The effectiveness of computer system tools on potentially inappropriate medications ordered at discharge for adults older than 65 years of age: a systematic review

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Executive summaryBackgroundPrescribing potentially inappropriate medications to the elderly leads to adverse health outcomes. The use of computer systems decision making tools has been shown to decrease the incidence of prescribing potentially inappropriate medications for the elderly; however, these results are often dependent upon other variables, such as provider compliance.ObjectiveTo examine and synthesize the best available evidence related to the effect of computer systems clinical decision making tools on frequency of ordering potentially inappropriate medications at discharge and related unplanned emergency room visits or hospital readmissions in community dwelling patients older than 65 years of age.Inclusion criteriaTypes of participantsAdults older than 65 years of age prescribed potentially inappropriate medications.Types of interventions Electronic or computer based clinical decision making supplement or support related to prescribing of potentially inappropriate medications.Types of outcomesThe outcome measures were frequency of ordering potentially inappropriate medications (PIMs) for patients at discharge, unexpected hospital readmission rate and unexpected emergency room visits of patients who were discharged on PIMs.Types of studiesRandomised control trials and quasi-experimental studies.Search strategyThe search strategy aimed to find both published and unpublished studies in the English language from January 2003 through July 2011. A search of PubMED, CINAHL, Health Source Nursing/Academic Edition, MasterFILE Premier, Scopus, DARE, Academic Search Premier, Scirus, Embase was conducted.Methodological qualityStudies were critically evaluated by two independent reviewers using standardised critical appraisal instruments from the Joanna Briggs Institute.Data CollectionData were extracted using the standardised data extraction instruments from the Joanna Briggs Institute.Data SynthesisResults from quantitative papers were pooled in statistical meta-analysis as appropriate using JBI-MAStARI. Where statistical pooling was not possible, the findings are presented in narrative form.ResultsA total of five articles, four randomised control studies and one quasi-experimental study were included. One study demonstrated that a computerised alert tool along with collaboration of the health care providers resulted in a statistically significant (p=0.002) decrease in ordering of PIMs as well as improved medication safety in patients older than 65 years of age. Similarly, a randomised controlled study demonstrated that computerised physician order entry with decision support significantly (p=0.02) reduced prescribing of PIMs for seniors (odds ratio=0.55, 95% CI=0.34 - 0.89). Another study demonstrated that computer-based access to complete drug profiles and alerts reduced the rate of initiation of potentially inappropriate prescriptions by 18% (RR=0.82, 95% CI=0.69-0.98). Yet another study demonstrated that implementation of age specific alerts decreases prescription writing of PIMs from 21.9 prescriptions to 16.8 per 10,000 patients; p value < 0.01. One study demonstrated that age specific alerts reduced prescribing of PIMs from 150.2 to 137.2 prescriptions per 10,000 patients; the p value = 0.75 was not statistically significant. Results from two trials were pooled for meta-analysis, with summary RR = 0.82, and 95%CI (0.76 - 0.88). No studies were found that specifically addressed unexpected hospital readmission or unexpected visits to the emergency room of patients who were discharged on PIMs.ConclusionsReduction in prescribing of potentially inappropriate medications occurs when clinical decision making computer support tools, such as drug specific alerts, are available to providers.Implications for practiceComputer systems clinical decision making tools have potential for reducing numbers of potentially inappropriate medications prescribed for the community based population older than 65 years of age.Implications for researchFuture research should continue to explore the effects of computerized clinical decision making tools on prescription writing habits of practitioners for the elderly population. In addition, documentation of unplanned ER visits and unplanned readmission rates needs to be correlated with the use of potentially inappropriate medications.

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