A Randomized Trial of Electronic Clinical Reminders to Improve Medication Laboratory Monitoring

Brigham and Women's Hospital, Boston, Massachusetts, United States
Journal of the American Medical Informatics Association (Impact Factor: 3.5). 04/2008; 15(4):424-9. DOI: 10.1197/jamia.M2602
Source: DBLP


Recommendations for routine laboratory monitoring to reduce the risk of adverse medication events are not consistently followed. We evaluated the impact of electronic reminders delivered to primary care physicians on rates of appropriate routine medication laboratory monitoring.
We enrolled 303 primary care physicians caring for 1,922 patients across 20 ambulatory clinics that had at least one overdue routine laboratory test for a given medication between January and June 2004. Clinics were randomized so that physicians received either usual care or electronic reminders at the time of office visits focused on potassium, creatinine, liver function, thyroid function, and therapeutic drug levels.
Primary outcomes were the receipt of recommended laboratory monitoring within 14 days following an outpatient clinic visit. The effect of the intervention was assessed for each reminder after adjusting for clustering within clinics, as well as patient and provider characteristics.
Medication-laboratory monitoring non-compliance ranged from 1.6% (potassium monitoring with potassium-supplement use) to 6.3% (liver function monitoring with HMG CoA Reductase Inhibitor use). Rates of appropriate laboratory monitoring following an outpatient visit ranged from 14% (therapeutic drug levels) to 64% (potassium monitoring with potassium-sparing diuretic use). Reminders for appropriate laboratory monitoring had no impact on rates of receiving appropriate testing for creatinine, potassium, liver function, renal function, or therapeutic drug level monitoring.
We identified high rates of appropriate laboratory monitoring, and electronic reminders did not significantly improve these monitoring rates. Future studies should focus on settings with lower baseline adherence rates and alternate drug-laboratory combinations.

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    • "As presented in Additional file 2, Table S2, the majority of CCDSS systems in our sample were integrated with an EMR (n = 38/61, 62%) [17,18,20,23-26,28,31,32,34,40,42,44-47,49,55,56,58-66,68-70,73,74,77-85,87,89], delivered feedback via a computer display (n = 44/62, 71%) [17,18,20,23-26,28,30-36,38-40,42,44,46-49,51,55-58,60-66,68-71,73-76,80,82-84] at the time of care (n = 53/64, 83%) [16-21,23-26,28,30-35,38,40,42,44,46-51,53,55-58,60-70,72-85,87-89]. A minority of authors reported testing a CCDSS with a graphical user interface (n = 22/25, 88%) [16-18,20,21,23-25,28,30,31,34,38,40,45,46,55,56,58-60,63,65,70,73,75,83], pilot-testing the system before the trial (n = 25/45, 56%) [17-19,24,28,29,31-33,35,38,39,43-45,47,48,55,59,63,66,70-72,74,75,77-79,84], or training users on system use (n = 29/52, 56%) [16,19,21,26,28,29,31,32,34,35,38,43-47,53,56-60,62,64-66,69,75-79,83-85]. "
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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.
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    • "CCDSSs in 80% of trials (28/35) gave advice at the time of care [25-27,30,31,34-37,39-51,54,56-64,66-68]; most were integrated with electronic medical records (82%; 27/33) [15,26,27,30-34,36,37,39,40,42-51,54,56-58,60-64,66-68] and some were integrated with computerized physician order entry (CPOE) systems (26%; 7/27) [31-33,37,50,54,67,68]; 77% (24/31) automatically obtained data needed to trigger recommendations from electronic medical records [15,26,27,30-34,36,37,39,40,45,46,50,51,54,56-58,60-64,66-68], while others relied on practitioners, existing non-prescribing staff, or research staff to enter data. In most trials (61%; 20/33) advice was delivered on a desktop or laptop computer [15,26,27,31,34,36-41,50,51,54,58-63,66-68], but other methods included personal digital assistants, email, or existing staff. Seventy-four percent (26/35) of systems were implemented in primary care [15,25-40,42-45,50-54,58,60-65,67]; 56% (14/25) were pilot tested [25,28-33,36,38,42-45,51,54,62,63,66,67]; and users of 59% (17/29) were trained [25-29,31-33,35,37,39-44,46,51,54,58-60,67]. "
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    ABSTRACT: Underuse and overuse of diagnostic tests have important implications for health outcomes and costs. Decision support technology purports to optimize the use of diagnostic tests in clinical practice. The objective of this review was to assess whether computerized clinical decision support systems (CCDSSs) are effective at improving ordering of tests for diagnosis, monitoring of disease, or monitoring of treatment. The outcome of interest was effect on the diagnostic test-ordering behavior of practitioners. We conducted a decision-maker-researcher partnership systematic review. We searched MEDLINE, EMBASE, Ovid's EBM Reviews database, Inspec, and reference lists for eligible articles published up to January 2010. We included randomized controlled trials comparing the use of CCDSSs to usual practice or non-CCDSS controls in clinical care settings. Trials were eligible if at least one component of the CCDSS gave suggestions for ordering or performing a diagnostic procedure. We considered studies 'positive' if they showed a statistically significant improvement in at least 50% of test ordering outcomes. Thirty-five studies were identified, with significantly higher methodological quality in those published after the year 2000 (p = 0.002). Thirty-three trials reported evaluable data on diagnostic test ordering, and 55% (18/33) of CCDSSs improved testing behavior overall, including 83% (5/6) for diagnosis, 63% (5/8) for treatment monitoring, 35% (6/17) for disease monitoring, and 100% (3/3) for other purposes. Four of the systems explicitly attempted to reduce test ordering rates and all succeeded. Factors of particular interest to decision makers include costs, user satisfaction, and impact on workflow but were rarely investigated or reported. Some CCDSSs can modify practitioner test-ordering behavior. To better inform development and implementation efforts, studies should describe in more detail potentially important factors such as system design, user interface, local context, implementation strategy, and evaluate impact on user satisfaction and workflow, costs, and unintended consequences.
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    • "Three cluster-RCTs [21,32,34] assessed the effect of a CCDSS on multiple drug therapy issues, including TDMD. Matheny et al. [34] showed no effect on overdue laboratory test ordering to assess therapeutic drug levels in primary care. "
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    ABSTRACT: Some drugs have a narrow therapeutic range and require monitoring and dose adjustments to optimize their efficacy and safety. Computerized clinical decision support systems (CCDSSs) may improve the net benefit of these drugs. The objective of this review was to determine if CCDSSs improve processes of care or patient outcomes for therapeutic drug monitoring and dosing. We conducted a decision-maker-researcher partnership systematic review. Studies from our previous review were included, and new studies were sought until January 2010 in MEDLINE, EMBASE, Evidence-Based Medicine Reviews, and Inspec databases. Randomized controlled trials assessing the effect of a CCDSS on process of care or patient outcomes were selected by pairs of independent reviewers. 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. Thirty-three randomized controlled trials were identified, assessing the effect of a CCDSS on management of vitamin K antagonists (14), insulin (6), theophylline/aminophylline (4), aminoglycosides (3), digoxin (2), lidocaine (1), or as part of a multifaceted approach (3). Cluster randomization was rarely used (18%) and CCDSSs were usually stand-alone systems (76%) primarily used by physicians (85%). Overall, 18 of 30 studies (60%) showed an improvement in the process of care and 4 of 19 (21%) an improvement in patient outcomes. All evaluable studies assessing insulin dosing for glycaemic control showed an improvement. In meta-analysis, CCDSSs for vitamin K antagonist dosing significantly improved time in therapeutic range. CCDSSs have potential for improving process of care for therapeutic drug monitoring and dosing, specifically insulin and vitamin K antagonist dosing. However, studies were small and generally of modest quality, and effects on patient outcomes were uncertain, with no convincing benefit in the largest studies. At present, no firm recommendation for specific systems can be given. More potent CCDSSs need to be developed and should be evaluated by independent researchers using cluster randomization and primarily assess patient outcomes related to drug efficacy and safety.
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