Clinicians Override Most Rx Safety Alerts

March 13, 2009

Clinicians often override electronic medication safety alerts, according to study findings published in the February issue of the Archives of Internal Medicine, indicating that such systems need to be more selective to be truly useful.

Clinicians often override electronic medication safety alerts, according to study findings published in the February issue of the Archives of Internal Medicine, indicating that such systems need to be more selective to be truly useful.
Senior author Saul Weingart, MD, PhD, vice president for patient safety at Dana-Farber Cancer Institute and an internist at Beth Israel Deaconess Medical Center (BIDMC), said their findings suggest that many clinicians consider current medication alerts “more of an annoyance” than a useful tool to ensure patient safety. The authors conclude that if electronic prescribing is to be effective, significant improvements are needed.

“Electronic prescribing clearly will improve medication safety, but its full benefit will not be realized without the development and integration of high-quality decision support systems to help clinicians better manage medication safety alerts,” said Weingart.

The researchers reviewed the electronic prescriptions and related medication safety alerts generated by 2872 clinicians at community-based outpatient practices in Massachusetts, New Jersey, and Pennsylvania. Of the 3.5 million electronic prescriptions written between January 1 and September 30, 2006, 1 in 15 prescriptions (6.6%) produced an alert for a drug interaction or drug allergy. The vast majority (98.6%) of the 233,537 alerts were for a potential interaction with a drug the patient was already taking.

Clinicians overrode 90% of the drug interaction alerts and 77% of the drug allergy alerts. Even when a drug interaction was rated as having high severity, clinicians typically dismissed those alerts for medications commonly used in combination to treat specific diseases. They were also less likely to accept an alert if a patient had been previously treated with the medication.

“The sheer volume of alerts generated by electronic prescribing systems stands to limit the safety benefits,” said Thomas Isaac, MD, MBA, MPH, of Dana-Farber and BIDMC, and the study’s lead author. “Too many alerts are generated for unlikely events, which can lead to alert fatigue. Better decision support programs will generate more pertinent alerts, making electronic prescribing more effective and safer,” he added.

On the basis of these findings, the researchers offered several recommendations to improve medication safety alerts, including: reclassifying severity of alerts, especially for those frequently overridden; providing an option for clinicians to suppress alerts for medications patients have already received; and customizing the alerts for a clinician’s specialty.

The research team identified potentially dangerous drug interactions based on those alerts that most often changed the clinician’s decision to prescribe a specific medication. The list is available at www.dana-farber.org/electronic-medication-safety. Although the study was limited to prescriptions generated through the Zix Corp’s PocketScript system, the researchers said their observations are relevant for other commercial systems.

“We need to find a way to help clinicians separate the proverbial wheat from the chaff,” said Weingart. “Until then, electronic prescribing systems stand to fall far short of their promise to enhance patient safety and to generate greater efficiencies and cost savings.”

Physicians Worry Patients Are Skipping Medications
Physicians are concerned that patients are not complying with their treatment recommendations because of financial considerations. Nearly three-quarters of 705 physicians (73%) were either significantly concerned (38%) or concerned (35%), according to results of a survey of its physician customers conducted by Epocrates, Inc. Physicians were most concerned about patients not filling prescriptions (563 of 705), skipping doses (550), and splitting pills (355).

Physicians said that in the past 6 months, more patients are asking for generic medications (58%) and, in response, they are prescribing more generic medications (55%). While 53% agreed that generics are clinically equivalent to brand-name drugs, 42% said it depends on the medication.

Asked how they typically identify generic alternatives, the most frequent response was mobile (hand-held) reference (357), followed by online drug reference (237) and pharmacist recommendation (180). Electronic formularies were said by physicians to be the health care technology most likely to help patients save money.

Prescribing Course Available Online
An online course for physicians, physician assistants, nurse practitioners, and medical students that was designed to help clinicians optimize their prescribing is available at no charge. The SmartPrescribe course is accessed through www.smartprescribe.org, and continuing education credit is available.

The SmartPrescribe course was developed by Wake Forest University School of Medicine and the Northwest Area Health Education Center of the North Carolina Area Health Education Centers Program.

The 5-lesson course helps clinicians evaluate information from multiple sources to make treatment decisions based on credible scientific evidence. The 5 lessons are:
• A clinician’s guide to critical appraisal of clinical trials.
• What does drug approval by the FDA mean?
• Pharmaceutical marketing: its goal is to influence your prescribing practices.
• Ways to recognize and avoid marketing influence.
• Principles of rational prescribing.

Funding for this and 27 other projects in the United States are from a settlement between a subsidiary of Pfizer Inc and the attorneys general of 50 states and the District of Columbia following allegations that the company’s marketing of the prescription drug Neurontin violated state consumer protection laws.

Systolic, Diastolic ReadingsTogether Predict CV Risk
Persons with elevated systolic blood pressure along with diastolic blood pressure less than 70 mm Hg may be at higher risk for myocardial infarction and stroke than indicated by systolic blood pressure levels alone, according to study findings published in the January 20 issue of Circulation.

Stanley Franklin, MD, and colleagues at the University of California at Irvine Heart Disease Prevention Program and researchers at the Framingham Heart Study reviewed blood pressure data from 9657 participants in the Framingham Heart Study who had not received antihypertensive treatment. They found the combination of high systolic and low diastolic readings to be a better predictor of future adverse cardiovascular events by indicating increased stiffening of arteries.

“Systolic blood pressure as a single component is usually superior to diastolic blood pressure in predicting cardiovascular risk in middle-aged and older individuals,” said Franklin. “But a very high or very low diastolic blood pressure can add to the risks identified by systolic blood pressure alone.”

Hypertension is diagnosed in persons with systolic and diastolic blood pressure levels of 140/90 mm Hg and above. These findings suggest that clinicians should give even greater consideration to systolic blood pressure when the diastolic blood pressure is low.

Savella Approved for Fibromyalgia
Forest Laboratories and Cypress Bioscience received FDA approval to market Savella (milnacipran HCl) for the management of fibromyalgia. Savella, a dual selective serotonin and norepinephrine reuptake inhibitor, was expected to be in pharmacies this month. Clinical trials demonstrated significant improvement in pain, patient global assessment, and physical function in patients with fibromyalgia with the use of 100 to 200 mg daily. Savella is the third drug to gain FDA approval for the treatment of fibromyalgia.