized controlled trials, one was a crossover study, and five were pre-post intervention studies. A total of 266,562 participants were included; of those, 233,144 participants were included and assessed in randomized controlled trials. Intervention designs had several different features. Computerized decision support tools consistently reduced the number of potentially inappropriate prescriptions started and mean number of potentially inappropriate prescriptions per patient. Computerized decision support tools also increased potentially inappropriate prescriptions discontinuation and drug appropriateness. However, in several studies, statistical significance was not achieved. A meta-analysis was not possible due to the significant heterogeneity among the systems used and the definitions of outcomes. Conclusions: Computerized decision support tools may reduce potentially inappropriate prescriptions and potentially inappropriate medications. More randomized controlled trials assessing the impact of computerized decision support tools that could be used both in primary and secondary health care are needed to evaluate the use of medication targets defined by the Beers or STOPP (Screening Tool of Older People's Prescriptions) criteria, adverse drug reactions, quality of life measurements, patient satisfaction, and professional satisfaction with a reasonable follow-up, which could clarify the clinical usefulness of these tools.
JAMA, 1998
Context.-Pharmacotherapy is among the most powerful interventions to improve health outcomes in the elderly. However, since some medications are less appropriate for older patients, systems approaches to improving pharmacy care may be an effective way to reduce inappropriate medication use. Objective.-To determine whether a computerized drug utilization review (DUR) database linked to a telepharmacy intervention can improve suboptimal medication use in the elderly. Design.-Population-based cohort design, April 1, 1996, through March 31, 1997. Setting.-Ambulatory care. Patients.-A total of 23 269 patients aged 65 years and older throughout the United States receiving prescription drug benefits from a large pharmaceutical benefits manager during a 12-month period. Intervention.-Evaluation of provider prescribing through a computerized online DUR database using explicit criteria to identify potentially inappropriate drug use in the elderly. Computer alerts triggered telephone calls to physicians by pharmacists with training in geriatrics, whereby principles of geriatric pharmacology were discussed along with therapeutic substitution options. Main Outcome Measures.-Contact rate with physicians and change rate to suggested drug regimen. Results.-A total of 43 007 alerts were triggered. From a total of 43 007 telepharmacy calls generated by the alerts, we were able to reach 19 368 physicians regarding 24 266 alerts (56%). Rate of change to a more appropriate therapeutic agent was 24% (5860), but ranged from 40% for long half-life benzodiazepines to 2% to 7% for drugs that theoretically were contraindicated by patients' self-reported history. Except for rate of change of -blockers in patients with chronic obstructive pulmonary disease, all rates of change were significantly greater than the expected baseline 2% rate of change. Conclusions.-Using a system integrating computers, pharmacists, and physicians, our large-scale intervention improved prescribing patterns and quality of care and thus provides a population-based approach to advance geriatric clinical pharmacology. Future research should focus on the demonstration of improved health outcomes resulting from improved prescribing choices for the elderly.
Journal of the American Geriatrics Society, 2000
OBJECTIVES: To examine the effect of replacing drugspecific computerized prescribing alerts with age-specific alerts on rates of dispensing potentially inappropriate medications in older people and to determine whether group academic detailing enhances the effectiveness of these alerts. DESIGN: Cluster-randomized trial of group academic detailing and interrupted time-series analysis. SETTING: Fifteen clinics of a staff-model health maintenance organization. PARTICIPANTS: Seven practices (113 clinicians, 24,119 patients) were randomly assigned to receive age-specific prescribing alerts plus the academic detailing intervention; eight practices (126 clinicians, 26,805 patients) received alerts alone. Prior implementation of drug-specific alerts established a downward trend in use of target medications that served as the baseline trend for the present study. INTERVENTION: The computerized age-specific alerts occurred at the time of prescribing a targeted potentially inappropriate medication (e.g., tertiary tricyclic amine antidepressants, long-acting benzodiazepines, propoxyphene) and suggested an alternative medication. Clinicians at seven sites were randomized to group academic detailing, an interactive educational program delivering evidence-based information. MEASUREMENTS: Number of target medications dispensed per 10,000 patients per quarter, 2 years before and 1.5 years after the replacement of drug-specific with agespecific alerts.
Journal of Evaluation in Clinical Practice, 2018
Rationale, aims, and objectives: The prescription of potentially inappropriate medication (PIM) is a global issue associated with increased adverse drug events, mortality, and health care expenditure. Computerized decision support system (CDSS) for the detection of PIM is a novel alert system in Thailand for reducing PIM prescriptions. The aim of this study was to evaluate the effect of a CDSS on PIM prescriptions for elderly patients in Thai community hospitals. Methods: The study design comprised two phases with a duration of 12 months each: pre-CDSS implementation (October 2015-March 2016) and post-CDSS implementation (October 2016-March 2017). Medical services and prescription claims data from four hospitals were used to calculate the prevalence of PIM prescriptions among elderly patients aged 60 years and older. Chi-square tests were used to analyse changes in PIM prescriptions across hospitals post CDSS. Results: The overall prevalence of PIM prescriptions post-CDSS implementation significantly decreased from 87.7% to 74.4%. The severity of mild and moderate PIMs was significantly reduced from 71.9% to 49.0% and from 64.5% to 48.7%, respectively. All hospitals had only one severe PIM, which was hyoscine. It was reduced from 4.7% to 1.5%, but the change was not significant (P = 0.74). The proportion of frequently prescribed PIMs in all PIM levels was significantly decreased, regardless of existing alternative medications. Conclusions: Specific CDSS for PIM in community hospital setting was associated with a reduction of PIM prescription in elderly patients. This CDSS can change physician's prescription behaviour to avoid inappropriate medications.
Clinical interventions in aging, 2016
Elderly people (aged 65 years or more) are at increased risk of polypharmacy (five or more medications), inappropriate medication use, and associated increased health care costs. The use of clinical decision support (CDS) within an electronic medical record (EMR) could improve medication safety. Participatory action research methods were applied to preproduction design and development and postproduction optimization of an EMR-embedded CDS implementation of the Beers' Criteria for medication management and the Cockcroft-Gault formula for estimating glomerular filtration rates (GFR). The "Seniors Medication Alert and Review Technologies" (SMART) intervention was used in primary care and geriatrics specialty clinics. Passive (chart messages) and active (order-entry alerts) prompts exposed potentially inappropriate medications, decreased GFR, and the possible need for medication adjustments. Physician reactions were assessed using surveys, EMR simulations, focus groups, an...
Journal of the American Medical Informatics Association, 2008
Prescribing alerts generated by computerized drug decision support (CDDS) may prevent drug-related morbidity. However, the vast majority of alerts are ignored because of clinical irrelevance. The ability to customize commercial alert systems should improve physician acceptance because the physician can select the circumstances and types of drug alerts that are viewed. We tested the effectiveness of two approaches to medication alert customization to reduce prevalence of prescribing problems: on-physician-demand versus computertriggered decision support. Physicians in each study condition were able to preset levels that triggered alerts. Design: This was a cluster trial with 28 primary care physicians randomized to either automated or on-demand CDDS in the MOXXI drug management system for 3,449 of their patients seen over the next 6 months. Measurements: The CDDS generated alerts for prescribing problems that could be customized by severity level. Prescribing problems included dosing errors, drug-drug, age, allergy, and disease interactions. Physicians randomized to on-demand activated the drug review when they considered it clinically relevant, whereas physicians randomized to computer-triggered decision support viewed all alerts for electronic prescriptions in accordance with the severity level they selected for both prevalent and incident problems. Data from administrative claims and MOXXI were used to measure the difference in the prevalence of prescribing problems at the end of follow-up. Results: During follow-up, 50% of the physicians receiving computer-triggered alerts modified the alert threshold (n ϭ 7), and 21% of the physicians in the alert-on-demand group modified the alert level (n ϭ 3). In the ondemand group 4,445 prescribing problems were identified, 41 (0.9%) were seen by requested drug review, and in 31 problems (75.6%) the prescription was revised. In comparison, 668 (10.3%) of the 6,505 prescribing problems in the computer-triggered group were seen, and 81 (12.1%) were revised. The majority of alerts were ignored because the benefit was judged greater than the risk, the interaction was known, or the interaction was considered clinically not important (computer-triggered: 75.8% of 585 ignored alerts; on-demand: 90% of 10 ignored alerts). At the end of follow-up, there was a significant reduction in therapeutic duplication problems in the computertriggered group (odds ratio 0.55; p ϭ 0.02) but no difference in the overall prevalence of prescribing problems.
Utilization of computerized clinical decision support for potentially inappropriate medications
Clinical Interventions in Aging, 2019
Background: Electronic medical record (EMR) alerts may inform point of care decisions, including the decision to prescribe potentially inappropriate medications (PIM) identified in the Beers criteria. EMR alerts may not be considered relevant or informative in the clinician context, leading to a phenomenon colloquially known as "alert fatigue." Objective: To assess the frequency of clinical interaction with EMR alerts and associated deprescribing behaviors in ambulatory settings. Methods: This is a retrospective observational study in two ambulatory clinics (the Kaye Edmonton Clinic Senior's Clinic and the Lynnwood Family Practice Clinic) in Edmonton over an observational period of 30 months. Statistical analysis was done using descriptive statistics, chi-square and regression analysis. Results: The reminder performance for interactions with the alert was 17.2% across the two clinics. The Number Needed to Remind (NNR) or mean number of alerts shown on clinician screens prior to a single interaction of any kind with the alert was 5.8. When actions were defined as a deprescribing (ie discontinuation) event that was related to the alert and that particular interaction in the EMR, the reminder performance was 1.2%, for an NNR of 82.8. Conclusion: The configuration of alerts in the EMR was not associated with a clinically detectable increase in the uptake of the Beers criteria for high hazard medications.
The Impact of Prescribing Safety Alerts for Elderly Persons in an Electronic Medical Record
Archives of Internal Medicine, 2006
Background: Considerable effort and attention have focused on medication safety in elderly persons; one approach that has been understudied in the outpatient environment is the use of computerized provider order entry with clinical decision support. The objective of this study was to examine the effects of computerized provider order entry with clinical decision support in reducing the use of potentially contraindicated agents in elderly persons.