Computerized Decision Support to Reduce Potentially Inappropriate Prescribing to Older Emergency Department Patients: A Randomized, Controlled Trial

Authors

  • Kevin M. Terrell DO, MS,

    1. From the *Department of Emergency Medicine, Indiana University Center for Aging Research, Regenstrief Institute, Inc., and §School of Medicine, Indiana University, Indianapolis, Indiana.
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  • Anthony J. Perkins MS,

    1. From the *Department of Emergency Medicine, Indiana University Center for Aging Research, Regenstrief Institute, Inc., and §School of Medicine, Indiana University, Indianapolis, Indiana.
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  • Paul R. Dexter MD,

    1. From the *Department of Emergency Medicine, Indiana University Center for Aging Research, Regenstrief Institute, Inc., and §School of Medicine, Indiana University, Indianapolis, Indiana.
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  • Siu L. Hui PhD,

    1. From the *Department of Emergency Medicine, Indiana University Center for Aging Research, Regenstrief Institute, Inc., and §School of Medicine, Indiana University, Indianapolis, Indiana.
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  • Christopher M. Callahan MD,

    1. From the *Department of Emergency Medicine, Indiana University Center for Aging Research, Regenstrief Institute, Inc., and §School of Medicine, Indiana University, Indianapolis, Indiana.
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  • Douglas K. Miller MD

    1. From the *Department of Emergency Medicine, Indiana University Center for Aging Research, Regenstrief Institute, Inc., and §School of Medicine, Indiana University, Indianapolis, Indiana.
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  • This research was presented at the 2008 Annual Scientific Meeting of the American Geriatrics Society on May 2, 2008, in Washington, DC, and the 2008 Annual Meeting of the Society for Academic Emergency Medicine on May 29, 2008, in Washington, DC.

Address correspondence to Kevin Terrell, Regenstrief Institute, Inc., 410 West 10th Street, Suite 2000, Indianapolis, IN 46202-3012. E-mail: kterrell@regenstrief.org

Abstract

OBJECTIVES: To evaluate the effectiveness of computer-assisted decision support in reducing potentially inappropriate prescribing to older adults.

DESIGN: Randomized, controlled trial.

SETTING: An academic emergency department (ED) in Indianapolis, Indiana, where computerized physican order entry was used to write all medication prescriptions.

PARTICIPANTS: Sixty-three emergency physicians were randomized to the intervention (32 physicians) or control (31 physicians) group.

INTERVENTION: Decision support that advised against use of nine potentially inappropriate medications and recommended safer substitute therapies.

MEASUREMENTS: The primary outcome was the proportion of ED visits by seniors that resulted in one or more prescriptions for an inappropriate medication. The main secondary outcomes were the proportions of medications prescribed that were inappropriate and intervention physicians' reasons for rejecting the decision support.

RESULTS: The average age of the patients was 74, two-thirds were female, and just over half were African American. Decision support was provided 114 times to intervention physicians, who accepted 49 (43%) of the recommendations. Intervention physicians prescribed one or more inappropriate medications during 2.6% of ED visits by seniors, compared with 3.9% of visits managed by control physicians (P=.02; odds ratio=0.55, 95% confidence interval=0.34–0.89). The proportion of all prescribed medications that were inappropriate significantly decreased from 5.4% to 3.4%. The most common reason for rejecting decision support was that the patient had no prior problems with the medication.

CONCLUSION: Computerized physican order entry with decision support significantly reduced prescribing of potentially inappropriate medications for seniors. This approach might be used in other efforts to improve ED care.Trial Registration: Clinical trials.gov Identifier: NCT00297869.

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