Reduction in targeted potentially inappropriate medication use in elderly inpatients: a pragmatic randomized controlled trial.

PURPOSE: The use of potentially inappropriate medications (PIMs) in hospitalized older adults is a complex problem, but the use of computerized alert systems (CAS) has shown some potential. The study's objective is to assess the change in PIM use with a CAS-based pharmacist-physician intervention model compared to usual clinical care. METHODS: Pragmatic single-site randomized controlled trial was conducted at a university teaching hospital. Hospitalizations identified with selected Beers or STOPP criteria were randomized to usual clinical care or to the CAS-based pharmacist-physician intervention. The primary outcome was PIM drug cessation or dosage decrease. Clinical relevance of the CAS alerts was assessed. RESULTS: Analyses included 231 patients who had 128 and 126 hospitalizations in the control and intervention groups, respectively. Patients had a mean age of 81, and 60% were female. In the intervention compared to the control group, drug cessation or dosage decrease were more frequent at 48 h post-alert (45.8 vs 15.9%; absolute difference 30.0%; 95%CI 13.8 to 46.1%) and at discharge from the hospital (48.1 vs 27.3%; absolute difference 20.8%; 95%CI 4.6 to 37.0%). In a post hoc analysis of all alerts, regardless of their clinical relevance, the absolute difference in drug cessation or dosage decrease between the intervention and control groups was 16.2% (95%CI 2.9 to 29.6%) at 48 h and 8.0% (95%CI -4.0 to 20.0%) at discharge from the hospital. CONCLUSIONS: In hospitalized older adults, a CAS-based pharmacist-physician intervention, compared to usual clinical care, resulted in significant higher number of drug cessation and dosage reductions for targeted PIMs.

Knowledge Translation Strategy to Reduce the Use of Potentially Inappropriate Medications in Hospitalized Elderly Adults.

OBJECTIVES: To evaluate the effect of a knowledge translation (KT) strategy to reduce potentially inappropriate medication (PIM) use in hospitalized elderly adults. DESIGN: Segmented regression analysis of an interrupted time series. SETTING: Teaching hospital. PARTICIPANTS: Individuals aged 75 and older discharged from the hospital in 2013/14 (mean age 83.3, 54.5% female). INTERVENTION: The KT strategy comprises the distribution of educational materials, presentations by geriatricians, pharmacist-physician interventions based on alerts from a computerized alert system, and comprehensive geriatric assessments. MEASUREMENTS: Rate of PIM use (number of patient-days with use of at least one PIM/number of patient-days of hospitalization for individuals aged ≥75). RESULTS: For 8,622 patients with 14,071 admissions, a total of 145,061 patient-days were analyzed. One or more PIMs were prescribed on 28,776 (19.8%) patient-days; a higher rate was found for individuals aged 75 to 84 (24.0%) than for those aged 85 and older (14.4%) (P < .001), and in women (20.8%) than in men (18.6%) (P < .001). The drug classes most frequently accounting for the PIM were gastrointestinal agents (21%), antihistamines (18%), and antidepressants (17%). An absolute decrease of 3.5% (P < .001) of patient-days with at least one PIM was observed immediately after the intervention. CONCLUSION: A KT strategy resulted in decreased use of PIM in elderly adults in the hospital. Additional interventions will be implemented to maintain or further reduce PIM use.

A Pharmacist-Physician Intervention Model Using a Computerized Alert System to Reduce High-Risk Medication Use in Elderly Inpatients.

BACKGROUND: Prescription is a complex challenge facing clinicians caring for elderly inpatients. Potentially inappropriate medication (PIM) use frequently leads to adverse drug events and geriatric syndromes. Strategies to reduce PIM use are thus urgently needed. OBJECTIVES: The objectives of this study were to assess (1) the applicability of a pharmacist-physician intervention model to reduce the use of high-risk medications; and (2) the clinical relevance of the alerts generated by a computerized alert system (CAS). METHODS: The study was conducted in patients aged 65 years or older admitted to a teaching hospital between April and June 2014. In the intervention model, the pharmacist determined the clinical relevance of the Beers criteria-based CAS alerts, analyzed the patient's pharmacotherapy, and developed a geriatric pharmacotherapeutic plan to be discussed with the treating physician. The main outcome was the change rate, defined as the number of patient-days with a change in at least one medication out of the number of patient-days with a pharmacist intervention. RESULTS: The CAS identified at least one alert in 200 patient-days, i.e., 4.3% of screened patient-days. In 74.5% of those patient-days, at least one alert was judged to be clinically relevant. The change rate was 77.7%. The most frequent changes were drug discontinuation (42.4%) and dose reduction (29.1%). The inpatient geriatric consultation team was involved in only 24% of the hospitalizations with at least one change in medication. CONCLUSION: The intervention model reduced high-risk medication use in older inpatients. Most of the vulnerable inpatients identified by CAS alerts would not have otherwise had a geriatric medication review.