Monane M, Matthias D M, Nagle B A, Kelly M A
Department of Medical Affairs, Merck-Medco Managed Care, LLC, Montvale, NJ 07645, USA.
JAMA. 1998 Oct 14;280(14):1249-52. doi: 10.1001/jama.280.14.1249.
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.
To determine whether a computerized drug utilization review (DUR) database linked to a telepharmacy intervention can improve suboptimal medication use in the elderly.
Population-based cohort design, April 1, 1996, through March 31, 1997.
Ambulatory care.
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.
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.
Contact rate with physicians and change rate to suggested drug regimen.
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 24 266 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 beta-blockers in patients with chronic obstructive pulmonary disease, all rates of change were significantly greater than the expected baseline 2% rate of change.
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.
药物治疗是改善老年人健康结局的最有效干预措施之一。然而，由于某些药物对老年患者不太适用，采用系统方法改善药学服务可能是减少不适当用药的有效途径。
确定与远程药学干预相连接的计算机化药物利用审查（DUR）数据库能否改善老年人用药不当的情况。
基于人群的队列设计，时间为1996年4月1日至1997年3月31日。
门诊护理。
在12个月期间，美国共有23269名65岁及以上的患者从一家大型药品福利管理机构获得处方药福利。
通过计算机化在线DUR数据库，利用明确标准评估医生的处方，以识别老年人潜在的不适当药物使用情况。计算机警报会促使接受老年医学培训的药剂师致电医生，并与医生讨论老年药理学原理及治疗替代方案。
与医生的联系率以及采用建议药物治疗方案的变化率。
共触发43007次警报。在警报引发的43007次远程药学呼叫中，我们就24266次警报联系到了19368名医生（56%）。采用更合适治疗药物的变化率为24%（5860次），但长效苯二氮䓬类药物的变化率为40%，而理论上因患者自我报告病史而禁忌使用的药物变化率为2%至7%。除慢性阻塞性肺疾病患者中β受体阻滞剂的变化率外，所有变化率均显著高于预期的基线2%变化率。
通过整合计算机、药剂师和医生的系统，我们的大规模干预改善了处方模式和护理质量，从而提供了一种基于人群的方法来推进老年临床药理学。未来的研究应聚焦于证明改善老年人处方选择能带来更好的健康结局。
