Computerized Clinical Decision Support During Medication Ordering for Long-term Care Residents with Renal Insufficiency

Meyers Primary Care Institute, Worcester, MA 01605, USA.
Journal of the American Medical Informatics Association (Impact Factor: 3.5). 05/2009; 16(4):480-5. DOI: 10.1197/jamia.M2981
Source: PubMed


Objective: To determine whether a computerized clinical decision support system providing patient-specific recommendations in real-time improves the quality of prescribing for long-term care residents with renal insufficiency.
Design: Randomized trial within the long-stay units of a large long-term care facility. Randomization was within blocks by unit type. Alerts related to medication prescribing for residents with renal insufficiency were displayed to prescribers in the intervention units and hidden but tracked in control units.
Measurement: The proportions of final drug orders that were appropriate were compared between intervention and control units within alert categories: (1) recommended medication doses; (2) recommended administration frequencies; (3) recommendations to avoid the drug; (4) warnings of missing information.
Results: The rates of alerts were nearly equal in the intervention and control units: 2.5 per 1,000 resident days in the intervention units and 2.4 in the control units. The proportions of dose alerts for which the final drug orders were appropriate were similar between the intervention and control units (relative risk 0.95, 95% confidence interval 0.83, 1.1) for the remaining alert categories significantly higher proportions of final drug orders were appropriate in the intervention units: relative risk 2.4 for maximum frequency (1.4, 4.4); 2.6 for drugs that should be avoided (1.4, 5.0); and 1.8 for alerts to acquire missing information (1.1, 3.4). Overall, final drug orders were appropriate significantly more often in the intervention units—relative risk 1.2 (1.0, 1.4).
Conclusions: Clinical decision support for physicians prescribing medications for long-term care residents with renal insufficiency can improve the quality of prescribing decisions.
Trial Registration: Identifier: NCT00599209

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Available from: Monica Lee, Feb 13, 2014
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    • "Often prescribing physicians do not consider the renal function of the patients, rely on their clinical experience, consult FASS (the Swedish Physicians' Desk Reference) or occasionally take advice from a consultant physician with specific knowledge in the field or from a clinical pharmacologist. Automated CDSS for kidney related drug prescribing has previously shown promise in reducing medication errors and improving the frequency of appropriate dosing in hospital care [18] [19] and can reduce the occurrence of preventable adverse drug effects related to the renal function [20]. Successful CDSS frequently use automated data entry and real time feedback [21]. "
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    ABSTRACT: To develop and verify proof of concept for a clinical decision support system (CDSS) to support prescriptions of pharmaceutical drugs in patients with reduced renal function, integrated in an electronic health record system (EHR) used in both hospitals and primary care. A pilot study in one geriatric clinic, one internal medicine admission ward and two outpatient healthcare centers was evaluated with a questionnaire focusing on the usefulness of the CDSS. The usage of the system was followed in a log. The CDSS is considered to increase the attention on patients with impaired renal function, provides a better understanding of dosing and is time saving. The calculated glomerular filtration rate (eGFR) and the dosing recommendation classification were perceived useful while the recommendation texts and background had been used to a lesser extent. Few previous systems are used in primary care and cover this number of drugs. The global assessment of the CDSS scored high but some elements were used to a limited extent possibly due to accessibility or that texts were considered difficult to absorb. Choosing a formula for the calculation of eGFR in a CDSS may be problematic. A real-time CDSS to support kidney-related drug prescribing in both hospital and outpatient settings is valuable to the physicians. It has the potential to improve quality of drug prescribing by increasing the attention on patients with renal insufficiency and the knowledge of their drug dosing. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
    International Journal of Medical Informatics 02/2015; 84(6). DOI:10.1016/j.ijmedinf.2015.02.005 · 2.00 Impact Factor
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    • "Outpatient settings were studied more often (n = 55, 85%) [16,18-23,26-41,43-47,49-67,69-71,73,75-79,81,83,85-89] than other settings of care. Studies were conducted in both academic settings (n = 34, 52%) [18,23,25,26,28,33-35,38,39,42,46,48,51,55-57,60,61,66,68,71-74,76,80-85,87-89] and outside academic centres (n = 31, 48%) [16,17,19-22,24,27,29-32,36,37,40,41,43-45,47,49,50,52-54,58,59,62-65,67,69,70,75,77-79,86]. "
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    ABSTRACT: Computerized clinical decision support systems (CCDSSs) for drug therapy management are designed to promote safe and effective medication use. Evidence documenting the effectiveness of CCDSSs for improving drug therapy is necessary for informed adoption decisions. The objective of this review was to systematically review randomized controlled trials assessing the effects of CCDSSs for drug therapy management on process of care and patient outcomes. We also sought to identify system and study characteristics that predicted benefit. We conducted a decision-maker-researcher partnership systematic review. We updated our earlier reviews (1998, 2005) by searching MEDLINE, EMBASE, EBM Reviews, Inspec, and other databases, and consulting reference lists through January 2010. Authors of 82% of included studies confirmed or supplemented extracted data. We included only randomized controlled trials that evaluated the effect on process of care or patient outcomes of a CCDSS for drug therapy management compared to care provided without a CCDSS. A study was considered to have a positive effect (i.e., CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive. Sixty-five studies met our inclusion criteria, including 41 new studies since our previous review. Methodological quality was generally high and unchanged with time. CCDSSs improved process of care performance in 37 of the 59 studies assessing this type of outcome (64%, 57% of all studies). Twenty-nine trials assessed patient outcomes, of which six trials (21%, 9% of all trials) reported improvements. CCDSSs inconsistently improved process of care measures and seldomly improved patient outcomes. Lack of clear patient benefit and lack of data on harms and costs preclude a recommendation to adopt CCDSSs for drug therapy management.
    Implementation Science 08/2011; 6(1):89. DOI:10.1186/1748-5908-6-89 · 4.12 Impact Factor
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    • "Care transitions might be better managed with electronic access to information using HIT (Resnick, Manard, Stone, & Alwan, 2009). Further, electronic reminder prompts may improve the responsiveness of provider behavior in nursing homes (Linder et al., 2007; Field et al., 2009). In contrast, HIT intervention might negatively affect time spent on paperwork and documentation; several studies from non-long-term care settings have found mixed results, with some studies actually showing increased documentation time (Poissant et al., 2006; Overhage, Perkins, Tierney, & McDonald, 2001; Tierney, Miller, Overhage, & McDonald, 1993). "
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    ABSTRACT: To examine the effects of electronic health information technology (HIT) on nursing home residents. The study evaluated the impact of implementing a comprehensive HIT system on resident clinical, functional, and quality of care outcome indicators as well as measures of resident awareness of and satisfaction with the technology. The study used a prospective, quasi-experimental design, directly assessing 761 nursing home residents in 10 urban and suburban nursing homes in the greater New York City area. No statistically significant impact of the introduction of HIT on residents was found on any outcomes, with the exception of a significant negative effect on behavioral symptoms. Residents' subjective assessment of the HIT intervention were generally positive. The absence of effects on most indicators is encouraging for the future development of HIT in nursing homes. The single negative finding suggests that further investigation is needed on possible impact on resident behavior.
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