Jerry H. Gurwitz, M.D. Executive Director Meyers Primary Care Institute

1. Using Clinical Decision Support Systems to Measure and Improve Quality of Care for Special Populations:The 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 day’s 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 evening’s 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 patient’s 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 Parkinson’s 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 resident’s functional decline is attributed to Parkinson’s 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. Barbiturates Chlorpropamide Flurazepam Meperidine Meprobamate Pentazocine Belladonna alkaloids Dicyclomine Hyoscyamine Propantheline Trimethobenzamide 11 drugs that should always be avoided in the elderly: 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. ADEs 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 (n=815)Preventable vs Non-Preventable

24. Adverse Drug Events by Severity(n=815)

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(n=338 preventable ADEs)

27. 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% Drug Categories Preventable events

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

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, Dx’s, Labs & Clinical Info Complexity Drugs, Dx’s & Labs Drugs & Dx’s Drug Data Validity

32. CPOE with Clinical Decision Support at Baycrest Centre for Geriatric Care in Toronto, Ontario

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?

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 CLASSIFY/COMPARE BEGIN 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 CLASSIFY/COMPARE BEGIN 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 (OR=3.09; 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 Parkinson’s disease.

47. The Prescribing Cascade Drug 1 ADE Drug 2