Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system

Abstract

Background: Potentially inappropriate medication (PIM) use in hospitalized older patients is common. Our objective was to determine whether a computerized provider order entry (CPOE) drug warning system can decrease orders for PIMs in hospitalized older patients.

Methods: We used a prospective before-and-after design among patients 65 years or older admitted to a large, urban academic medical center in Boston, Massachusetts, from June 1, 2004, through November 29, 2004 (for patients admitted before the warning system was added), and from March 17, 2005, through August 30, 2008 (patients admitted after the warning system was added). We instituted a medication-specific warning system within CPOE that alerted ordering providers at the point of care when ordering a PIM and that advised alternative medication or dose reduction. The main outcome measure was the rate of orders for PIMs before and after the warning system was deployed.

Results: The mean (SE) rate of ordering medications that were not recommended dropped from 11.56 (0.36) to 9.94 (0.12) orders per day after the implementation of a CPOE warning system (difference, 1.62 [0.33]; P<.001), with no evidence that the effect waned over time. There were no appreciable changes in the rate of ordering medications for which only dose reduction was recommended or that were not targeted after CPOE implementation. These effects persisted in autoregressive models that accounted for secular trends and season (P<.001).

Conclusion: Specific alerts embedded into a CPOE system, used in patients 65 years or older, can decrease the number of orders of PIMs quickly and specifically.

Figure 1

Daily rate of medication orders among hospitalized elders for each of three medication classes before and after implementation of a computerized provider order entry alert system. The vertical axis indicates the number of medications ordered on a daily basis for patients aged 65 and older divided by the number of older adults admitted on the corresponding day. The horizontal axis indicates time, with ticks at the beginning and end dates of follow-up and the dates that the alert system was first and then completely implemented. Black circles indicate the pre-intervention period and blue diamonds the post-intervention period. The upper panel shows medications that were flagged by the alert system. The middle panel shows medications that were flagged with a recommendation for dose reduction. The lower panel shows medications that were not flagged. The lines in each panel indicate smoothed splines fit separately for the pre- and post-intervention periods. There was a significant change in the rate of ordering following intervention only for the middle panel (p<0.001).