Our January 15, 2008 Patient Safety Tip of the Week “Potentially Inappropriate Medication Use in Elderly Hospitalized Patients” we focused on an article by Rothberg et al (2008) that sheds some light on use of such medications on the inpatient side. They found that almost half of all inpatients over the age of 65 in a widely representative hospital sample received at least one medication meeting criteria as a “potentially inappropriate medication” (PIM) from the Beers classification. 49% received at least one PIM, 38% received at least one PIM with a high severity rating, and 6% received 3 or more PIM’s.“ focused on prescribing of medications on Beers List that may be potentially inappropriate for elderly patients. That column discussed the origin and updating of Beers List and ways to improve medication management in the elderly. Most of the published literature on Beers List has focused on outpatient or nursing home settings. Then in our June 2008 What’s New in the Patient Safety World “
Note that the study, which was based on review of administrative data, was not able to determine which PIM’s might have been continuation of medications prescribed prior to admission vs. medications newly started in the hospital. The process of medication reconciliation, which is now done on admission and discharge and should be done at all transfers of care, offers a good opportunity to minimize use of PIM’s.
As we implement CPOE (computerized physician order entry) with clinical decision support, alerts can be programmed to trigger when a PIM is ordered on a patient over a specified age. To minimize the number of alerts a physician may encounter (to avoid “alert fatigue”), we usually try to use standardized order sets wherever possible. However, the Rothberg article raises the possibility that sometimes the standardized order set, which often fails to take into consideration the age of the patient, might actually promote use of certain PIM’s. Therefore, organizations would be wise to review their standardized order sets to see whether any modification for Beer’s list medications is desirable.
Though we have been strong advocates of incorporating alerts to Beers list medications in CPOE (computerized physician order entry) there had been no studies delineating the efficacy or the unintended consequences of such alerts. Now, researchers at the Beth Israel Deaconess Medical System in Boston (Mattison 2010) have published results of such a system. Cognizant of the real potential for alert fatigue, these researchers carefully chose a subset of “potentially inappropriate drug (PIM’s)” from Beers list drugs to which to attach computerized warnings. They were able to demostrate approximately a 20% reduction in prescribing of flagged drugs. That decrease was noted immediately after implementation and was sustained over time. As a “control” they noted no reduction in those other Beers list drugs that were not flagged. Of specific drugs from the list, diphenhydramine had been the most often prescribed drug and showed the biggest reduction.
The study is important in that it confirms that alerts during CPOE can reduce prescription of potentially inappropriate drugs in the elderly. But it also contains other very useful lessons:
Don’t expect as great a reduction in prescribing of Beers list drugs when you incorporate alerts into e-prescribing on an outpatient basis. In our previous column, we mentioned that when a system in the outpatient setting notifies physicians that one of their patients is on a drug that is on the Beers List, the physician seldom discontinues the flagged drug in that individual patient. However, the number of new prescriptions for that drug diminishes in the patient population cared for by that physician.
Some continue to argue that the Beers List concept is not truly “evidence-based”. It is true that the list was originally conceived by an expert consensus panel and there are no randomized controlled trials regarding the safety in the elderly for each of the drugs on the list. However, there is ample evidence in the literature that each of those drugs may be associated with untoward effects in the elderly and the List has proven to be quite useful now in a variety of healthcare settings. We remain strong advocates of using clinical decision support tools to alert healthcare providers of such potentially inappropriate drugs in the elderly. The Mattison paper provides very helpful advice on how to implement such clinical decision support.
Update: See also our Patient Safety Tips of the Week for January 15, 2008 “ and October 19, 2010 “ ” and September 22, 2009 “Psychotropic Drugs and Falls in the SNF” and our What’s New in the Patient Safety World columns for June 2008 “Potentially Inappropriate Medication Use in Elderly Hospitalized Patients”.
Rothberg MB, Pekow PS, Liu F, Korc-Grodzicki B, Brennan MJ, Bellantonio S, Heelon M, Lindenauer PK. Potentially Inappropriate Medication Use in Hospitalized Elders. Journal of Hospital Medicine 2008; 3: 91-102 http://www3.interscience.wiley.com/journal/118860229/abstract
Mattison MLP, Afonso KA, Ngo LH, Mukamal KJ. Preventing Potentially Inappropriate Medication Use in Hospitalized Older Patients With a Computerized Provider Order Entry Warning System. Arch Intern Med. 2010; 170(15): 1331-1336