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A System Linking the Physician, Pharmacist, and Computer

Mark Monane, MD, MS; Dipika M. Matthias, MBA; Becky A. Nagle, PharmD; Miriam A. Kelly, PhD, MEd

JAMA. 1998;280:1249-1252.

Context.— Pharmacotherapy is among the most powerful interventions to improve health outcomes in the elderly. However, since some medications are less appropriate for older patients, systems approaches to improving pharmacy care may be an effective way to reduce inappropriate medication use.

Objective.— To determine whether a computerized drug utilization review (DUR) database linked to a telepharmacy intervention can improve suboptimal medication use in the elderly.

Design.— Population-based cohort design, April 1, 1996, through March 31, 1997.

Setting.— Ambulatory care.

Patients.— A total of 23269 patients aged 65 years and older throughout the United States receiving prescription drug benefits from a large pharmaceutical benefits manager during a 12-month period.

Intervention.— Evaluation of provider prescribing through a computerized online DUR database using explicit criteria to identify potentially inappropriate drug use in the elderly. Computer alerts triggered telephone calls to physicians by pharmacists with training in geriatrics, whereby principles of geriatric pharmacology were discussed along with therapeutic substitution options.

Main Outcome Measures.— Contact rate with physicians and change rate to suggested drug regimen.

Results.— A total of 43007 alerts were triggered. From a total of 43007 telepharmacy calls generated by the alerts, we were able to reach 19368 physicians regarding 24266 alerts (56%). Rate of change to a more appropriate therapeutic agent was 24% (5860), but ranged from 40% for long half-life benzodiazepines to 2% to 7% for drugs that theoretically were contraindicated by patients' self-reported history. Except for rate of change of -blockers in patients with chronic obstructive pulmonary disease, all rates of change were significantly greater than the expected baseline 2% rate of change.

Conclusions.— Using a system integrating computers, pharmacists, and physicians, our large-scale intervention improved prescribing patterns and quality of care and thus provides a population-based approach to advance geriatric clinical pharmacology. Future research should focus on the demonstration of improved health outcomes resulting from improved prescribing choices for the elderly.

From the Departments of Medical Affairs (Drs Monane, Nagle, and Kelly) and Health and Utilization Management (Ms Matthias), Merck-Medco Managed Care, LLC, Montvale, NJ.

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