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Service Delivery Innovation Profile

Automated Pharmacy Alerts Followed by Pharmacist-Physician Collaboration Reduce Inappropriate Prescriptions Among Elderly Outpatients


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Snapshot

Summary

Kaiser Permanente Colorado developed a computerized alert system to notify pharmacists when elderly patients are prescribed potentially inappropriate medications. Alerted pharmacists consult with the physicians to discuss the prescription. The program reduced inappropriate prescriptions, with 1.8 percent of intervention patients receiving them, compared with 2.2 percent of control group patients.

Evidence Rating (What is this?)

Strong: The evidence consists of a 1-year, prospective randomized control trial comparing the rate of inappropriate medication dispensing to the elderly in an intervention group and a control group; the results show a clear, direct link between the innovation and lower rates of inappropriate prescribing.
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Developing Organizations

Kaiser Permanente Colorado
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Date First Implemented

2005
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Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years)end pp

Problem Addressed

Inappropriate medication use is common in elderly patients, leading to the potential for significant adverse outcomes.
  • High prevalence of inappropriate medication use: A 1996 analysis found that 21.3 percent of community-dwelling seniors received at least 1 of 33 potentially inappropriate medications.1 A more recent analysis of 157,000 seniors enrolled in 10 health maintenance organizations (HMOs) in 2000 and 2001 found that almost 30 percent received at least one of these potentially inappropriate medications.2
  • Adverse outcomes associated with the use of certain drugs by the elderly: Certain drugs, such as flurazepam, belladonna alkaloids, amitriptyline, and ketorolac, have been found to be associated with increased risk of adverse events in the elderly; as a result, some drugs are considered inappropriate for any older adult (regardless of diagnosis), whereas others are considered appropriate for elders only in certain limited circumstances.3

What They Did

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Description of the Innovative Activity

Kaiser Permanente Colorado developed a patient medication safety intervention in which the pharmacy information management system is linked with the Kaiser database that provides information regarding patient age; pharmacists are notified via a medication alert when a patient aged 65 or older is prescribed a potentially inappropriate medication. The pharmacist then contacts the patient's physician to review the prescription and discuss alternatives. Key elements of the program are described below:
  • Eligible patients: All members of Kaiser Permanente Colorado aged 65 and older (59,680 patients) are eligible for the program; for the purposes of the pilot test, patients were randomized to an intervention group or control group.
  • Guideline-based alert system: The computerized alert system incorporates Kaiser-developed guidelines covering 11 medications initially that can be prescribed inappropriately to seniors (amitriptyline, chlordiazepoxide, chlorpropamide, diazepam, doxepin, flurazepam, aspirin/hydrocodone combination therapy, aspirin/oxycodone combination therapy, ketorolac, oral meperidine, and piroxicam). As the program continues, some medications have been added and some removed from the list. These guidelines include information such as when the drug should or should not be used, safer therapeutic alternatives, and circumstances in which the provider should be contacted. The system can also provide information on an individual patient's prior use of a particular drug.
  • Pharmacist alert system: When a physician prescribes a medication from the medication list to an intervention group patient, the pharmacist is notified via a medication alert generated by the pharmacy information management system. The system does not allow the pharmacist to print a medication label (i.e., to fill the prescription) until the pharmacist actively intervenes to determine whether the prescription should be dispensed.
  • Communication with physician and patients: If the pharmacy information management system indicates that the patient's indication for the drug is acceptable, the pharmacist makes a note in the system and dispenses the medication as written. However, if the system suggests a safer alternative based on the patient's indication, the pharmacist contacts the physician by telephone (or, rarely, by e-mail) to discuss whether the medication should be dispensed as written or modified, whether the alternative should be dispensed, or whether no drug should be dispensed. These calls take place either while the patient is waiting for the prescription or before the patient arrives. After the consultation, the pharmacist makes a note in the system to document the decision, using a template containing brief, standardized questions. To assist with this process, the pharmacist is provided with scripts and other guidance to assist with physician conversations as well as scripts that can be used to explain the program and any prescription changes to patients.

Context of the Innovation

Kaiser Permanente Colorado is a group-model health maintenance organization that provides health care to more than 400,000 members in the Denver-Boulder-Longmont metropolitan area. Taking advantage of its sophisticated electronic medical record (EMR) system, Kaiser Permanente Colorado initiated and conducted a series of six patient medication safety intervention studies (four randomized control trials and two before-and-after studies) in the ambulatory care environment beginning in 2000. This program was one of the interventions tested.

Did It Work?

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Results

The program resulted in fewer elderly patients being dispensed potentially inappropriate medications. During the 1-year study, 543 (1.8 percent) intervention-group patients were dispensed new prescriptions for targeted medications, compared with 644 (2.2 percent) control-group patients, a 16-percent reduction in relative risk.
  • Fewer inappropriate drugs: In the intervention group, 535 patients received one medication from the target list of inappropriate drugs, while 8 received two drugs from the list. In the usual care group, 632 patients received one medication from the list, 11 received two, and 1 patient received three. In total, 1.8 percent of intervention-group patients received an inappropriate drug, compared with 2.2 percent of control-group patients. Much of the benefit appears to have been concentrated in two drugs—amitriptyline and diazepam—which were the only two drugs to display significantly lower dispensing rates in the intervention group than in the control group (37 percent lower for amitriptyline and 21 percent lower for diazepam).
  • Many cases where inappropriate prescribing averted: In 12 cases, the postalert pharmacist–physician consultation led to the decision not to dispense any drug, whereas, in 93 cases, the prescription was modified (81 instances of switching medications and 12 cases in which the dosage or dosing frequency was modified). There were 220 "false positives"—that is, cases in which alerts were generated, but physicians believed it was nevertheless appropriate to dispense the drug (e.g., because of a patient's previous safe use of the drug).

Evidence Rating (What is this?)

Strong: The evidence consists of a 1-year, prospective randomized control trial comparing the rate of inappropriate medication dispensing to the elderly in an intervention group and a control group; the results show a clear, direct link between the innovation and lower rates of inappropriate prescribing.

How They Did It

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Planning and Development Process

The planning and development process for this intervention included the following:
  • Preliminary selection of medications: A preliminary list of medications was selected based on several existing lists of drugs to be avoided in seniors, including one developed by the Kaiser Permanente Care Management Institute.
  • Clinician review and development of final list: The preliminary list was circulated to a group of physicians and pharmacists in the geriatrics, continuing care, gastroenterology, neurology, internal medicine, and family medicine departments. The list was also discussed at a meeting of the Kaiser Permanente Colorado Primary Care Regional Geriatrics Committee. Based on these reviews and discussions, the list of medications and potential alternatives was finalized.
  • Development of pharmacist guidelines and scripts: An intervention guideline for pharmacists was developed based on published medical literature, national Kaiser guidelines, and local expert opinion for each of the 11 medications on the list; the guideline was reviewed and agreed upon by physician leaders and pharmacists. Researchers also developed scripts for the pharmacists to use in discussing the alerts with prescribing physicians and for explaining the program to patients. The clinical leaders signed off on the content of the intervention guidelines and the patient-counseling scripts.
  • Data linkages: Using an established electronic interface, data on patient age was transferred to the pharmacy information management system.
  • Information dissemination and promotion of the program: Information about the intervention, its purpose, and the development process was disseminated to Kaiser Permanente Colorado physicians. In addition, six "intervention champions"—pharmacist opinion leaders located in the pharmacies—promoted the program and answered questions from pharmacists and pharmacy technicians.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff, as pharmacists incorporate the use of the system into their regular workflow; pharmacists and physicians involved need to be able to work collaboratively on developing guidelines and discussing appropriate medication use in elderly patients. Clinicians, including both pharmacists and physicians, donated the time needed to develop the initial set of guidelines.
  • Costs: No data on costs are available.
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Funding Sources

Agency for Healthcare Research and Quality; Kaiser Permanente Colorado; Garfield Memorial Fund
The program was funded by the Agency for Healthcare Research and Quality and internally by Kaiser Permanente Colorado, with a grant from the Garfield Memorial Fund supporting some of the development work.end fs

Tools and Other Resources

Use of High-Risk Medications in the Elderly is currently an National Quality Forum–endorsed HEDIS® (Healthcare Effectiveness Data and Information Set) measure. This measure includes a medication list of drugs to be avoided in seniors that may also be used in developing similar programs. This information can be found on page 59 of the National Quality Forum–Endorsed Measures Specifications list available at http://www.ncqa.org/tabid/59/Default.aspx

Medications included in this list are comprised of Potentially Inappropriate Medications for the Elderly According to the Revised Beers Criteria: http://www.dcri.duke.edu/ccge/curtis/beers.html, and Zhan study: http://jama.ama-assn.org/cgi/content/abstract/286/22/2823.

Adoption Considerations

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Getting Started with This Innovation

  • Determine how data capabilities affect the ability to link information regarding patient age, drug indications, and medication alerts. A pharmacy information system is needed to support this project; an organization that only has claims data would likely have to limit the program only to drugs that are absolutely contraindicated for seniors in all situations.
  • Devise a medication list based on input and agreement from clinicians in the system. For example, at Kaiser Permanente Colorado, clinician input led to the decision to exclude some drugs that physicians would never substitute for alternatives, such as gastrointestinal antispasmodics.
  • Give pharmacists scripts and/or other support tools to boost their confidence in interacting with physicians and patients. In particular, some pharmacists are reluctant to call physicians, even though both pharmacists and physicians know that inappropriate prescribing is a significant safety issue for elderly patients.

Sustaining This Innovation

  • Enlist the support of program "champions" onsite at the pharmacies to address ongoing questions and concerns.
  • Consider developing physician-approved protocols to allow pharmacists to automatically switch a drug to a safer alternative to streamline the process and eliminate unnecessary physician–pharmacist interactions. (Kaiser Colorado did not take this step during the project evaluation.)

Additional Considerations

  • Although Kaiser Colorado benefited from having a direct link between the ambulatory EMR and the pharmacy management system, this intervention can also be used in a nonintegrated system that lacks such linkages; the only patient-specific information needed is age.
  • That said, Kaiser controls its pharmacy and dispensing practices, enabling the implementation of this model. In contrast, this model may not work in a network or independent practice associations–type health plan, in which members/patients go to commercial pharmacies to fill their prescriptions.

More Information

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Contact the Innovator

Marsha A. Raebel, PharmD
Kaiser Permanente Colorado
Clinical Research Unit
PO Box 378066
Denver, CO 80237-8066
E-mail: marsha.a.raebel@kp.org

Innovator Disclosures

Ms. Raebel has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Raebel MA, Charles J, Dugan J, et al. Randomized trial to improve prescribing safety in ambulatory elderly patients. J Am Geriatr Soc. 2007;55(7):977-85. [PubMed]

Footnotes

1 Zhan C, Sangl J, Bierman A, et al. Potentially inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel Survey. JAMA. 2001;286:2823-9. [PubMed]
2 Simon SR, Chan K, Soumerai S, et al. Potentially inappropriate medication use among elderly persons in the United States HMOs, 2000-2001. J Am Geriatr Soc. 2005;53(2):227-32. [PubMed]
3 Raebel MA, Charles J, Dugan J, et al. Randomized trial to improve prescribing safety in ambulatory elderly patients. J Am Geriatr Soc. 2007;55(7):977-85. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 14, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.