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A computerized decision support program significantly decreases prescribing of potentially inappropriate medications to older patients.

A computerized decision support program significantly decreases prescribing of potentially inappropriate medications to older patients.

Critique date: Fri, 09/04/2009 - 3:40pm
Institution: 
Mount Sinai School of Medicine
   
Article Citation
Citation: 
Terrell, KM., et al. Computerized Decision Support to Reduce Potentially Inappropriate Prescribing to Older Emergency Department Patients: A Randomized, Controlled Trial. JAGS. 2009; 57 1388-1394.
   
Clinical Bottom Lines
  1. Clinical Decision Support significantly reduced the proportion of ED discharges that resulted in a potentially inappropriate prescription:  Absolute Risk Reduction 1.3% (95% CI 0.4-2.3%)                       Level of Evidence=1
  2. The overall proportion of potentially inappropriate medications prescribed by physicians was significantly reduced from 5.4% to 3.4% (P=0.006) with absolute reduction of 2.0% (95% CI 0.7-3.3%)    Level of Evidence = 1
  3. An analysis of PGY-1 residents found that there was no significant difference in prescribing inappropriate medications between the intervention physicians and the usual care physicians (6.4% vs 6.2%, P=0.87, 95% CI 0.67-1.59)
   
Methods
Study Design: 
Randomized, controlled clinical trial
Follow-up Period: 
January 12, 2005-July 7, 2007: 30 month study
Patient Population: 

Participants: Emergency Room Physicians stratified according to year of residency

Inclusions: Emergency Medicine Faculty and ER residents

Significant Exclusions: 

Three ER physicians who conducted the study were excluded

Also PGY-1 ER residents were excluded ACCIDENTALLY

Intervention/Exposure: 

A computer-based decision support designed to reduce prescribing of medications potentially inappropriate for older adults.

An expert panel chose nine high-use and high-impact potentially inappropriate medications which represented 80% of potentially inappropriate meds Rx’d to seniors in the ED the previous year.

Outcome Measures: 

Primary Outcome: Proportion of ED visits by older adults that resulted in one or more prescriptions for a targeted inappropriate medication.

Secondary Outcomes:

- Proportion of all prescribed medications that were potentially inappropriate

- Number of times the potentially inappropriate med was initially Rx’d as well as the proportion of times the intervention physicians chose an alternative therapy.

- Intervention physicians reported primary reasons for rejecting the decision support.

- Patient and physician factors associated with decisions to prescribe inappropriate meds

   
Conclusion
Results: 

Analysis (ITT): Physicians randomized during residency training who later joined the faculty (n=4) remained in the study groups to which they were originally assigned.

Results:

Outcome Measure

Control

Intervention

p-value

Odds Ratio (95% CI)

Primary: visits with an inappropriate med, n (%)

99 (3.9)

69 (2.6)

0.02

0.55 (0.34-0.89)

 

Absolute risk reduction of 1.3 %

Secondary: Prescriptions that were inappropriate, n (%)

103 (5.4)

69 (3.4)

0.006

0.59 (0.41-0.85)

 

Absolute risk reduction of 2.0%

 

Concerns Regarding Methodology, Applicability to Older Adults, etc.: 
  1. Of the 7500 ED visits 2300 were excluded as they either resulted in admission or death in the ED-this may be a limitation in that  only patients well enough to be discharged home from the ED are accounted for.
  2. Study only performed at a single site with a small sample of academic physicians and residents-thus it may not be generalizable.
  3. Only process outcomes were obtained; would be beneficial to look at patient outcomes over times in those patients that were and were not prescribed potentially adverse meds.
Funding Source and Role: 
none stated
Created By: 
Allison Margold, MD Second Year Fellow, Brookdale Department of Geriatrics, Mt Sinai School of Medicine
This is a review of the validity of a single study; the ‘bottom lines’ do not reflect comparison with the rest of the literature on this subject.