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Computerized drug alerts when ordering medications reduce inappropriate prescribing for the elderly

Experts describe certain medications that should be avoided in elderly people due to problems such as daytime sedation and falls. Computerized alerts can substantially reduce inappropriate drug prescribing for the elderly, concludes a study supported by the Agency for Healthcare Research and Quality (HS11843). Researchers examined drug prescribing over a 39-month period for elderly patients of a large health maintenance organization (HMO), 12 months before and 27 months after implementation of computerized order entry system (CPOE) alerts. The computer alerts popped up when a clinician from 1 of 15 HMO primary care clinics ordered medications from 2 drug classes: long-acting benzodiazepines and tertiary amine tricyclic antidepressants (TCAs).

Besides noting the inappropriate prescription, the alerts also suggested alternatives, such as shorter-acting and less-sedating benzodiazepines and secondary amine TCAs or other medications such as buspirone. The order could be changed by accepting the alternative medication. The alerts led to a 22 percent decline (5.1 prescriptions per 10,000 members per month) in inappropriate or nonpreferred prescribing from these 2 drug classes compared with the month prior to the drug-specific alerts. This reduction was sustained over the entire 2-year post-alert period, and was driven primarily by decreased dispensing of nonpreferred TCAs.

Among all the medications studied, the TCAs amitriptyline and nortriptyline had the largest changes in dispensing rates. Before the alert, the nonpreferred TCA amitriptyline was prescribed more often at every time point than the preferred TCA nortriptyline. However, after the alert, this finding was reversed.

Despite decreased use of nonpreferred medications for the elderly, there was no overall offsetting increase in the use of preferred medications. This suggests that the alerts decreased overall prescribing of both nonpreferred and preferred drugs. While this may have been clinically appropriate for some patients, it is possible that others were denied appropriate medication, or the clinicians may have switched to other medications that were not included in the analysis.

More details are in "The impact of prescribing safety alerts for elderly persons in an electronic medical record," by David H. Smith, R.Ph., Ph.D., Nancy Perrin, Ph.D., Adrianne Feldstein, M.S., M.D., and others, in the May 22, 2006, Archives of Internal Medicine 166, pp. 1098-1104.

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