Use of an electronic decision support tool to reduce polypharmacy in elderly people with chronic diseases: cluster randomised controlled trial

Abstract

<jats:title>Abstract</jats:title> <jats:sec> <jats:title>Objective</jats:title> <jats:p>To evaluate the effects of a computerised decision support tool for comprehensive drug review in elderly people with polypharmacy.</jats:p> </jats:sec> <jats:sec> <jats:title>Design</jats:title> <jats:p>Pragmatic, multicentre, cluster randomised controlled trial.</jats:p> </jats:sec> <jats:sec> <jats:title>Setting</jats:title> <jats:p>359 general practices in Austria, Germany, Italy, and the United Kingdom.</jats:p> </jats:sec> <jats:sec> <jats:title>Participants</jats:title> <jats:p>3904 adults aged 75 years and older using eight or more drugs on a regular basis, recruited by their general practitioner.</jats:p> </jats:sec> <jats:sec> <jats:title>Intervention</jats:title> <jats:p>A newly developed electronic decision support tool comprising a comprehensive drug review to support general practitioners in deprescribing potentially inappropriate and non-evidence based drugs. Doctors were randomly allocated to either the electronic decision support tool or to provide treatment as usual.</jats:p> </jats:sec> <jats:sec> <jats:title>Main outcome measures</jats:title> <jats:p>The primary outcome was the composite of unplanned hospital admission or death by 24 months. The key secondary outcome was reduction in the number of drugs.</jats:p> </jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p> 3904 adults were enrolled between January and October 2015. 181 practices and 1953 participants were assigned to electronic decision support (intervention group) and 178 practices and 1951 participants to treatment as usual (control group). The primary outcome (composite of unplanned hospital admission or death by 24 months) occurred in 871 (44.6%) participants in the intervention group and 944 (48.4%) in the control group. In an intention-to-treat analysis the odds ratio of the composite outcome was 0.88 (95% confidence interval 0.73 to 1.07; P=0.19, 997 of 1953 <jats:italic>v</jats:italic> 1055 of 1951). In an analysis restricted to participants attending practice according to protocol, a difference was found favouring the intervention (odds ratio 0.82, 95% confidence interval 0.68 to 0.98; 774 of 1682 <jats:italic>v</jats:italic> 873 of 1712, P=0.03). By 24 months the number of prescribed drugs had decreased in the intervention group compared with control group (uncontrolled mean change −0.42 <jats:italic>v</jats:italic> 0.06: adjusted mean difference −0.45, 95% confidence interval −0.63 to −0.26; P&lt;0.001). </jats:p> </jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>In intention-to-treat analysis, a computerised decision support tool for comprehensive drug review of elderly people with polypharmacy showed no conclusive effects on the composite of unplanned hospital admission or death by 24 months. Nonetheless, a reduction in drugs was achieved without detriment to patient outcomes.</jats:p> </jats:sec> <jats:sec> <jats:title>Trial registration</jats:title> <jats:p> Current Controlled Trials <jats:ext-link xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="ISRCTN10137559" ext-link-type="isrctn">ISRCTN10137559</jats:ext-link> . </jats:p> </jats:sec>

Rationale and design of the Novel Uses of adaptive Designs to Guide provider Engagement in Electronic Health Records (NUDGE-EHR) pragmatic adaptive randomized trial: a trial protocol

“…EHR tools may currently be ineffective in part due to insufficient focus on factors behind clinical inertia, prescribing behavior, or workflow. To our knowledge, only three trials have specifically studied decision support for inappropriate prescribing in ambulatory older adults, which found modest effectiveness [ 20 , 21 , 52 , 55 ]. Other decision supports, such as prescribing defaults, have not to our knowledge been applied to inappropriate prescribing in older adults [ 32 , 56 ].…”

“…Once the trial is completed, these results will also need to be considered in relation to other efforts to reduce inappropriate prescribing in older adults. Limited prior evidence suggests that providing information alone via decision support at the time of a patient encounter could be insufficient at reducing prescribing on its own [ 20 , 21 , 55 ]. Other interventions that are not exclusively provider-facing, such as pharmacist interventions, including medication reviews, and in-person patient education, have also demonstrated some success in reducing inappropriate prescribing, yet these can be more resource intensive and may require actions outside of typical clinical workflow [ 11 , 21 , 57 ].…”

“…Computerized clinical decision support tools in electronic health record (EHR) systems are a widely scalable strategy to influence physician behavior and have demonstrated effectiveness in implementation science interventions to increase the uptake of preventive health screenings, test ordering, and prescribing guidelineindicated medications [9,15,16]. Several prior studies have evaluated the use of decision support to facilitate the deprescribing of high-risk medications to older adults and have found inconsistent results [17][18][19][20][21]. The lack of effectiveness of these EHR interventions may have resulted from aspects of their designs, such as their not presenting clinically actionable information to overcome true barriers to de-prescribing like clinical inertia, patient pressure, or limited access to alternative treatments, or the decision support being insufficiently focused on workflow and cognitive heuristics, such as providing large blocks of text to communicate risks [22][23][24].…”

Inappropriate medication use and polypharmacy in older people

“…In a linked study, Rieckert and colleagues (doi:10.1136/bmj.m1822) present the results of a large randomised controlled trial in primary care in Austria, Germany, Italy, and the United Kingdom that evaluated the performance of PRIMA-eDS (polypharmacy in chronic diseases: reduction of inappropriate medication and adverse drug events in older populations by electronic decision support), a computerised tool providing individualised evidence based recommendations on deprescribing 4. Use of this tool for patients aged 75 and older who were taking at least eight drugs each resulted in a reduction of 0.42 drugs per patient and a modest risk reduction in mortality and admission to hospital.…”

Nobody ever questions—Polypharmacy in care homes: A mixed methods evaluation of a multidisciplinary medicines optimisation initiative

“…There is little evidence that existing interventions to improve the appropriateness of polypharmacy in older people improve outcomes [27]. Pharmacist-led innovations in pharmaceutical care and computerised decision support improve prescribing but not outcomes [27][28][29][30][31][32], and single-problem initiatives may be ineffective [33]. However, nurses' and carers' contributions to medicines optimisation remain unexplored.…”