Using Clinical Decision Support Systems to Measure and Improve Quality of Care for Special Populatio - PowerPoint PPT Presentation

1 / 47
About This Presentation
Title:

Using Clinical Decision Support Systems to Measure and Improve Quality of Care for Special Populatio

Description:

Using Clinical Decision Support Systems to Measure and Improve Quality of Care ... Belladonna alkaloids. Dicyclomine. Hyoscyamine. Propantheline. Trimethobenzamide ... – PowerPoint PPT presentation

Number of Views:238
Avg rating:3.0/5.0
Slides: 48
Provided by: terrys54
Category:

less

Transcript and Presenter's Notes

Title: Using Clinical Decision Support Systems to Measure and Improve Quality of Care for Special Populatio


1
Using Clinical Decision Support Systems to
Measure and Improve Quality of Care for Special
PopulationsThe Elderly in the Long-term Care
Setting
  • Jerry H. Gurwitz, M.D.
  • Executive Director
  • Meyers Primary Care Institute
  • Chief, Division of Geriatric Medicine
  • University of Massachusetts Medical School
  • Worcester, Massachusetts

2
It is much easier to write upon a disease than
upon a remedy. The former is in the hands of
nature and a faithful observer with an eye of
tolerable judgement cannot fail to delineate a
likeness. The latter will ever be subject to the
whim, the inaccuracies and the blunder of
mankind.William Withering (1741-1799)
3
Case Study
  • E.G. is an 85 year-old female nursing home
    resident with a history of atrial fibrillation,
    stroke, dementia, and hypertension, who is
    receiving chronic therapy with warfarin. Her
    primary care provider has been dosing her
    warfarin to maintain her at an INR of 2.0.

4
Case Study
  • One evening, a covering physician is called
    with a report that the patient has developed a
    fever. The patient is initiated on empiric
    antibiotic therapy with cephalexin (500 mg po TID
    for 7 days) to treat a presumed urinary tract
    infection.

5
Case Study
  • The next morning the primary care physician is
    called with the previous days INR, 1.75. He
    increases the daily warfarin dose from 4 mg to 5
    mg per day. He is not notified of the cephalexin
    ordered the previous evening by the covering
    physician.

6
Case Study
  • One week later, the INR comes back at 13.8 and
    a covering physician is notified. That evenings
    warfarin dose is held. The INR the following day
    is 16.1. The warfarin continues to be held. No
    vitamin K is administered.

7
Case Study
  • The very next day the patient develops
    congestion and shortness of breath. A chest
    x-ray reveals an infiltrate and the covering
    physician orders Augmentin 875 mg po q12 hours
    for 10 days. The next day the patient passes
    tarry stool and omeprazole is initiated.

8
Case Study
  • The following morning the patients hematocrit
    is 25 and her INR is 11.3. The primary care
    physician is notified, and vitamin K 10 mg sc is
    administered for 3 days with a decrease in the
    INR to 0.9. The physician writes that warfarin
    will not be reinitiated because anticoagulation
    has been difficult to control for unclear reasons.

9
The Prescribing Casade
  • B.F. is an 80 year-old female nursing home
    resident with a history of Parkinsons Disease
    treated with long-term Sinemet therapy (25-100
    TID). She has suffered occasional hallucinations
    attributed to the Sinemet therapy, which have
    recently increased in frequency. The
    hallucinations sometimes involve large animals
    and can be quite terrifying.

10
The Prescribing Cascade
  • The resident is initiated on olanzapine 2.5 mg
    at bedtime. Due to agitation and continued
    hallucinations, the olanzapine dose is increased
    to 5 mg and lorazepam 0.5 mg po q4 hours prn is
    added to the medication regimen. The
    hallucinations continue and the evening dose of
    olanzapine is increased to 7.5 mg.

11
The Prescribing Cascade
  • The resident is noted by the nursing staff to
    be shaky and stiff, but no change is made in the
    olanzapine dose. She becomes increasingly
    lethargic. She is described as rigid and stooped
    over with ambulation and begins to have more
    difficulty with activities of daily living
    including bathing, dressing, toileting, and
    tranferring. She begins to require a wheelchair.

12
The Prescribing Cascade
  • The residents functional decline is
    attributed to Parkinsons Disease...

13
Measuring the quality of prescribing to the
elderly?
  • The Beers list
  • List of 33 drugs
  • Drugs that should always be avoided
  • Drugs that are rarely appropriate
  • Drugs with some indications, but that are often
    misused

14
11 drugs that should always be avoided in the
elderly
  • Barbiturates
  • Chlorpropamide
  • Flurazepam
  • Meperidine
  • Meprobamate
  • Pentazocine
  • Belladonna alkaloids
  • Dicyclomine
  • Hyoscyamine
  • Propantheline
  • Trimethobenzamide

Zhan et al. JAMA 2001
15
Use of Always Avoid Drugs
Percent
16
The Incidence and Preventability of Adverse Drug
Events in Two Large Academic Long-term Care
Facilities
Funded by AHRQ
17
Adverse Drug Events
Medication Errors
Preventable
18
Methods
  • Study conducted in two large academic long-term
    care facilities
  • Total of 1229 beds
  • Time period 2000-2001

19
Methods
  • Drug-related incidents were detected using
    multiple methods
  • Review of nursing home records in monthly
    segments
  • Computer-generated signals

20
Computer Generated Signals
  • Abnormal laboratory results
  • Elevated INRs, high potassium levels
  • Medications (antidotes)
  • Vitamin K, sodium polystyrene sulfonate
  • Abnormal drug levels
  • Phenytoin
  • Digoxin

21
Methods
  • Chart reviews were performed by trained clinical
    pharmacist investigators
  • Incidents were classified by two independent
    physician reviewers
  • adverse drug event
  • severity
  • preventability

22
Results - Event Rates
  • Adverse drug events
  • Events 815
  • Rate 9.8 per 100 resident-months
  • Preventable adverse drug events
  • Events 338
  • Rate 4.1 per 100 resident-months

23
Adverse Drug Events (n815)Preventable vs
Non-Preventable
24
Adverse Drug Events by Severity(n815)
25
Preventability of Adverse Drug Events
Of fatal, life-threatening serious events
Of less serious events
Preventable 61
Preventable 34
26
Error Stage for Preventable ADEs(n338
preventable ADEs)
27
Drug Categories
Preventable events
  • Warfarin 12
  • Atypical antipsych 12
  • Loop diuretics 10
  • Benzos (intermediate) 9
  • Opioids 8
  • ACE inhibitors 8
  • Other antidepressants 7
  • Antiplatelets 7
  • Insulin 5
  • Laxatives 5

28
Event Categories - Preventable
  • Neuropsychiatric 29
  • Hemorrhagic 16
  • Gastrointestinal 16
  • Renal/electrolytes 12
  • Fall with injury
    5
  • Cardiovascular 4
  • Fall without injury 3
  • EPS
    2
  • Syncope/dizziness 2

29
Guiding Principles for Quality Measures
  • Compelling importance
  • Clear relevance to improving care
  • Parsimony
  • Reasonable administrative burden

30
Guiding Principles for Development of Quality
Measures
  • Is it possible to arrive at a set of measures
    that are of compelling importance and which have
    clear relevance to care, and that are also
    scientifically valid, usable, and feasible?

31
Translating Quality Measures into Clinical
Decision Support
Drugs, Dxs, Labs Clinical Info
Complexity
Drugs, Dxs Labs
Drugs Dxs
Drug Data
Validity
32
CPOE with Clinical Decision Support at Baycrest
Centre for Geriatric Care in Toronto, Ontario
33
(No Transcript)
34
(No Transcript)
35
The Big Question
  • Can the types of errors and events that I shared
    with you be captured with a set of quality
    measures that can guide the development of
    computerized clinical decision support systems in
    the long-term care setting?

36
(No Transcript)
37
Quality Indicators for Appropriate Medication Use
in Older AdultsAssessing Care of Vulnerable
Elders (ACOVE)
  • Warfarin INR should be monitored using
    standardized protocols
  • Loop diuretics Check electrolytes within 1 week
    and at least annually
  • Avoid chlorpropamide
  • Avoid drugs with strong anticholinergic
    properties
  • Avoid barbiturates
  • Avoid meperidine
  • ACE inhibitors Monitor renal function and
    potassium in patients on ACE inhibitors

38
Quality Indicators for Appropriate Medication Use
in Older AdultsAssessing Care of Vulnerable
Elders (ACOVE)
  • Document the indication for a new drug therapy
  • Educate patients on the benefits and risks
  • Maintain a current medication list
  • Document response to therapy
  • Periodically review ongoing need for therapy

39
The Prescribing Cascade
Drug 1
ADE
Drug 2
40
DRUG 2
PROXY FOR ADE

41
Case-Control Study Design
BEGIN
CLASSIFY/COMPARE
Drug Exposure Yes or No?
Cases (ADE)
Drug Exposure Yes or No?
Controls
42
The Prescribing Cascade
Metoclopramide
Extrapyramidal Effects
Levodopa Rx
43
Case-Control Study Design
BEGIN
CLASSIFY/COMPARE
Metoclopramide Yes or No?
L-dopa Rx
Metoclopramide Yes or No?
Controls
44
Results
  • Metoclopramide users were over three times more
    likely to begin use of L-dopa therapy compared
    with non-users (OR3.09 95 CI 2.25 to 4.26).

45
Likelihood of L-dopa Treatment by Metoclopramide
Dose
46
Conclusion
  • Metoclopramide confers an increased risk for the
    initiation of treatment generally reserved for
    the managment of idiopathic Parkinsons disease.

47
The Prescribing Cascade
Drug 1
ADE
Drug 2
Write a Comment
User Comments (0)
About PowerShow.com