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
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Jerry H. Gurwitz, M.D. Executive Director Meyers Primary Care Institute
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 - PowerPoint PPT Presentation
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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 InstituteChief, Division of Geriatric Medicine
University of Massachusetts Medical SchoolWorcester, Massachusetts
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)
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.
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.
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.
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.
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.
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.
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.
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.
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.
The Prescribing Cascade
The resident’s functional decline is attributed to Parkinson’s Disease...
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
11 drugs that should always be avoided in the elderly:
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?
Translating Quality Measures into Clinical Decision Support
Com
plex
ity
Validity
DrugData
Drugs & Dx’s
Drugs, Dx’s& Labs
Drugs, Dx’s, Labs& Clinical Info
CPOE with Clinical Decision Support at Baycrest Centre for Geriatric Care in
Toronto, Ontario
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?
Quality Indicators for Appropriate Medication Use in Older Adults
Assessing 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
Quality Indicators for Appropriate Medication Use in Older Adults
Assessing 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
The Prescribing Cascade
Drug 1
ADE
Drug 2
DRUG 2 == PROXY FOR ADE
Case-Control Study Design
Drug Exposure:Yes or No?
Drug Exposure:Yes or No?
BEGIN
Cases(ADE)
Controls
CLASSIFY/COMPARE
The Prescribing Cascade
Metoclopramide
Extrapyramidal Effects
Levodopa Rx
Case-Control Study Design
Metoclopramide:Yes or No?
Metoclopramide:Yes or No?
BEGIN
L-dopaRx
Controls
CLASSIFY/COMPARE
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).
Likelihood of L-dopa Treatment by Metoclopramide Dose
1.2
3.3
5.3
0123456
>0-10 >10-20 >20DAILY DOSE (mg/day)
OD
DS
RAT
IO
Conclusion
Metoclopramide confers an increased risk for the initiation of treatment generally reserved
for the managment of idiopathic Parkinson’s disease.