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Improving Prescribing Patterns for the Elderly Through an Online Drug Utilization Review Intervention a System Linking the Physician, Pharmacist, and Computer

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Improving Prescribing Patterns for the Elderly Through an Online Drug Utilization Review Intervention a System Linking the Physician, Pharmacist, and Computer Improving Prescribing Patterns for the Elderly Through an Online Drug Utilization Review Intervention A System Linking the Physician, Pharmacist, and Computer Mark Monane, MD, MS; Dipika M. Matthias, MBA; Becky A. Nagle, PharmD; Miriam A. Kelly, PhD, MEd Context.—Pharmacotherapy is among the most powerful interventions to INDIVIDUALS aged 65 years and improve health outcomes in the elderly. However, since some medications are less older constitute 12% of the US popula- appropriate for older patients, systems approaches to improving pharmacy care tion; however, they consume approxi- 1 may be an effective way to reduce inappropriate medication use. mately 30% of prescribed medications. Objective.—To determine whether a computerized drug utilization review (DUR) Olderpatientsarepronetoadversedrug events (ADEs) because use of multiple database linked to a telepharmacy intervention can improve suboptimal medication medications regardless of age increases use in the elderly. the chance of ADEs2,3 and age-related Design.—Population-based cohort design, April 1, 1996, through March 31, physiologic changes alter the pharmaco- 1997. kinetic and pharmacodynamic proper- Setting.—Ambulatory care. ties of many drugs.4 The incidence of Patients.—A total of 23 269 patients aged 65 years and older throughout the ADEs in the elderly varies from 5% to United States receiving prescription drug benefits from a large pharmaceutical 35%, depending on the method used to 5 benefits manager during a 12-month period. define and measure the event. Adverse Intervention.—Evaluation of provider prescribing through a computerized drug events may result in the need for additional medications, disability, de- online DUR database using explicit criteria to identify potentially inappropriate drug creased quality of life and functioning, use in the elderly. Computer alerts triggered telephone calls to physicians by phar- hospitalization, or death.5 macists with training in geriatrics, whereby principles of geriatric pharmacology Some medications are particularly were discussed along with therapeutic substitution options. prone to precipitating ADEs. Beers et Main Outcome Measures.—Contact rate with physicians and change rate to al6 used a Delphi survey with a panel of suggested drug regimen. experts in geriatrics to develop explicit Results.—A total of 43 007 alerts were triggered. From a total of 43 007 criteria to identify medications that telepharmacy calls generated by the alerts, we were able to reach 19 368 should be avoided in older patients. The physicians regarding 24 266 alerts (56%). Rate of change to a more appropriate recommendation focused on drugs that therapeutic agent was 24% (5860), but ranged from 40% for long half-life benzo- should be avoided, excessive dosing, and excessive duration of treatment. A sub- diazepines to 2% to 7% for drugs that theoretically were contraindicated by patients’ set of these criteria was applied to the self-reported history. Except for rate of change of b-blockers in patients with chronic community-dwelling elderly in the Na- obstructive pulmonary disease, all rates of change were significantly greater than tional Medical Expenditure Survey in the expected baseline 2% rate of change. 1987, which showed that nearly 25% of Conclusions.—Using a system integrating computers, pharmacists, and physicians, our large-scale intervention improved prescribing patterns and qual- ity of care and thus provides a population-based approach to advance geriatric From the Departments of Medical Affairs (Drs Monane, Nagle, and Kelly) and Health and Utilization clinical pharmacology. Future research should focus on the demonstration of Management (Ms Matthias), Merck-Medco Managed improved health outcomes resulting from improved prescribing choices for the Care, LLC, Montvale, NJ. elderly. Reprints: Mark Monane, MD, MS, Merck-Medco Managed Care, LLC, 100 Summit Ave, Montvale, NJ JAMA. 1998;280:1249-1252 07645 (e-mail: [email protected]). JAMA, October 14, 1998—Vol 280, No. 14 Improving Prescribing Patterns for the Elderly—Monane et al 1249 ©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Type of Drug Utilization Review (DUR) Alert by Therapeutic Model and DUR Change Rate than 65 years. Drug-disease criteria de- Alerts, DUR Alert fined drugs that should not be used in an Description No.* Change Rate, %† older patient in the presence of a specific Drug-age interaction (n = 19 362) condition that could be aggravated by Long elimination half-life benzodiazepine hypnotics (flurazepam) 1679 40‡ the drug. The disease history informa- Antidiabetic (chlorpropamide) 728 33‡ tion was self-reported by the patient Short-acting barbiturates (pentobarbital, secobarbital) 44 25‡ during enrollment in the Partners for Long elimination half-life benzodiazepine anxiolytics 11 344 24‡ Healthy Aging Program,t a health man- (chlordiazepoxide, clorazepate, diazepam, quazepam) agement program for the elderly de- Anxiolytics (meprobamate) 835 23‡ signed and implemented by MMMC. Cardiovascular (methyldopa) 1300 22‡ Thesesenior-specificDURcriteriawere Anticholinergic antidepressants (amitriptyline, doxepin) 2856 17‡ then computerized and coded by the Na- Narcotic analgesic (meperidine, pentazocine) 576 19‡ tional Drug Code to identify prescrip- Maximum daily dose exceeded (n = 4532) tions requiring intervention. Intermediate- or short-acting benzodiazepine 4532 25‡ Pharmacist training for the DUR pro- (alprazolam, lorazepam, oxazepam, temazepam, triazolam) gram was conducted by a team of geri- Drug-disease interaction (n = 372) Any nonsteroidal anti-inflammatory drug and peptic ulcer disease 238 7‡ atric pharmacy experts at all of the 13 Any b-adrenergic receptor antagonist and 134 2 MMMC mail-service pharmacies. These chronic obstructive pulmonary disease pharmacists were instructed in both the pharmacy science around the DUR *Alert refers to specific computer-based DUR criteria with a recommended change in prescribing as categorized by drug-age (inappropriate use due to age of patient); maximum daily dose (prescribed level outside of therapeutic alerts, as well as communication theory dose); drug-disease (possible adverse reaction based on known disease state). to conduct telephone one-to-one educa- †DUR alert change rate is indicated by the percentage of events in which physicians were contacted and 11 recommended action was taken (change rate = [number of accepted recommendations/number of recommenda- tional outreach with physicians. If a tions] 3100). potentially unsafe medication was re- ‡P,.001 vs no change. quested, the computer sent the pharma- cist a warning. The pharmacist subse- quently attempted to call the physician the elderly take at least 1 medication proximately 51 million Americans. Dur- to discuss the alert, possible therapeutic that should be avoided.7 ing the study period from April 1, 1996, alternatives, and applicable withdrawal Inappropriate prescribing in the el- through March 31, 1997, 2.3 million pa- recommendations.Theinterventionout- derly is often attributed to the lack of tients aged 65 years and older filled at comes included the following: (1) a dis- training in geriatrics in medical and least 1 prescription through an MMMC continuation or change in therapy, (2) no pharmacy education.8 An effective way mail-service pharmacy. In general, pa- changeintherapy,or(3)considerationof to overcome this problem may be tients use mail service more frequently a change in therapy at the next patient throughaconcurrentdrugutilizationre- to obtain maintenance medications for visit. Both the physician and the patient view (DUR) program. This type of uti- chronic diseases. We report on all pa- received an explanatory confirmation lization management system is designed tients targeted through our computer- letter in the mail if the original prescrip- to send a warning to pharmacists when ized DUR system with an actionable tion was changed. The prescription or potentially inappropriate drugs are pre- alert (alert triggering a conversation be- changes were then filled and dispensed scribed.9,10 tween physician and pharmacist) com- The warning provides an op- to the patient through the MMMC mail- pleted in the 1-year surveillance period portunity to educate the pharmacist and service channel. All relevant data per- (N = 23 269). physician through a discussion about the taining to the intervention were re- safety and effectiveness of a targeted corded electronically in MMMC DUR medication before it is dispensed. Study Intervention files. The purpose of this study was to An independent medical advisory evaluateaprogramdesignedtodecrease board, established by MMMC, consist- Statistical Analysis the use of potentially inappropriate ing of geriatric specialists in pharmacy, Frequency distributions as well as uni- medications among the elderly through medicine, and nursing adopted the cri- variate and bivariate statistics were com- a computer-based DUR intervention. teria of Beers et al6 to identify the most puted to measure use of the targeted medi- The intervention included the rationale dangerous drugs for the elderly from a cations and the number of physician for the alert, therapeutic alternatives, safety perspective. The MMMC Depart- contacts. The DUR change rate was de- and withdrawal protocols if necessary, ment of Medical Affairs developed an termined as a function of the number of and presented an opportunity to change integrated DUR education and inter- interventions completed
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