The impact of prescribing safety alerts for elderly persons in an electronic medical record: an interrupted time series evaluation

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David H. Smith,RPh, PhD; Nancy Perrin, PhD; Adrianne Feldstein,MS, MD;Xiuhai Yang, MS; Daniel Kuang, MS; Steven R. Simon, MD,MPH; Dean F. Sittig, PhD; Richard Platt, MS, MD; Stephen B. Soumerai, ScD. Arch Internal Medicine,Volume 166, May 22, 2006

Considerable attention has been given to medication safety in elderly persons, however the use of computerized provider order entry with clinical decision support has been understudied in the outpatient environment. The above article is an interrupted time series evaluation with the objective to evaluate the impact of decision support at provider medication order entry. The decision support aimed to reduce the use of two classes of medications generally contraindicated in elderly persons. The study used data over a 39-month period and was set at a group-model HMO in the Pacific Northwest caring for about 450,000 people. All adult enrollees of the health plan participated. The study sample was based on electronic data on monthly outpatient medication dispensings from prescriptions written by primary care providers from October 1, 1999 to December 31, 2002. This period included 12 months before the alerts were implemented and 27 months after the implementation.

The alerts were presented when any non-preferred drugs were prescribed regardless of age or other clinical characteristics. The main outcome measure was dispensing per 10,000 members per month. Outcomes of interest were organized into 39 monthly intervals.

Following the implementation of the drug-specific alerts, a large and persistent reduction (5.1 prescriptions per 10,000, P=0.004), a 22% relative decrease from the month before alert implementation, in the exposure of elderly patients to nonpreferred agents was observed. No evidence of decrease in use of nonpreferred medications was found for nonelderly patients. Largest changes in dispensing rates in nonpreferred agents were observed for tertiary tricyclic agents. The research suggests that the rates of use of preferred medications increased for people in younger age groups.

The effect of the alerts on patient outcomes is less certain and needs further investigation. There is also some controversy surrounding the clinical appropriateness of recommendations regarding some of the medications targeted by the alerts in this study.