Title: Using Clinical Decision Support Systems to Measure and Improve Quality of Care for Special Populatio
1Using 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
2It 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)
3Case 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.
4Case 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.
5Case 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.
6Case 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.
7Case 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.
8Case 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.
9The 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.
10The 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.
11The 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.
12The Prescribing Cascade
- The residents functional decline is
attributed to Parkinsons Disease...
13Measuring 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
1411 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
15Use of Always Avoid Drugs
Percent
16The Incidence and Preventability of Adverse Drug
Events in Two Large Academic Long-term Care
Facilities
Funded by AHRQ
17Adverse Drug Events
Medication Errors
Preventable
18Methods
- Study conducted in two large academic long-term
care facilities - Total of 1229 beds
- Time period 2000-2001
19Methods
- Drug-related incidents were detected using
multiple methods - Review of nursing home records in monthly
segments - Computer-generated signals
20Computer Generated Signals
- Abnormal laboratory results
- Elevated INRs, high potassium levels
- Medications (antidotes)
- Vitamin K, sodium polystyrene sulfonate
- Abnormal drug levels
- Phenytoin
- Digoxin
21Methods
- Chart reviews were performed by trained clinical
pharmacist investigators - Incidents were classified by two independent
physician reviewers - adverse drug event
- severity
- preventability
22Results - 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
23Adverse Drug Events (n815)Preventable vs
Non-Preventable
24Adverse Drug Events by Severity(n815)
25Preventability of Adverse Drug Events
Of fatal, life-threatening serious events
Of less serious events
Preventable 61
Preventable 34
26Error Stage for Preventable ADEs(n338
preventable ADEs)
27Drug 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
28Event 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
29Guiding Principles for Quality Measures
- Compelling importance
- Clear relevance to improving care
- Parsimony
- Reasonable administrative burden
30Guiding 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?
31Translating Quality Measures into Clinical
Decision Support
Drugs, Dxs, Labs Clinical Info
Complexity
Drugs, Dxs Labs
Drugs Dxs
Drug Data
Validity
32CPOE with Clinical Decision Support at Baycrest
Centre for Geriatric Care in Toronto, Ontario
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35The 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?
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37Quality 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
38Quality 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
39The Prescribing Cascade
Drug 1
ADE
Drug 2
40DRUG 2
PROXY FOR ADE
41Case-Control Study Design
BEGIN
CLASSIFY/COMPARE
Drug Exposure Yes or No?
Cases (ADE)
Drug Exposure Yes or No?
Controls
42The Prescribing Cascade
Metoclopramide
Extrapyramidal Effects
Levodopa Rx
43Case-Control Study Design
BEGIN
CLASSIFY/COMPARE
Metoclopramide Yes or No?
L-dopa Rx
Metoclopramide Yes or No?
Controls
44Results
- 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).
45Likelihood of L-dopa Treatment by Metoclopramide
Dose
46Conclusion
- Metoclopramide confers an increased risk for the
initiation of treatment generally reserved for
the managment of idiopathic Parkinsons disease.
47The Prescribing Cascade
Drug 1
ADE
Drug 2