Five ways you can reduce inappropriate prescribing in the elderly: A systematic review
Four methods were supported by controlled trials, thus providing a higher level of evidence to support: 1) incorporating pharmacist recommendations, 2) use of computerized alerts, 3) review of patient’s medication list and 4) patient education (TABLE W2). The fifth method, avoiding inappropriate medications, was based on consensus guidelines and expert opinions.
Method 1: Incorporate pharmacist recommendations
Having a pharmacist participate in the care of elderly patients can reduce polypharmacy and adverse drug events.
A randomized controlled trial of 208 patients at a Veterans’ Administration (VA) medical clinic, aged 65 years of age or older and taking 5 or more medications, demonstrated that involving a clinical pharmacist in the patient’s care reduces inappropriate prescribing and adverse drug effects without adversely affecting health-related quality of life.15
In this VA study, patients were randomized to an intervention group and a control group. In the intervention group, a clinical pharmacist met with patients during all scheduled office visits to evaluate and make recommendations about their drug regimens. Before each visit, the clinical pharmacist reviewed the patient’s medical record and current medications, and assessed each medication using the “Medication Appropriateness Index” as a guideline.18,19 Written drug therapy recommendations were then sent to the physician.
Key outcome measures in this study were the rate of prescribing inappropriateness, medication compliance and knowledge, number of medications, adverse drug events, health-related quality of life, patient satisfaction, and physician receptivity to the intervention.
The results show that inappropriate prescribing and the number of drugs prescribed decreased by 24% in the intervention group but only by 6 % in the control group. In addition, fewer intervention-group patients than control patients experienced adverse drug events (30% vs. 40%; P=.19). Physicians were receptive to the clinical pharmacist’s interventions and enacted changes recommended by the clinical pharmacist more frequently than they enacted changes independently for control patients (55.1% vs. 19.8%; P=.001).15
Engaging the pharmacist. Encourage your patients to fill prescriptions by all physicians at the same pharmacy, thereby enabling the maintenance of a single current list of medications. Have your office staff alert the pharmacist whenever a medication is discontinued.
When a patient refills medications, the pharmacist routinely reviews the database for potential adverse drug events. The pharmacist should then alert the physician of potential inappropriate medications or adverse drug events.
Method 2: Use computerized alerts
Computerized alerts provide warnings to physicians using computerized order entry systems. The system contains information on patients’ current medications and drug intolerances and allergies. An “alert” is generated by the system when there is a potential drug allergy, drug intolerance or drug interaction as defined by the National Drug Data File of First Databank Inc. The use of computerized alerts for reducing polypharmacy and inappropriate prescribing has been examined in both outpatient and inpatient settings.
Outpatient. A recent study examined the rate at which physicians overrode computerized alerts among 3481 consecutive alerts generated at 5 adult primary care practices that used a common computerized physician order entry system for prescription writing.20 Of the 3481 consecutive alerts, physicians overrode 91.2% of the alerts but 8.8% resulted in a change in prescribing.
Although few physicians changed their prescriptions in response to an alert, there were few adverse drug events despite the large number of alerts that were overridden. This may have indicated an alert threshold that was set too low.21
Inpatient. A randomized comparison study conducted at a large tertiary hospital demonstrated that physician computer order entry decreased the rate of serious medication errors by more than half.16 This study was divided into 2 phases. Phase I involved 2491 admissions and was designed as “baseline.” Phase II involved 4220 admissions that occurred after the intervention was implemented. The intervention itself was implementation of a computerized order entry system that required the ordering physician to complete a menu of information including drug name, medication dose, route, and frequency. Computerization ensured legibility of all orders. The main outcome measured was serious medication errors.
In comparison of the 2 phases, serious medication errors decreased 55%, from 10.7 events per 1000 patient-days in Phase I to 4.86 events per thousand in Phase II (P=.1). Preventable adverse drug events declined 17%, while most significantly potential adverse drug events declined 84%.16
Another study, this one a randomized controlled study of electronic alerts to remind physicians of prescribed measures to prevent venous thromboembolism in hospitalized patients, also found benefit to an alert system. But the results showed that 3 conditions are needed for the success of the clinical alerts. First, there must be acceptance by the physicians. Secondly, the electronic alerts should deliver simple messages that prevent physicians from routinely bypassing them. Thirdly, the physician should have access to all pertinent information to make an adequate decision.21
