PHILADELPHIA—An electronic alert system accurately identifies patients with dopamine-requiring diseases who should not receive dopamine antagonists, but it may have little effect on physicians’ prescribing behavior, according to research presented at the 66th Annual Meeting of the American Academy of Neurology. Nearly 75% of inappropriate prescriptions of dopamine antagonists were continued despite the alert. Inappropriate prescriptions were written at night more frequently.
The highest prevalence of inappropriate dopamine antagonist orders was among psychiatrists, said Marie Morris, medical student at the Washington University School of Medicine in St. Louis. The lowest prevalence of these orders was among neurologists. Of all inappropriate orders, those that came from psychiatrists were the least likely to be discontinued in response to the alert.
These findings suggest a need for improved education among health care providers about treating patients with dopamine-requiring diseases, said Ms. Morris. The study results also indicate a possible “need for greater supervision of residents at night, as these are the primary physicians who are working during the time that inappropriate orders occur more often,” she added. Modifying the alert to suggest alternative medications also could reduce inappropriate prescriptions.
Researchers Analyzed Alerts for Inpatients With Dopaminergic Dysfunction
In January 2009, Barnes Jewish Hospital in St. Louis added a new alert to its electronic medication entry system. The alert was designed to notify physicians who prescribed levodopa and a dopamine antagonist concurrently to a patient. Ms. Morris and colleagues conducted a retrospective study to evaluate whether the alert system prevented inappropriate prescriptions of levodopa and dopamine antagonists.
The study population included inpatients at Barnes Jewish Hospital who had been prescribed levodopa and a dopamine antagonist concurrently between January 1, 2009, and January 1, 2013. The researchers reviewed the patients’ medical records and gathered information about patients’ demographics, medical histories, presenting symptoms, diagnoses, and dopamine-requiring diseases. The investigators also recorded details about the specific dopamine antagonist prescriptions that triggered alerts (eg, dosing, type of medication, start and stop time, number of doses, and prescribing physician). This information helped the researchers determine physicians’ responses to the alerts.
Two movement disorder specialists evaluated patient data and classified the dopamine antagonist prescriptions as appropriate or inappropriate. The two specialists agreed on the initial classifications approximately 96% of the time.
Most Prescriptions for Dopamine Antagonists Were Inappropriate
A total of 237 patients were the subject of an alert. The patients’ average age was 68, and the most common dopamine-requiring diseases in these patients were parkinsonism and restless legs syndrome. Approximately 83% of the dopamine antagonist prescriptions were considered inappropriate. Prochlorperazine was the most common inappropriately prescribed dopamine antagonist. Nausea and vomiting was the most common indication for the dopamine antagonist; it accounted for approximately 45% of inappropriate prescriptions.
The hospital’s general medicine service was responsible for about 56% of inappropriate dopamine antagonist prescriptions. The surgical specialties were responsible for about 25% of the prescriptions, psychiatry accounted for approximately 10%, and neurology accounted for about 9%. After the researchers adjusted for the size of each service, they found that inpatients with a dopamine-requiring disease who visited the general medicine service had a 7.5% chance of being prescribed a dopamine antagonist inappropriately. Surgical inpatients with a dopamine-requiring disease had a 6% chance of this outcome.
Inpatients in the psychiatry service had a 16% chance of being prescribed a dopamine antagonist inappropriately. “This was really an impressive difference, especially when you compared it to a neurology service, where inpatients with a dopamine-requiring disease had a less than 1% chance of being inappropriately prescribed a dopamine antagonist,” said Ms. Morris. Almost 95% of the inappropriate dopamine antagonist prescriptions in the psychiatry service were not discontinued in response to the alert.
“An important thing for future studies to examine is the role of alert fatigue,” said Ms. Morris. “Whenever you enter in a long list of medications for one patient, a lot of alerts can come up at once, and physicians can easily become desensitized to alerts,” she concluded.