Physicians’ response to computerised alerts for psychotropic drugs in older persons: a multilevel analysis of the associated alert, patient and physician characteristics

OBJECTIVE: Computerised drug alerts are expected to reduce patients’ risk of adverse drug events. However, physicians over-ride most drug alerts, because they believe that the benefit exceeds the risk. The purpose of this study was to determine the drug alert, patient and physician characteristics associated with the: (1) occurrence of psychotropic drug alerts for elderly patients and the (2) response to these alerts by their primary care physicians. SETTING: Primary care, Quebec, Canada. DESIGN: Prospective cohort study. PARTICIPANTS: Sixty-one physicians using an electronic prescribing and drug alert decision-support system in their practice, and 3413 elderly patients using psychotropic drugs. PRIMARY AND SECONDARY MEASURES: Psychotropic drug class, alert severity, patient risk for fall injuries and physician experience, practice volume and computer use were evaluated in relationship to the likelihood of having: (1) a psychotropic drug alert, (2) the prescription revised in response to an alert. Cluster-adjusted alternating logistic regression was used to assess multilevel predictors of alert occurrence and response. RESULTS: In total 13 080 psychotropic drug alerts were generated in 8931 visits. Alerts were more likely to be generated for male patients at higher risk of fall-related injury and for physicians who established the highest alert threshold. In 9.9% of alerts seen, the prescription was revised. The highest revision rate was for antipsychotic alerts (22.6%). Physicians were more likely to revise prescriptions for severe alerts (OR 2.03; 95%CI 1.39 to 2.98), if patients had cognitive impairment (OR 1.95; 95%CI 1.13 to 3.36), and if they made more visits to their physician (OR 1.05 per 5 visits; 95%CI 1 to 1.09). CONCLUSIONS: Physicians view and respond to a small proportion of alerts, mainly for higher-risk patients. To reduce the risk of psychotropic drug-related fall injuries, a new generation of evidence-based drug alerts should be developed.