Evaluation of Clinical Decision Support to Reduce Sedative-Hypnotic Prescribing in Older Adults

Abstract

Objective We sought to characterize the performance of inpatient and outpatient computerized clinical decision support (CDS) alerts aimed at reducing inappropriate benzodiazepine and nonbenzodiazepine sedative medication prescribing in older adults 18 months after implementation. Methods We reviewed the performance of two CDS alerts in the outpatient and inpatient settings in 2019. To examine the alerts' effectiveness, we analyzed metrics including overall alert adherence, provider-level adherence, and reasons for alert trigger and override. Results In 2019, we identified a total of 14,534 and 4,834 alerts triggered in the outpatient and inpatient settings, respectively. Providers followed only 1% of outpatient and 3% of inpatient alerts. Most alerts were ignored (68% outpatient and 60% inpatient), while providers selected to override the remaining alerts. In each setting, the top 2% of clinicians were responsible for approximately 25% of all ignored or overridden alerts. However, a small proportion of clinicians (2% outpatient and 4% inpatient) followed the alert at least half of the time and accounted for a disproportionally large fraction of the total followed alerts. Our analysis of the free-text comments revealed that many alerts were to continue outpatient prescriptions or for situational anxiety. Conclusion Our findings highlight the importance of evaluation of CDS performance after implementation. We found large variation in response to the inpatient and outpatient alerts, both with respect to follow and ignore rates. Reevaluating the alert design by providing decision support by indication may be more helpful and may reduce alert fatigue.

Modulators Influencing Medication Alert Acceptance: An Explorative Review

“…After the removal of 110 duplicates and the exclusion of 276 articles following title and abstract screening, a total of 153 full texts were read. In compliance with the inclusion and exclusion criteria, 31 articles reporting quantitative and qualitative parameters 13 33 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 and 29 articles reporting exclusively qualitative parameters of alert acceptance 1 6 12 17 32 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 were included in the analysis.…”

“…Patient characteristics such as the surroundings in which the patient was treated can influence alert acceptance whereas alerts in the in-patient setting were more frequently accepted than in the outpatient setting. 33,67 Furthermore, one study reported that alerts were more often accepted if they concerned male patients. 57 However, this result remained unconfirmed in other studies 54 and might be influenced by other factors not assessed in this study.…”

A Qualitative Description of Clinician Free-Text Rationales Entered within Accountable Justification Interventions

“… 18 This confirms the finding of Joglekar et al that suggests postimplementation evaluation of alerts, including qualitative review of free-text override responses, can contribute to the construction of better triggers that minimize unnecessary prompts that can contribute to alert fatigue. 10 Additionally, clinicians would have been spared the CDS alert in the study of overtesting of older adults if relevant diagnoses were entered into the patient problem or encounter diagnosis list because the diagnoses of a past prostate cancer history or specific urinary symptoms would have suppressed the alert. It is possible these instances will appear less often as clinicians learn from previous exposures that doing so saves them from interacting with CDS alerts.…”

“…9 Joglekar and colleagues have described a review of reasons for alert override when the justification was optional and not visible to others. 10 However, we are not aware of other studies that have reviewed visible free-text accountable justifications entered during clinical encounters in outpatient primary care to qualitatively describe what content clinicians enter.…”

Comparative Risk of Harm Associated with Zopiclone or Trazodone Use in Nursing Home Residents: a Retrospective Cohort Study in Alberta, Canada

“…( 2 , 11 , 12 ) Unlike benzodiazepines and antipsychotics, quality improvement work aimed at reducing potentially inappropriate prescribing of these alternative psychotropic medications has been limited. ( 13 – 15 ) This is important because there is growing evidence describing the risk of falls and fractures in older adults dispensed trazodone and nonbenzodiazepine sedative hypnotics (e.g., zopiclone). ( 16 – 18 ) Further, trazodone is associated with a similar risk of harm from injurious falls or fractures as benzodiazepines and atypical antipsychotics.…”