Computer systems tools and potentially inappropriate medications ordered at discharge for adults 65 years of age and older: a systematic review.

Reviewers: Nancy Iankowitz RN, MS, FNP-BC, DNPc Doctoral Candidate, Pace University Telephone: (845) 878-7708 Email: [email protected] Margaret Dowden RN, MS, FNP-BC, DNPc Doctoral Candidate, Pace University Sara Palomino RN, MS, ANP-BC, DNPc Doctoral Candidate, Pace University Helen Uzokwe BSC, RN, MS, FNP-BC, DNPc Doctoral Candidate, Pace University Dr. Priscilla Worral PhD, RN Adjunct Professor, Pace University Centre Submitting Review Pace University, College of Health Professions, Lienhard School of Nursing and New Jersey Centre for Evidence Based Practice at UMDNJ School of Nursing; A Collaborating Centre of the Joanna Briggs Institute Review question/objective The overall objective of this systematic review is to determine the best available evidence related to the effectiveness of computer systems tools that assist in clinical decision making regarding reduction in frequency of potentially inappropriate medications (PIMs) ordered at discharge and PIMs-related unplanned emergency room (ER) visits or hospital readmissions in community dwelling patients ≥ 65 years of age. More specifically, the focused systematic review question is: what is the effectiveness of computer systems tools that assist in clinical decision making on reduction in frequency of PIMs ordered at discharge and PIMs-related unplanned ER visits or hospital readmissions in community dwelling patients ≥ 65 years of age? Background The rapidly increasing number of elderly patients in the developed world constitutes “one of the most important challenges for health systems” 1, p.31. Advances in pharmaco-therapy have contributed to this trend as new medications make it possible for people to live longer by delaying the consequences of chronic diseases. However, as people age, the burden of these diseases is typically met with the simultaneous administration of several drugs 1. To date there exist no systematic reviews focusing specifically on the role of computer systems tools in reducing prescriptions of potentially inappropriate medications for the elderly population. PIMs refers to those medications prescribed that are known to pose risks of adverse drug-related reactions when there are alternative medications that have equal or greater efficacy with less of a chance of causing adverse drug-related events 2. Inappropriate prescribing encompasses extended use of medications past the recommended duration as determined by clinical trials, as well as use of concomitant medications with known interactions with each other and/or with a disease state present in the patient. Of note, inappropriate prescribing also refers to the lack of use of medications that have been clinically indicated for a particular disease state or condition 2. The Beers' Criteria were developed by experts in the fields of geriatric care, clinical pharmacology, and psychopharmacology based upon an extensive review of the existing literature 3. The Beers Criteria were established initially in 1991, published in 1997 and then updated in the interest of remaining useful since there are a growing number of a wide variety of medication on the market for patients ≥ 65, and these must be continually considered. It was in 2003 that a United States consensus panel of experts revised the Beers’ Criteria list of PIMs 3. Over-prescribing of PIMs to the elderly population (≥ 65) is not unique to the United States, but is reported throughout European countries as well. The percentages range from 12% in community-dwelling members of this population to 40% in those who live in nursing homes.2 A study conducted in the Czech Republic, Denmark, Finland, Iceland, Italy, Netherlands, Norway and the United Kingdom found that 20 percent of elderly patients who were living in the community were using at least one inappropriate medication 4. Although data are lacking regarding the relationship between use of PIMs and health outcomes, there is a positive relationship between PIMs and adverse drug events 2. The possibility of adverse drug reactions increases with age; furthermore, the pharmacological effect of many drugs on the body is known to either increase or decrease depending on the age of the patient 1. Mounting evidence on the topic of PIMs suggests that knowledge and awareness on the part of health professionals are both important factors when addressing this issue. Physicians’ knowledge about prescribing inappropriate medications in the elderly was investigated using a convenience sample of 198 physicians 5. The physicians were asked to complete a questionnaire and 89 physicians completed the survey. Only 14% of respondents reported using the Beers' criteria showing that many primary care physicians lack knowledge of PIMs 5. Inappropriate medications are used in the elderly, whether they be community dwelling or residents in nursing homes. In an effort to reduce hospital readmission rates, it is incumbent upon all healthcare providers to become knowledgeable about PIMs in order to avoid prescribing the growing number of medications that pose increased risk to this patient population. The literature reflects that prescribing PIMs has been cited as a major contributory factor in hospital readmissions 6,7. Two additional examples of medication inappropriateness are overuse (polypharmacy) as well as underuse. These factors contribute to avoidable morbidity among elderly populations. A significant health outcome of PIM use among the elderly is an increased risk for hospitalization. In a review that used the Beers criteria for determining PIM use, three of the four studies, which primarily examined community dwelling elderly, revealed an “earlier onset of hospitalization, greater risk of acute hospitalization and greater number of inpatient admissions” 6, p. 408. The relationship between PIMs and the risk for hospitalization among the elderly over a three year span using data from a retiree health claims database was examined 6. Elderly patients who were taking one or more PIMs were between 1.8 and 1.9 times more likely to be hospitalised6. A number of studies have tested the effectiveness of various computer-based tools developed to support clinical decision making related to appropriate prescribing of medications. Raebel et al 9 demonstrated that a computerized 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 randomized controlled study conducted by Terrell and colleagues 10 to evaluate the effectiveness of computer assisted decision support in reducing potentially inappropriate prescribing to older adults also demonstrated that computerized 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). Tamblyn et al11 set out to determine whether inappropriate prescribing could be reduced by computer systems decision making tools. They concluded 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). The literature strongly indicates that the topic of PIMs is a prevalent issue that poses serious danger to elderly patients 1-13. In addition, computerized decision making tools seem to play a valuable role in addressing the issue of ordering PIMs for the community dwelling elderly population ≥ 65 years of age 9-11; therefore, in order to effect change to improve patient outcomes, further investigation regarding this important issue is of paramount importance. A preliminary search of Medline, CINAHL, JBI Library of Systematic Reviews was performed and no existing or ongoing systematic review on this topic was identified. Inclusion Criteria Types of Participants This review will consider studies that include community based adults ≥ 65 years of age (regardless of diagnosis, gender, ethnicity, stage of disease co-morbidities, and previous treatment received) who were admitted to the hospital from the community and then discharged back into the community and prescribed potentially inappropriate medications. For the purposes of this review, community-based adults will include those living at home or with family members. Adults living in nursing homes or assisted living facilities will be excluded. Types of Intervention This review will include studies that evaluate any intervention described as an electronic or computer based clinical decision making supplement or support related to prescribing of potentially inappropriate medications PIMs. Comparator This review will include studies in which the comparator is absence of computer systems support tools (ex., before-and-after studies) and either no other intervention or an intervention which does not include electronic or computer based support. Types of Outcomes This review will consider studies that include any of the following outcome measures: frequency of ordering potentially inappropriate medications PIMs for patients at discharge, unexpected hospital readmission rate of patients who were discharged on PIMs, and unexpected visits to the ED of patients who were discharged on PIMs. Frequency of ordering potentially inappropriate medications (PIMs) is measured as a proportion or percentage. For this systematic review we will use the following definitions: Unexpected hospital readmission will be defined as any admission that was not planned at discharge during a previous hospital visit. Unexpected visits to the ED will be defined as any patient visit to the ED that was not scheduled upon discharge. Types of Studies The review will consider randomised control trials (RCTs). In the absence of RCTs, other research designs such as quasi-experimental studies (time series or non equivalent control group design), case-control, cohort, and descriptive studies (comparative studies with either retrospective or prospective baseline data collection, prospective case series) will be considered for inclusion in the systematic review. Search Strategy The search strategy aims to find both published and unpublished studies available in the English language from 2003 to present. The time frame for the database search was determined by the Beers’ criteria which became the initial gold standard. The 2003 updated Beers’ criteria served as the point of comparison for more recently developed criteria 13. A three-step search strategy will be utilised in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be hand searched for additional studies. Studies identified from reference list searches will be assessed for relevance based on the study title. The databases to be searched include: PubMED, CINAHL Health Source: Nursing/Academic Edition; MasterFILE Premier, Scopus, Database of Abstracts of Reviews of Evidence, Academic Search Premier, Scirus and Embase. A grey literature search to identify unpublished studies/papers will include: Mednar, Virginia Henderson Library of Sigma Theta Tau International, Clinical Trials Register, and conference proceedings of relevant organizations such as The American Gerontological Society and the American College of Clinical Pharmacology. Hand searching of relevant journals such as Clinical Pharmacology & Therapeutics and The Journal of Clinical Pharmacology will be performed to reveal additional grey literature and unpublished studies. Keywords to be used will be: PIMs, prescribing, inappropriate medications, adverse events, elderly, older adults, computer systems tools, computerised/computerized systems AND prescribing, electronic prescribing systems, hospital readmission, medications, PIMs, prescribing, inappropriate medications, polypharmacy, adverse events, elderly, older adults, and Medical Subject Heading (MeSH) term: inappropriate prescribing. Assessment of Methodological Quality Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data Collection Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Where necessary, the principal investigator of a study will be contacted (when possible) to obtain any missing information. Data Synthesis Quantitative papers will, where possible be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different quantitative study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Conflicts of Interest No conflicts of interest noted. Acknowledgements This study is conducted in partial fulfilment as a requirement for the Doctor of Nursing Practice degree.