Use of computer decision support interventions to improve medication prescribing in older adults: a systematic review

Background: Older adults take multiple medications and are at high risk for adverse drug effects.Objective: This systematic review was conducted to describe the impact of computer decision support (CDS) interventions designed to improve the quality of medication prescribing in older adults.Methods: PubMed and EMBASE databases were searched from January 1980 through July 2007 (English-language only); studies were eligible if they described a CDS intervention intended to improve medication prescribing in adults aged ≥60 years. Studies were retained if they were observational or experimental in design and reported ≥1 process or clinical outcome measurement related to medication prescribing. In the main analysis, study characteristics and major outcome results were extracted. A combination of searches was performed using relevant medical subject headings: aged; drug therapy, computer-assisted; medication errors; medication errors/prevention and control; decision making, computer-assisted; decision support systems, clinical; and clinical pharmacy information systems.Results: After review of study abstracts, 10 articles met the eligibility criteria. Of those 10 studies testing CDS interventions, 8 showed at least modest improvements (median number needed to treat, 33) in prescribing, as measured by minimizing drugs to avoid, optimizing drug dosage, or more generally improving prescribing choices in older adults (according to each study's intervention protocols). Findings for the impact of CDS interventions on clinical outcomes were mixed and were reported for only 2 studies.Conclusions: Various types of CDS interventions may be effective in improving medication prescribing in older adults, but few studies reported clinical outcomes related to changes in medication prescribing. Data from this study should help to guide refinement and testing of future CDS interventions that specifically target older adult populations that are taking multiple medications.     

Mitigating fall risk: A community fall reduction program

One fourth of all American’s over 65 years of age fall each year. Falls are a common and often devastating event that can pose a serious health risk for older adults. Healthcare providers are often unable to spend the time required to assist older adults with fall risk issues. Without a team approach to fall prevention the system remains focused on fragmented levels of health promotion and risk prevention. The specific aim of this project was to engage older adults from the community in a fall risk assessment program, using the Stopping Elderly Accidents, Deaths & Injuries (STEADI) program, and provide feedback on individual participants’ risks that participants could share with their primary care physician. Older adults who attended the risk screening were taking medications that are known to increase falls. They mentioned that their health care providers do not screen for falls and appreciated a community based screening.     

Methodology of a pilot study to improve the quality of medication use in older adults: Enhancing quality in psychiatry using pharmacists (EQUIPP)

Background: Medication-related problems are prevalent in older adults, contributing to increased harm and health care costs and negatively impacting quality of care. Older adults with psychiatric disease are at an increased risk because of their underlying disease and types of medications prescribed. Efforts to improve the quality of medication use often focus on select medication-related problems, select diagnoses, or predefined quality indicators; however, such an approach fails to consider the potential for multiple coexisting problems within individuals.Objective: A pilot study was conducted to test the feasibility of a medication management program designed to improve the quality of medication use in older adults with underlying psychiatric disease. This article describes the methodology of the study and details of the intervention, and presents baseline characteristics of the study population.Methods: English-speaking psychiatry outpatients aged ≥65 years taking ≥2 drugs that are active in the central nervous system were enrolled into a medication management program, in which medication management was provided by a clinical pharmacist for 6 months. Patients were evaluated at baseline, 3 months, and 6 months. Data were collected on the patients' demographic characteristics, health and medications, health literacy, functional status, symptoms of depression, health services utilization, quality of medication use, adherence, and patient satisfaction with the program.Results: One hundred seventy-three older adults were assessed for inclusion; 146 were not eligible, not reachable, or not interested in participating. Twenty-seven older adults were enrolled in the study, all but one of whom completed the 3- and 6-month visits. The mean (SD) age of the 27 participants was 74.7 (8.1) years; 63% were female, 74% were white, and 70% had no cognitive impairment.Conclusions: This pilot study tested the feasibility of a medication management program designed to improve the quality of medication use in older adults with underlying psychiatric disease. Findings from this study, which will be reported at a later date, will help to refine the program and subsequent testing, with the overall goal of improving the quality of medication use and health outcomes in older adults.     

Predictors of falls in a high risk population: results from the prevention of falls in the elderly trial (PROFET)

Objectives: The prevention of falls in the elderly trial (PROFET) provides evidence of the benefits of structured interdisciplinary assessment of older people presenting to the accident and emergency department with a fall. However, the service implications of implementing this effective intervention are significant. This study therefore examined risk factors from PROFET and used these to devise a practical approach to streamlining referrals from accident and emergency departments to specialist falls services.

Methods: Logistic regression analysis was used in the control group to identify patients with an increased risk of falling in the absence of any intervention. The derived predictors were investigated to see whether they also predicted loss to follow up. A second regression analysis was undertaken to test for interaction with intervention.

Results: Significant positive predictors of further falls were; history of falls in the previous year (OR 1.5 (95%CI 1.1 to 1.9)), falling indoors (OR 2.4 (95%CI 1.1 to 5.2)), and inability to get up after a fall (OR 5.5 (95%CI 2.3 to 13.0)). Negative predictors were moderate alcohol consumption (OR 0.55 (95%CI 0.28 to 1.1)), a reduced abbreviated mental test score (OR 0.7 (95%CI 0.53 to 0.93)), and admission to hospital as a result of the fall (OR 0.26 (95%CI 0.11 to 0.61)). A history of falls (OR 1.2 (95%CI 1.0 to 1.3)), falling indoors (OR 3.2 (95%CI 1.5 to 6.6)) and a reduced abbreviated mental test score (OR 1.3 (95%CI 1.0 to 1.6)) were found to predict loss to follow up.

Conclusions: The study has focused on a readily identifiable high risk group of people presenting at a key interface between the primary and secondary health care sectors. Analysis of derived predictors offers a practical risk based approach to streamlining referrals that is consistent with an attainable level of service commitment.

     

Addressing delays in medication administration for patients transferred from the hospital to the nursing home: A pilot quality improvement project

Background: Patients being transferred to a nursing home (NH) after an acute hospitalization are subject to adverse effects, including medication errors, related to poor coordination of care across settings.Objective: The goal of this study was to develop, implement, and evaluate the impact of a pilot intervention to improve patient safety by reducing delays in administration and omission of medications among patients discharged from the hospital to the NH.Methods: An expedited discharge protocol was developed in collaboration with hospital physician residents, hospital discharge planners, and NH staff (administrators, directors of nursing services, and licensed nurses). The intervention included education of the involved health care professionals and implementation of the expedited protocol to ensure that medication orders were transmitted to the NH-contracted pharmacy before patients' arrival at the NH. The intervention protocol was compared with a standard discharge protocol among patients aged ≥65 years being discharged from 2 university-affiliated hospitals to a single proprietary NH. The primary outcomes were the time between arrival at the NH and administration of first dose of an ordered medication; the number of omitted medications; the proportion of patients experiencing medication omissions; and the proportion of patients with omitted medications that had a low, medium, and high potential for negative consequences.Results: The study involved 10 patients discharged from each of the 2 hospitals and transferred to the NH. Although several components of the intervention were successfully implemented, none of the medication orders were transmitted to the NH-ccontracted pharmacy before patients' arrival at the NH. All 17 patients with medications ordered to be administered in the evening had ≥1 dose of a medication omitted after their arrival at the NH. The mean (SD) delay from arrival at the NH to administration of the first dose of an ordered medication was 12.55 (7.45) hours. The mean number of doses of different medications omitted per patient was 3.4 (2.60). Sixty-seven doses of medications were omitted; 53 of these omissions involved only 1 dose of a medication. Thirty-three percent of omitted doses involved medications with the highest potential for resulting in a negative consequence.Conclusions: The intervention to improve patient safety by reducing medication delays for patients making the transition from the hospital to the NH was not successfully implemented, as medication orders were not transmitted to the NH-contracted pharmacies before patients' arrival at the NH. All patients making the transition from hospital to NH experienced a >12-hour delay in medication administration, and the mean number of missed doses of medications was >3. There is a need for further exploration of the reasons for and possible solutions to delays in medication administration during the transition to the NH, as well as of the impact of such delays on patient outcomes, including adverse drug events, emergency department visits, and rehospitalizations.     

医疗失效模式与效应分析在预防社区脑卒中跌倒中的应用

[目的]运用医疗失效模式与效应分析(HFMEA)方法对社区防跌倒管理流程进行改进并实施,以有效规避脑卒中患者跌倒高危因素,降低脑卒中患者跌倒发生率。[方法]选取2016年1-12月静安区某社区卫生服务中心管理的脑卒中患者163名。首先,进行脑卒中患者跌倒风险调查,了解跌倒发生情况,并进行多因素分析筛选跌倒高危因素;然后,采用HFMEA 方法,将上述调查对象随机分为二组,实施6个月干预,并对二组脑卒中患者首次入户随访时间、跌倒风险因素及跌倒次数进行评价。[结果]调查对象一年内跌倒发生率为31.29%,行走辅助用具、视力对日常的影响、对外界反应能力、脚无力是跌倒的独立危险因素,见表3。二组在首次入户干预时间、跌倒风险评估总分、跌倒次数方面存在显著差异 (P<0.05),见表4。[结论]运用医疗失效模式与效应分析(HFMEA)方法改进并实施社区防跌倒管理流程和控制方案,可降低跌倒风险,减少跌倒发生。