Simon SR et al. 2006 "Computerized prescribing alerts and group academic detailing to reduce the use of potentially inappropriate medications in older people."

Reference
Simon SR, Smith DH, Feldstein AC, et al. Computerized prescribing alerts and group academic detailing to reduce the use of potentially inappropriate medications in older people. J Am Geriatr Soc 2006;54(6):963-968.
Abstract
"OBJECTIVES: To examine the effect of replacing drug-specific computerized prescribing alerts with age-specific alerts on rates of dispensing potentially inappropriate medications in older people and to determine whether group academic detailing enhances the effectiveness of these alerts. DESIGN: Cluster-randomized trial of group academic detailing and interrupted time-series analysis. SETTING: Fifteen clinics of a staff-model health maintenance organization. PARTICIPANTS: Seven practices (113 clinicians, 24,119 patients) were randomly assigned to receive age-specific prescribing alerts plus the academic detailing intervention; eight practices (126 clinicians, 26,805 patients) received alerts alone. Prior implementation of drug-specific alerts established a downward trend in use of target medications that served as the baseline trend for the present study. INTERVENTION: The computerized age-specific alerts occurred at the time of prescribing a targeted potentially inappropriate medication (e.g., tertiary tricyclic amine antidepressants, long-acting benzodiazepines, propoxyphene) and suggested an alternative medication. Clinicians at seven sites were randomized to group academic detailing, an interactive educational program delivering evidence-based information. MEASUREMENTS: Number of target medications dispensed per 10,000 patients per quarter, 2 years before and 1.5 years after the replacement of drug-specific with age-specific alerts. RESULTS: Age-specific alerts resulted in a continuation of the effects of the drug-specific alerts without measurable additional effect (P=.75 for level change), but the age-specific alerts led to fewer false-positive alerts for clinicians. Group academic detailing did not enhance the effect of the alerts. CONCLUSION: Age-specific alerts sustained the effectiveness of drug-specific alerts to reduce potentially inappropriate prescribing in older people and resulted in a considerably decreased burden of the alerts."
Objective
"To examine the effect of replacing drug-specific computerized prescribing alerts with age-specific alerts on rates of dispensing potentially inappropriate medications in older people and to determine whether group academic detailing enhances the effectiveness of these alerts."
Type Clinic
Primary care
Size
Large
Other Information
"The study was conducted at a nonprofit, group-model HMO [health maintenance organization] in Oregon and Washington with approximately 448,000 members."
Type of Health IT
Computerized clinical reminders (CRs) and alerts
Type of Health IT Functions
"From November 2000 through December 2002, the EHR employed drug-specific alerts for long-acting benzodiazepines and tertiary amine tricyclic antidepressants. These alerts resulted in a significant decrease in the use of the target medications. In January 2003, the drug-specific alerts were discontinued, and at the same time a new system of age-specific prescribing alerts was implemented. The alerts were programmed to 'pop up' only when both of the following circumstances occurred: 1. Clinician ordered one of the target medications [tertiary tricyclic amine antidepressants, long-acting benzodiazepines, NSAIDs, narcotics and skeletal muscle relaxants] for a patient aged 65 and older. 2. The patient did not have a current supply for the same medication from a prescription dispensed in the preceding 6 months. This condition was included so that prescribers would not receive multiple alerts for the same patient within a 6-month period. Each alert suggested that clinicians change the originally intended medication order to an alternative preferred medication; the order could be changed manually (retyping the drug name) or by activating a list of medication alternatives and choosing a medication from the menu of options."
Context or other IT in place
Since 1996, the HMO has used an electronic health record (EHR) application "with computerized order entry and decision support."
Workflow-Related Findings
"In the practices receiving group detailing plus alerts, the pre- and postintervention quarterly rates of use of target medications per 10,000 members were 146.3 and 126.6, respectively, resulting in a decrease of
19.7 dispensed medications per 10,000 members. In comparison,
in the practices receiving alerts alone, the pre- and post-intervention rates were 150.2 and 137.2, respectively, a decrease of 13.0 dispensed medications per 10,000 members per quarter."
"The transition in January 2003 from drug-specific alerts to patient-specific alerts for the same target medications resulted in a continuation of the established downward trend without apparent change in the level (P=.75) or slope (P=.22) of the time series.... The immediate decrease in the rate of medication dispensing was 3.4 prescriptions per 10,000 members per quarter, a 5.7% decrease" from the expected level based on preintervention trends.
"In the [period with the drug-specific alerts] (January to June 2002),...each clinician received an average of 18 alerts over a 6-month period.... Approximately 14 (82%) alerts per clinician occurred while ordering these medications for patients younger than 65 (false-positive alerts). In contrast, within a similar 6-month period during the age-specific intervention (January to June 2004), [they received] approximately four alerts per clinician, all of which, by design, occurred after prescribing one of the target medications to an elderly patient."
Study Design
Pre-postintervention (no control group)
Study Participants
"Study participants included all primary care clinicians (physicians, nurse practitioners, and physician assistants) at the 15 enrolled clinics and the elderly patients receiving primary care at those sites."