Effect of Alerts for Drug Dosage Adjustment in Inpatients with Renal Insufficiency

Assistance Publique des Hôpitaux de Paris Georges Pompidou European Hospital, Medical Informatics and Public Health Department, and Paris Descartes University, Paris, France.
Journal of the American Medical Informatics Association (Impact Factor: 3.5). 03/2009; 16(2):203-10. DOI: 10.1197/jamia.M2805
Source: PubMed


Medication errors constitute a major problem in all hospitals. Between 20% and 46% of prescriptions requiring dosage adjustments based on renal function are inappropriate. This study aimed to determine whether implementing alerts at the time of ordering medication integrated into the computerized physician order entry decreases the proportion of inappropriate prescriptions based on the renal function of inpatients.
Six alternating 2-month control and intervention periods were conducted between August 2006 and August 2007 in two medical departments of a teaching hospital in France. A total of 603 patients and 38 physicians were included. During the intervention periods, alerts were triggered if a patient with renal impairment was prescribed one of the 24 targeted drugs that required adjustment according to estimated glomerular filtration rate (eGFR).
The main outcome measure was the proportion of inappropriate first prescriptions, according to recommendation.
A total of 1,122 alerts were triggered. The rate of inappropriate first prescriptions did not differ significantly between intervention and control periods (19.9% vs. 21.3%; p=0.63). The effect of intervention differed significantly between residents and senior physicians (p=0.03). Residents tended to make fewer errors in intervention versus control periods (Odds ratio 0.69; 95% confidence interval 0.41 to 1.15), whereas senior physicians tended to make more inappropriate prescriptions in intervention periods (odds ratio 1.88; 95% confidence interval 0.91 to 3.89).
Alert activation was not followed by a significant decrease in inappropriate prescriptions in our study. Thus, it is still necessary to evaluate the impact of these systems if newly implemented in other settings thanks to studies also designed to watch for possible unanticipated effects of decision supports and their underlying causes.

Download full-text


Available from: Elodie Sellier,
  • Source
    • "The significant focus on pharmacotherapy within the included studies may reflect the importance of drug selection within computerized provider order entry (CPOE) systems, which are foundational to CDS in many inpatient settings. 50% [14,16,17,19,22-26,28-30,35-37,41-43],[45,46,48,50,56,58,60,61],[64,66-68,72,73,75,76,80,85],[87,89,90] of the studies overall involved CDS in the context of CPOE, of which 61.5% [16,17,23,24,26,35,37,41],[42,45,48,50,58,60,61,64],[67,68,72,73,76,85,89,90] were focused on pharmacotherapy. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Healthcare costs are increasing rapidly and at an unsustainable rate in many countries, and inpatient hospitalizations are a significant driver of these costs. Clinical decision support (CDS) represents a promising approach to not only improve care but to reduce costs in the inpatient setting. The purpose of this study was to systematically review trials of CDS interventions with the potential to reduce inpatient costs, so as to identify promising interventions for more widespread implementation and to inform future research in this area. To identify relevant studies, MEDLINE was searched up to July 2013. CDS intervention studies with the potential to reduce inpatient healthcare costs were identified through titles and abstracts, and full text articles were reviewed to make a final determination on inclusion. Relevant characteristics of the studies were extracted and summarized. Following a screening of 7,663 articles, 78 manuscripts were included. 78.2% of studies were controlled before-after studies, and 15.4% were randomized controlled trials. 53.8% of the studies were focused on pharmacotherapy. The majority of manuscripts were published during or after 2008. 70.5% of the studies resulted in statistically and clinically significant improvements in an explicit financial measure or a proxy financial measure. Only 12.8% of the studies directly measured the financial impact of an intervention, whereas the financial impact was inferred in the remainder of studies. Data on cost effectiveness was available for only one study. Significantly more research is required on the impact of clinical decision support on inpatient costs. In particular, there is a remarkable gap in the availability of cost effectiveness studies required by policy makers and decision makers in healthcare systems.
    BMC Medical Informatics and Decision Making 12/2013; 13(1):135. DOI:10.1186/1472-6947-13-135 · 1.83 Impact Factor
  • Source
    • "This correlation would indicate that whether these reactions are of significant clinical importance. Implementing computerized drug dosage checking alerts at the time of ordering, can also be helpful to decrease the inappropriate drug dosing, however further studies are still necessary to assess the impact of these alert systems on clinician’s drug dosing behavior (15). "
    [Show abstract] [Hide abstract]
    ABSTRACT: The purpose of this study was to determine the number of prescribed antibiotics being appropriately adjusted and to assess antibiotics with the highest incorrect dosing based on the patient’s renal function according to distinguished guidelines. The study was conducted at a 446-bed university hospital. One hundred and fifty patients admitted through different wards of the hospital were included in the study. Demographic data were extracted and creatinine clearance was calculated using either Cockcroft-Gault (C&G) or Modification of Diet in Renal Disease (MDRD) formula. In patients with creatinine clearances less than 50 mL/min, antibiotic dosages were compared with guideline dose recommendations to judge whether they were correctly adjusted. Two hundreds and ninety-one instructions (79.9%) of 364 antibiotic prescriptions required dosage adjustment based on the patient’s renal condition. These adjustments were rationally performed in 43.7% and 61.4% of prescriptions, according to the two guidelines used. Ciprofloxacin (29.1% of cases), and vancomycin (33.6% of cases), were the most inappropriate prescribed antibiotics in terms of dose administration. Drug dosing adjustments should be emphasized in patients with renal dysfunction. Failure to do so may lead to higher morbidity and mortality as well as therapeutic costs. Estimating creatinine clearance prior to drug ordering and use of a reliable dosing guideline is highly recommended.
    Iranian journal of pharmaceutical research (IJPR) 03/2012; 11(1):157-61. · 1.07 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: In this paper, we analyze the choice of primary prevention made by individuals who bear a risk of being in bad health and an additive risk (of complications) that occurs after a disease has been diagnosed. By considering a two argument utility (depending on wealth and health), we show that the presence of a well-known (no ambiguity) additive risk of complications induces more investment in primary prevention by a risk-averse agent only if her preferences does not display some cross prudence in wealth (u122 < 0). If there is some ambiguity on the e¤ective probability of complication, an increase in ambiguity aversion increases prevention if the agent is a correlation lover (u12 > 0). We also show that full (partial) insurance can be optimal even if insurance premia are loaded (fair). These results hold with and without prevention and the individuals attitudes toward correlation help explain the impact of ambiguity on the optimal individual decisions.
Show more