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Hall RK, Kazancıoğlu R, Thanachayanont T, Wong G, Sabanayagam D, Battistella M, Ahmed SB, Inker LA, Barreto EF, Fu EL, Clase CM, Carrero JJ. Drug stewardship in chronic kidney disease to achieve effective and safe medication use. Nat Rev Nephrol 2024; 20:386-401. [PMID: 38491222 DOI: 10.1038/s41581-024-00823-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 03/18/2024]
Abstract
People living with chronic kidney disease (CKD) often experience multimorbidity and require polypharmacy. Kidney dysfunction can also alter the pharmacokinetics and pharmacodynamics of medications, which can modify their risks and benefits; the extent of these changes is not well understood for all situations or medications. The principle of drug stewardship is aimed at maximizing medication safety and effectiveness in a population of patients through a variety of processes including medication reconciliation, medication selection, dose adjustment, monitoring for effectiveness and safety, and discontinuation (deprescribing) when no longer necessary. This Review is aimed at serving as a resource for achieving optimal drug stewardship for patients with CKD. We describe special considerations for medication use during pregnancy and lactation, during acute illness and in patients with cancer, as well as guidance for the responsible use of over-the-counter drugs, herbal remedies, supplements and sick-day rules. We also highlight inequities in medication access worldwide and suggest policies to improve access to quality and essential medications for all persons with CKD. Further strategies to promote drug stewardship include patient education and engagement, the use of digital health tools, shared decision-making and collaboration within interdisciplinary teams. Throughout, we position the person with CKD at the centre of all drug stewardship efforts.
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Affiliation(s)
- Rasheeda K Hall
- Division of Nephrology, Department of Medicine, and Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | | | | | - Sofia B Ahmed
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lesley A Inker
- Division of Nephrology, Department of Internal Medicine, Tufts Medical Center, Boston, MA, USA
| | | | - Edouard L Fu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, USA
| | - Catherine M Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Ontario, Canada
| | - Juan J Carrero
- Medical Epidemiology and Biostatistics, Karolinska Institutet, and Division of Nephrology, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden.
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2
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Stevens PE, Ahmed SB, Carrero JJ, Foster B, Francis A, Hall RK, Herrington WG, Hill G, Inker LA, Kazancıoğlu R, Lamb E, Lin P, Madero M, McIntyre N, Morrow K, Roberts G, Sabanayagam D, Schaeffner E, Shlipak M, Shroff R, Tangri N, Thanachayanont T, Ulasi I, Wong G, Yang CW, Zhang L, Levin A. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int 2024; 105:S117-S314. [PMID: 38490803 DOI: 10.1016/j.kint.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 10/31/2023] [Indexed: 03/17/2024]
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3
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Hamidi S, Kim SJ, Auguste BL. Electronic Alerts in Acute Kidney Injury-More Questions Than Answers. JAMA Netw Open 2024; 7:e2351682. [PMID: 38241052 DOI: 10.1001/jamanetworkopen.2023.51682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2024] Open
Affiliation(s)
- Shabnam Hamidi
- Division of Nephrology, Humber River Hospital, Toronto, Ontario, Canada
| | - S Joseph Kim
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Quality Improvement and Patient Safety, Toronto, Ontario, Canada
| | - Bourne L Auguste
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Quality Improvement and Patient Safety, Toronto, Ontario, Canada
- Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Eckardt KU, Delgado C, Heerspink HJL, Pecoits-Filho R, Ricardo AC, Stengel B, Tonelli M, Cheung M, Jadoul M, Winkelmayer WC, Kramer H. Trends and perspectives for improving quality of chronic kidney disease care: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2023; 104:888-903. [PMID: 37245565 DOI: 10.1016/j.kint.2023.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/11/2023] [Accepted: 05/15/2023] [Indexed: 05/30/2023]
Abstract
Chronic kidney disease (CKD) affects over 850 million people globally, and the need to prevent its development and progression is urgent. During the past decade, new perspectives have arisen related to the quality and precision of care for CKD, owing to the development of new tools and interventions for CKD diagnosis and management. New biomarkers, imaging methods, artificial intelligence techniques, and approaches to organizing and delivering healthcare may help clinicians recognize CKD, determine its etiology, assess the dominant mechanisms at given time points, and identify patients at high risk for progression or related events. As opportunities to apply the concepts of precision medicine for CKD identification and management continue to be developed, an ongoing discussion of the potential implications for care delivery is required. The 2022 KDIGO Controversies Conference on Improving CKD Quality of Care: Trends and Perspectives examined and discussed best practices for improving the precision of CKD diagnosis and prognosis, managing the complications of CKD, enhancing the safety of care, and maximizing patient quality of life. Existing tools and interventions currently available for the diagnosis and treatment of CKD were identified, with discussion of current barriers to their implementation and strategies for improving the quality of care delivered for CKD. Key knowledge gaps and areas for research were also identified.
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Affiliation(s)
- Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Cynthia Delgado
- Division of Nephrology, University of California, San Francisco, San Francisco, California, USA; Nephrology Section, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; The George Institute for Global Health, Sydney, Australia
| | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA; School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil
| | - Ana C Ricardo
- Division of Nephrology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois, USA
| | - Bénédicte Stengel
- CESP, Centre de Recherche en Epidémiologie et Santé des Populations, Clinical Epidemiology Team, INSERM UMRS 1018, University Paris-Saclay, Villejuif, France
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Holly Kramer
- Departments of Public Health Sciences and Medicine, Division of Nephrology and Hypertension, Loyola University Chicago, Maywood, Illinois, USA.
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AlQashqri H. Renally Inappropriate Medications in the Old Population: Prevalence, Risk Factors, Adverse Outcomes, and Potential Interventions. Cureus 2023; 15:e49111. [PMID: 38125263 PMCID: PMC10732268 DOI: 10.7759/cureus.49111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Like most organs, the renal system decreases in function as we age. In the elderly, chronic kidney disease is common. When patients with chronic kidney disease take nephrotoxic medications, they are more likely to suffer adverse drug reactions, be hospitalized, and spend an extended period in the hospital. Calculating the renal clearance of a drug dose based on its glomerular filtration rate, or creatinine clearance, is necessary. Multiple tools are available for identifying renally inappropriate medications (RIMs). RIM prescriptions can be influenced by various factors, which vary according to the study. A higher number of medications means a higher likelihood of using RIMs. Numerous studies have investigated RIMs. The most contraindicated drug in renal insufficiency patients was a non-steroidal anti-inflammatory medication. A variety of interventions have been used to reduce RIM prescriptions to varying degrees of success.
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Affiliation(s)
- Hamsa AlQashqri
- Community and Family Medicine, Umm Al-Qura University, Makkah, SAU
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Yeung AWK, Torkamani A, Butte AJ, Glicksberg BS, Schuller B, Rodriguez B, Ting DSW, Bates D, Schaden E, Peng H, Willschke H, van der Laak J, Car J, Rahimi K, Celi LA, Banach M, Kletecka-Pulker M, Kimberger O, Eils R, Islam SMS, Wong ST, Wong TY, Gao W, Brunak S, Atanasov AG. The promise of digital healthcare technologies. Front Public Health 2023; 11:1196596. [PMID: 37822534 PMCID: PMC10562722 DOI: 10.3389/fpubh.2023.1196596] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 09/04/2023] [Indexed: 10/13/2023] Open
Abstract
Digital health technologies have been in use for many years in a wide spectrum of healthcare scenarios. This narrative review outlines the current use and the future strategies and significance of digital health technologies in modern healthcare applications. It covers the current state of the scientific field (delineating major strengths, limitations, and applications) and envisions the future impact of relevant emerging key technologies. Furthermore, we attempt to provide recommendations for innovative approaches that would accelerate and benefit the research, translation and utilization of digital health technologies.
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Affiliation(s)
- Andy Wai Kan Yeung
- Oral and Maxillofacial Radiology, Applied Oral Sciences and Community Dental Care, Faculty of Dentistry, University of Hong Kong, Hong Kong, China
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
| | - Ali Torkamani
- Department of Integrative Structural and Computational Biology, Scripps Research Translational Institute, La Jolla, CA, United States
| | - Atul J. Butte
- Bakar Computational Health Sciences Institute, University of California, San Francisco, San Francisco, CA, United States
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
| | - Benjamin S. Glicksberg
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Björn Schuller
- Department of Computing, Imperial College London, London, United Kingdom
- Chair of Embedded Intelligence for Health Care and Wellbeing, University of Augsburg, Augsburg, Germany
| | - Blanca Rodriguez
- Department of Computer Science, University of Oxford, Oxford, United Kingdom
| | - Daniel S. W. Ting
- Singapore National Eye Center, Singapore Eye Research Institute, Singapore, Singapore
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - David Bates
- Department of General Internal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Eva Schaden
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Hanchuan Peng
- Institute for Brain and Intelligence, Southeast University, Nanjing, China
| | - Harald Willschke
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Jeroen van der Laak
- Department of Pathology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Josip Car
- Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
- Centre for Population Health Sciences, LKC Medicine, Nanyang Technological University, Singapore, Singapore
| | - Kazem Rahimi
- Deep Medicine Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Leo Anthony Celi
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, United States
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz (MUL), Lodz, Poland
- Department of Cardiology and Adult Congenital Heart Diseases, Polish Mother’s Memorial Hospital Research Institute (PMMHRI), Lodz, Poland
| | - Maria Kletecka-Pulker
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
- Institute for Ethics and Law in Medicine, University of Vienna, Vienna, Austria
| | - Oliver Kimberger
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Roland Eils
- Digital Health Center, Berlin Institute of Health (BIH), Charité – Universitätsmedizin Berlin, Berlin, Germany
| | | | - Stephen T. Wong
- Department of Systems Medicine and Bioengineering, Houston Methodist Cancer Center, T. T. and W. F. Chao Center for BRAIN, Houston Methodist Academic Institute, Houston Methodist Hospital, Houston, TX, United States
- Departments of Radiology, Pathology and Laboratory Medicine and Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, United States
| | - Tien Yin Wong
- Singapore National Eye Center, Singapore Eye Research Institute, Singapore, Singapore
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Tsinghua Medicine, Tsinghua University, Beijing, China
| | - Wei Gao
- Andrew and Peggy Cherng Department of Medical Engineering, California Institute of Technology, Pasadena, CA, United States
| | - Søren Brunak
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Atanas G. Atanasov
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria
- Institute of Genetics and Animal Biotechnology of the Polish Academy of Sciences, Jastrzebiec, Poland
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Sommers S, Tolle H, Napier C, Hoppe J. Targeted messaging to improve the adoption of clinical decision support for prescription drug monitoring program use. J Am Med Inform Assoc 2023; 30:1711-1716. [PMID: 37433582 PMCID: PMC10531197 DOI: 10.1093/jamia/ocad127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/08/2023] [Accepted: 06/30/2023] [Indexed: 07/13/2023] Open
Abstract
Clinical decision support (CDS) can prevent medical errors and improve patient outcomes. Electronic health record (EHR)-based CDS, designed to facilitate prescription drug monitoring program (PDMP) review, has reduced inappropriate opioid prescribing. However, the pooled effectiveness of CDS has exhibited substantial heterogeneity and current literature does not adequately detail why certain CDS are more successful than others. Clinicians regularly override CDS, limiting its impact. No studies recommend how to help nonadopters recognize and recover from CDS misuse. We hypothesized that a targeted educational intervention would improve CDS adoption and effectiveness for nonadopters. Over 10 months, we identified 478 providers consistently overriding CDS (nonadopters) and sent each up to 3 educational message(s) via email or EHR-based chat. One hundred sixty-one (34%) nonadopters stopped consistently overriding CDS and started reviewing the PDMP after contact. We concluded that targeted messaging is a low-resource way to disseminate CDS education and improve CDS adoption and best practice delivery.
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Affiliation(s)
- Stuart Sommers
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Heather Tolle
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Cheryl Napier
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Jason Hoppe
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
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Jhamb M, Weltman MR, Yabes JG, Kamat S, Devaraj SM, Fischer GS, Rollman BL, Nolin TD, Abdel-Kader K. Electronic health record based population health management to optimize care in CKD: Design of the Kidney Coordinated HeAlth Management Partnership (K-CHAMP) trial. Contemp Clin Trials 2023; 131:107269. [PMID: 37348600 PMCID: PMC10529809 DOI: 10.1016/j.cct.2023.107269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 06/06/2023] [Accepted: 06/19/2023] [Indexed: 06/24/2023]
Abstract
Primary care physicians (PCPs) provide the majority of medical care to patients with non-dialysis dependent CKD. However, PCPs report numerous limitations to providing expert CKD care, including poor patient education, inadequate diagnostic evaluation, suboptimal use of medications, and time limitations. The Kidney Coordinated HeAlth Management Partnership (Kidney CHAMP) trial is a cluster randomized controlled trial to evaluate the effectiveness of a novel centralized electronic health records (EHR)-delivered population health management (PHM) strategy for high-risk CKD patients on patient care, safety, and other outcomes of interest to patients, providers, and payors. Over a 42-month period, the trial will compare the effectiveness of a multifaceted intervention that combines early identification of high-risk patients, timely nephrology guidance, pharmacist-led medication management services, and CKD patient education to usual care and enroll 1650 high-risk CKD patients from 100 primary care practices. The primary outcome will be ≥40% decline in estimated glomerular filtration rate (eGFR) or end stage kidney disease. Key secondary outcomes will include blood pressure, renin-angiotensin aldosterone system inhibitors use, and exposure to potentially unsafe medications. If successful, our treatment approach could improve CKD care delivery and safety, resource allocation, and adoption of evidence-based CKD guideline-concordant care.
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Affiliation(s)
- Manisha Jhamb
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
| | - Melanie R Weltman
- Renal-Electrolyte Division, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Jonathan G Yabes
- Center for Research on Heath Care, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Sanjana Kamat
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Susan M Devaraj
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Gary S Fischer
- Department of Medicine and Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Bruce L Rollman
- Center for Research on Heath Care, Division of General Internal Medicine, Department of Medicine and Biostatistics, University of Pittsburgh, Pittsburgh, PA, United States of America; Center for Behavioral Health, Media, and Technology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Thomas D Nolin
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, United States of America
| | - Khaled Abdel-Kader
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
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Li YJ, Chang YL, Chou YC, Hsu CC. Hypoglycemia risk with inappropriate dosing of glucose-lowering drugs in patients with chronic kidney disease: a retrospective cohort study. Sci Rep 2023; 13:6373. [PMID: 37076583 PMCID: PMC10115797 DOI: 10.1038/s41598-023-33542-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 04/14/2023] [Indexed: 04/21/2023] Open
Abstract
The incidence rates and consequences of inappropriate dosing of glucose-lowering drugs remain limited in patients with chronic kidney disease (CKD). A retrospective cohort study was conducted to estimate the frequency of inappropriate dosing of glucose-lowering drugs and to evaluate the subsequent risk of hypoglycemia in outpatients with an estimated glomerular filtration rate (eGFR) of < 50 mL/min/1.73 m2. Outpatient visits were divided according to whether the prescription of glucose-lowering drugs included dose adjustment according to eGFR or not. A total of 89,628 outpatient visits were included, 29.3% of which received inappropriate dosing. The incidence rates of the composite of all hypoglycemia were 76.71 and 48.51 events per 10,000 person-months in the inappropriate dosing group and in appropriate dosing group, respectively. After multivariate adjustment, inappropriate dosing was found to lead to an increased risk of composite of all hypoglycemia (hazard ratio 1.52, 95% confidence interval 1.34, 1.73). In the subgroup analysis, there were no significant changes in the risk of hypoglycemia regardless of renal function (eGFR < 30 vs. 30-50 mL/min/1.73 m2). In conclusion, inappropriate dosing of glucose-lowering drugs in patients with CKD is common and associated with a higher risk of hypoglycemia.
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Affiliation(s)
- Yun-Jhe Li
- Department of Pharmacy, Taipei Veterans General Hospital, No. 201, Sect. 2, Shih-Pai Road, Taipei, 112, Taiwan
- Department of Pharmacy, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan
- Institute of Pharmacology, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yuh-Lih Chang
- Department of Pharmacy, Taipei Veterans General Hospital, No. 201, Sect. 2, Shih-Pai Road, Taipei, 112, Taiwan
- Institute of Pharmacology, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Pharmacy, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yueh-Ching Chou
- Department of Pharmacy, Taipei Veterans General Hospital, No. 201, Sect. 2, Shih-Pai Road, Taipei, 112, Taiwan
- Institute of Pharmacology, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Pharmacy, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-Chen Hsu
- Department of Pharmacy, Taipei Veterans General Hospital, No. 201, Sect. 2, Shih-Pai Road, Taipei, 112, Taiwan.
- Department of Pharmacy, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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10
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Non-steroidal anti-inflammatory drugs in chronic kidney disease and risk of acute adverse kidney events according to route of administration. Int Urol Nephrol 2023; 55:679-686. [PMID: 36065044 DOI: 10.1007/s11255-022-03344-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 08/19/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Topical non-steroidal anti-inflammatory drugs (NSAIDs) have lower risks for cardiovascular disease and gastrointestinal adverse effects compared to oral NSAIDs, but there are little data regarding their kidney risks in chronic kidney disease (CKD). We evaluated the risk of adverse acute kidney outcomes in CKD according to route of NSAID administration. METHODS Retrospective cohort study of adults with CKD (eGFR less than 60 ml/min/1.73 m2) who received prescriptions between 2015 and 2017 from a major healthcare cluster in Singapore. The adverse acute kidney outcomes were acute kidney injury (AKI) and need for nephrology specialist consult within 30 days. RESULTS Among 6298 adults with CKD (mean age 72.1 ± 13.3 years and eGFR 41.9 ± 12.2 ml/min/1.73 m2), systemic and topical NSAIDs were prescribed in 16.7% and 32.0%, respectively. Incident AKI (any severity), KDIGO Stage 2 or 3 AKI, and need for nephrology specialist consult occurred in 16.7%, 2.6%, and 10.6% of the study cohort, respectively. After adjusting for age, diabetes, recent cardiovascular hospitalization, baseline eGFR, RAAS blocker and diuretic, systemic NSAIDs, and topical NSAIDs, compared with the no-NSAID group, were independently associated with incident AKI [adjusted OR 1.77 (95% CI 1.46-2.15) and 1.38 (1.18-1.63), respectively]. Moderate and severe AKI (adjusted OR 1.68, 95% CI 1.09-2.58, p = 0.02) and need for nephrology consults (adjusted OR 1.41, 95% CI 1.09-1.82, p = 0.008) were also increased in systemic NSAIDs. CONCLUSION Among adults with CKD, both systemic and topical NSAIDs were independently associated with acute adverse kidney outcomes.
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11
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Atia J, Evison F, Gallier S, Pettler S, Garrick M, Ball S, Lester W, Morton S, Coleman J, Pankhurst T. Effectiveness of clinical decision support in controlling inappropriate red blood cell and platelet transfusions, speciality specific responses and behavioural change. BMC Med Inform Decis Mak 2022; 22:342. [PMID: 36581868 PMCID: PMC9798655 DOI: 10.1186/s12911-022-02045-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 10/10/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Electronic clinical decision support (CDS) within Electronic Health Records has been used to improve patient safety, including reducing unnecessary blood product transfusions. We assessed the effectiveness of CDS in controlling inappropriate red blood cell (RBC) and platelet transfusion in a large acute hospital and how speciality specific behaviours changed in response. METHODS We used segmented linear regression of interrupted time series models to analyse the instantaneous and long term effect of introducing blood product electronic warnings to prescribers. We studied the impact on transfusions for patients in critical care (CC), haematology/oncology (HO) and elsewhere. RESULTS In non-CC or HO, there was significant and sustained decrease in the numbers of RBC transfusions after introduction of alerts. In CC the alerts reduced transfusions but this was not sustained, and in HO there was no impact on RBC transfusion. For platelet transfusions outside of CC and HO, the introduction of alerts stopped a rising trend of administration of platelets above recommended targets. In CC, alerts reduced platelet transfusions, but in HO alerts had little impact on clinician prescribing. CONCLUSION The findings suggest that CDS can result in immediate change in user behaviour which is more obvious outside specialist settings of CC and HO. It is important that this is then sustained. In CC and HO, blood transfusion practices differ. CDS thus needs to take specific circumstances into account. In this case there are acceptable reasons to transfuse outside of these crude targets and CDS should take these into account.
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Affiliation(s)
- Jolene Atia
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK ,grid.412563.70000 0004 0376 6589Department of Health Informatics, University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK
| | - Felicity Evison
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK ,grid.412563.70000 0004 0376 6589Department of Health Informatics, University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK
| | - Suzy Gallier
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK ,grid.6572.60000 0004 1936 7486PIONEER: HDR-UK Health Data Research Hub for Acute Care, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2GW UK
| | - Sophie Pettler
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK ,grid.6572.60000 0004 1936 7486School of Medicine, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
| | - Mark Garrick
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK
| | - Simon Ball
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK ,grid.6572.60000 0004 1936 7486HDRUK Better Care Science Priority and Health Data Research UK Midlands, University of Birmingham, Birmingham, UK
| | - Will Lester
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK
| | - Suzanne Morton
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK ,grid.436365.10000 0000 8685 6563NHS Blood and Transplant, Vincent Drive, Edgbaston, Birmingham, B15 2SG UK
| | - Jamie Coleman
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK ,grid.6572.60000 0004 1936 7486School of Medicine, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
| | - Tanya Pankhurst
- grid.412563.70000 0004 0376 6589University Hospital Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW UK
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Gao L, Xu M, Zhao W, Zou T, Wang F, Da J, Wang Y, Wang L. Ultrathin, elastic, and self-adhesive nanofiber bio-tape: An intraoperative drug-loading module for ureteral stents with localized and controlled drug delivery properties for customized therapy. Bioact Mater 2022; 18:128-137. [PMID: 35387174 PMCID: PMC8961457 DOI: 10.1016/j.bioactmat.2022.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/14/2022] [Accepted: 03/15/2022] [Indexed: 12/03/2022] Open
Abstract
During the postoperative management of urinary diseases, oral or intravenous administration of drugs and implanting ureteral stents are usually required, making localized drug delivery by ureteral stent a precise and effective medication strategy. In the traditional drug loading method, the drug was premixed in the implants in production lines and the versatility of drugs was restricted. However, the complex situation in the urinary system fails the possibility of finding a “one fits all” medication plan, and the intraoperative drug-loading of implants is highly desired to support customized therapy. Here, we designed an ultrathin (8 μm), elastic, and self-adhesive nanofiber bio-tape (NFBT) that can easily encapsulate drugs on the stent surface for controllable localized drug delivery. The NFBT exhibited high binding strength to a ureteral stent, a sustained release over 7 d in PBS for hydrophilic drug, and a zero-order release curve over 28 days for the hydrophobic drug nitrofurantoin (NFT). Further in vivo experiments using a porcine ureteral tract infection model demonstrated that NFBT loaded with NFT could significantly reduce the bacterial concentration in urine. The total amount of NFT delivered by the NFBT was about 2.68 wt% of the recommended dose for the systemic administration. An intra operation drug-loading strategy and drug carrier for personalized post-operation management of urinary disease. The NFBT is ultrathin (∼8 μm) with enough binding stress to resist displacement bought by ureteral peristalsis. In vivo antibacterial rate >99.9% for 28 d (porcine UTI model), with 2.68 wt% of the systemically administration dosage.
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Sempionatto JR, Lasalde-Ramírez JA, Mahato K, Wang J, Gao W. Wearable chemical sensors for biomarker discovery in the omics era. Nat Rev Chem 2022; 6:899-915. [PMID: 37117704 DOI: 10.1038/s41570-022-00439-w] [Citation(s) in RCA: 93] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2022] [Indexed: 11/16/2022]
Abstract
Biomarkers are crucial biological indicators in medical diagnostics and therapy. However, the process of biomarker discovery and validation is hindered by a lack of standardized protocols for analytical studies, storage and sample collection. Wearable chemical sensors provide a real-time, non-invasive alternative to typical laboratory blood analysis, and are an effective tool for exploring novel biomarkers in alternative body fluids, such as sweat, saliva, tears and interstitial fluid. These devices may enable remote at-home personalized health monitoring and substantially reduce the healthcare costs. This Review introduces criteria, strategies and technologies involved in biomarker discovery using wearable chemical sensors. Electrochemical and optical detection techniques are discussed, along with the materials and system-level considerations for wearable chemical sensors. Lastly, this Review describes how the large sets of temporal data collected by wearable sensors, coupled with modern data analysis approaches, would open the door for discovering new biomarkers towards precision medicine.
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Sonoda A, Kondo Y, Iwashita Y, Nakao S, Ishida K, Irie T, Ishitsuka Y. In-Hospital Prescription Checking System for Hospitalized Patients with Decreased Glomerular Filtration Rate. KIDNEY360 2022; 3:1730-1737. [PMID: 36514725 PMCID: PMC9717669 DOI: 10.34067/kid.0001552022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 07/08/2022] [Indexed: 01/12/2023]
Abstract
Background Clinical decision support systems (CDSS) are reported to be useful in preventing dosage errors in renally excreted drugs by alerting hospital pharmacists to inadequate dosages for hospitalized patients with decreased GFR. However, it is unclear whether CDSS can reduce dosage errors in renally excreted drugs in hospitalized patients. To prevent dosage errors in renally excreted drugs, we introduced a prescription checking system (PCS) for in-hospital prescriptions. This retrospective study aimed to evaluate whether a prescription audit by hospital pharmacists using the PCS reduced the rate of dosage errors in renally excreted drugs. Methods The target drugs were allopurinol, cibenzoline, famotidine, and pilsicainide. Interrupted time series analysis was used to evaluate trends in the 4-weekly dosage error rates over 52 weeks before PCS implementation and 52 weeks after PCS implementation. Results Before and after PCS implementation, 474 and 331 prescriptions containing one of the targeted drugs, respectively, were generated. The estimated baseline level of the 4-weekly dosage error rates was 34%. The trend before the PCS implementation was stable with no observable trend. The estimated level change from the last point in the pre-PCS implementation to the first point in the PCS implementation was -20% (P<0.001). There was no change in the trend after PCS implementation. Conclusions We demonstrated that a prescription audit by hospital pharmacists using the PCS reduced the rate of dosage errors in the target renally excreted drugs in hospitalized patients. Although further studies are needed to confirm whether our results can be generalized to other health facilities, our findings highlight the need for a PCS to prevent the overdose of renally excreted drugs.
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Affiliation(s)
- Akihiro Sonoda
- Department of Pharmacy, Izumi Regional Medical Center, Akune, Japan
| | - Yuki Kondo
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | | | - Shoji Nakao
- Department of Pharmacy, Izumi Regional Medical Center, Akune, Japan
| | - Kazuhisa Ishida
- Department of Pharmacy, Izumi Regional Medical Center, Akune, Japan
| | - Tetsumi Irie
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan,Department of Pharmaceutical Packaging Technology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yoichi Ishitsuka
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
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Chen RI, Kuo BL, Kalur A, Muste JC, Deal C, Singh RP. Impact of an Electronic Decision Support Tool to Improve Ophthalmic Safety in Hydroxychloroquine Prescribing Practices. Ophthalmic Surg Lasers Imaging Retina 2022; 53:310-316. [PMID: 35724373 DOI: 10.3928/23258160-20220601-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE The purpose of this study was to implement a clinical decision support tool (CDS) and assess its impact on adherence to 2016 American Academy of Ophthalmology (AAO) hydroxychloroquine dosing recommendations. PATIENTS AND METHODS This retrospective, interventional study implemented an automated alert to calculate maximum daily hydroxychloroquine dose based on 2016 AAO recommendations and flag noncompliant orders. Prevalence of excessive dosing after CDS implementation was assessed. RESULTS A total of 7,417 patients met inclusion criteria. After intervention, prevalence of excessive dosing decreased from 27.4% to 21.1% (P < .001) among all prescriptions and from 26.8% to 16.2% (P < .001) among new prescriptions. Daily doses exceeding 400 mg decreased from 0.8% to 0.02% (P < .001). Risk factors for excessive dosing included low weight (odds ratio, 75.6 [95% CI, 54.0 to 105.8]) and nonrheumatologist prescriber (odds ratio, 1.60 to 3.63; all P < .005). CONCLUSIONS This study highlights the efficacy of a CDS in reducing excessive hydroxychloroquine dosing and improving adherence to AAO ophthalmic safety guidelines. [Ophthalmic Surg Lasers Imaging 2022;53:310-316.].
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Kumar M, Sahni N, Shafiq N, Yaddanapudi LN. Medication Prescription Errors in the Intensive Care Unit: Prospective Observational Study. Indian J Crit Care Med 2022; 26:555-559. [PMID: 35719459 PMCID: PMC9160616 DOI: 10.5005/jp-journals-10071-24148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction The WHO launched a 5-year global initiative to address the problem of medication errors on March 29, 2017, targeting a decrease in severe and avoidable medication-related harm by 50% in all the countries. Since prescription errors are preventable, this study was conducted to determine incidence and severity of medication prescription errors (MPEs). Settings and design Intensive care unit of a tertiary care academic hospital, prospective observational study. Methods and materials For all patients admitted in a medical ICU, baseline data (demographic, APACHE II, length of ICU stay, and days of mechanical ventilation) were noted. Treatment charts were reviewed daily, and each prescription was compared against a master chart prepared using standardized references to study the incidence of prescription errors. Severity classification was done using National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) classification. Mean and median, along with standard deviation and interquartile range, were calculated for all quantitative variables. Multivariate linear regression analysis model was used. Results Out of the total 24,572 medication orders, 2,624 had prescription errors, an error rate of 10.7% (95% CI, 10.3–11.1). When analyzed for severity, 1,757 (7.15%) (95% CI, 6.8–7.5) MPEs did not result in patient harm and 867 (3.52%) (95% CI, 3.3–3.8) MPEs required interventions and/or resulted in patient harm. Patients with deranged creatinine (p <0.001) and INR (p = 0.024) had higher number of severe MPEs. Conclusion The incidence of MPEs in the medical ICU at the tertiary care hospital was 10.7%, 3.52% being severe errors. How to cite this article Kumar M, Sahni N, Shafiq N, Yaddanapudi LN. Medication Prescription Errors in the Intensive Care Unit: Prospective Observational Study. Indian J Crit Care Med 2022;26(5):555–559.
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Affiliation(s)
- Mandeep Kumar
- Department of Anaesthesiology and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neeru Sahni
- Department of Anaesthesiology and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
- Neeru Sahni, Department of Anaesthesiology and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India, Phone: +91 9872646106, e-mail:
| | - Nusrat Shafiq
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Lakshmi Narayana Yaddanapudi
- Department of Anaesthesiology and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Li YJ, Lee WS, Chang YL, Chou YC, Chiu YC, Hsu CC. Impact of a Clinical Decision Support System on Inappropriate Prescription of Glucose-Lowering Agents for Patients With Renal Insufficiency in an Ambulatory Care Setting. Clin Ther 2022; 44:710-722. [DOI: 10.1016/j.clinthera.2022.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/03/2022] [Accepted: 03/05/2022] [Indexed: 11/03/2022]
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Martin L, Peine A, Gronholz M, Marx G, Bickenbach J. [Artificial Intelligence: Challenges and Applications in Intensive Care Medicine]. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:199-209. [PMID: 35320842 DOI: 10.1055/a-1423-8006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The high workload in intensive care medicine arises from the exponential growth of medical knowledge, the flood of data generated by the permanent and intensive monitoring of intensive care patients, and the documentation burden. Artificial intelligence (AI) is predicted to have a great impact on ICU work in the near future as it will be applicable in many areas of critical care medicine. These applications include documentation through speech recognition, predictions for decision support, algorithms for parameter optimisation and the development of personalised intensive care medicine. AI-based decision support systems can augment human therapy decisions. Primarily through machine learning, a sub-discipline of AI, self-adaptive algorithms can learn to recognise patterns and make predictions. For actual use in clinical settings, the explainability of such systems is a prerequisite. Intensive care staff spends a large amount of their working hours on documentation, which has increased up to 50% of work time with the introduction of PDMS. Speech recognition has the potential to reduce this documentation burden. It is not yet precise enough to be usable in the clinic. The application of AI in medicine, with the help of large data sets, promises to identify diagnoses more quickly, develop individualised, precise treatments, support therapeutic decisions, use resources with maximum effectiveness and thus optimise the patient experience in the near future.
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Kuo YC, Cheng SH, Chiu HC. Advanced Medication Alert System Decreased Hospital-Based Outpatient Duplicated Medications: A Longitudinal Hospital Cohort Study. J Patient Saf 2022; 18:124-129. [PMID: 35188926 DOI: 10.1097/pts.0000000000000824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This study aimed to examine the associations between adoption of an advanced medication alert system and decreases in hospital-based outpatient duplicated medication rates in Taiwan. METHODS The unit of analysis was the hospital. We merged the hospital medication alert system adoption survey data and Taiwan National Health Insurance outpatient claims data. The observation time was 1998 to 2011, divided into 5 periods (T1-T5). The analysis included 216 hospitals, and outcome variable was hospital-based outpatient duplicated medication rates. The system adoption time frame, hospital accreditation level, and number of drugs per prescription were defined as predicted variables. A generalized estimating equation regression model was used. RESULTS Adoption of the advanced medication alert system gradually increased, such that 100% of medical centers and 84% of regional hospitals, but less than 50% of district hospitals, had systems by T5. The hospital-based outpatient duplicated medication rate continually decreased, from 29.8% to 11.2%. The generalized estimating equation model showed rates of duplicated medications of b = -8.44 at T2 and b = -17.88 at T5 (P < 0.001) compared with T1. Medical centers and regional hospitals demonstrated much lower duplication rates (b = -13.71, b = -6.82; P < 0.001) compared with district hospitals. Hospitals with more medications per prescription had higher duplication rates than did hospitals with fewer items. CONCLUSIONS Hospitals accredited at higher levels tended to have advanced medication alert systems. Hospitals that implemented advanced systems decreased hospital-based outpatient duplicated medications, avoiding a potential risk due to inappropriate medication use.
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Affiliation(s)
- Yu-Chun Kuo
- From the Health Research Institute, Fujian Medical University, Fuzhou, Fujian, China
| | - Shou-Hsia Cheng
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
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20
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Mehta SJ, Torgersen J, Small DS, Mallozzi CP, McGreevey JD, Rareshide CA, Evans CN, Epps M, Stabile D, Snider CK, Patel MS. Effect of a Default Order vs an Alert in the Electronic Health Record on Hepatitis C Virus Screening Among Hospitalized Patients: A Stepped-Wedge Randomized Clinical Trial. JAMA Netw Open 2022; 5:e222427. [PMID: 35297973 PMCID: PMC8931559 DOI: 10.1001/jamanetworkopen.2022.2427] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
IMPORTANCE Hepatitis C virus (HCV) screening has been recommended for patients born between 1945 and 1965, but rates remain low. OBJECTIVE To evaluate whether a default order within the admission order set increases HCV screening compared with a preexisting alert within the electronic health record. DESIGN, SETTING, AND PARTICIPANTS This stepped-wedge randomized clinical trial was conducted from June 23, 2020, to April 10, 2021, at 2 hospitals within an academic medical center. Hospitalized patients born between 1945 and 1965 with no history of screening were included in the analysis. INTERVENTIONS During wedge 1 (a preintervention period), both hospital sites had an electronic alert prompting clinicians to consider HCV screening. During wedge 2, the first intervention wedge, the hospital site randomized to intervention (hospital B) had a default order for HCV screening implemented within the admission order set. During wedge 3, the second intervention wedge, the hospital site randomized to control (hospital A) had the default order set implemented. MAIN OUTCOMES AND MEASURES Percentage of eligible patients who received HCV screening during the hospital stay. RESULTS The study included 7634 patients (4405 in the control group and 3229 in the intervention group). The mean (SD) age was 65.4 (5.8) years; 4246 patients (55.6%) were men; 2142 (28.1%) were Black and 4625 (60.6%) were White; and 2885 (37.8%) had commercial insurance and 3950 (51.7%) had Medicare. The baseline rate of HCV screening in wedge 1 was 585 of 1560 patients (37.5% [95% CI, 35.1%-40.0%]) in hospital A and 309 of 1003 patients (30.8% [95% CI, 27.9%-33.7%]) in hospital B. The main adjusted model showed an increase of 31.8 (95% CI, 29.7-33.8) percentage points in test completion in the intervention group compared with the control group (P <. 001). CONCLUSIONS AND RELEVANCE This stepped-wedge randomized clinical trial found that embedding HCV screening as a default order in the electronic health record substantially increased ordering and completion of testing in the hospital compared with a conventional interruptive alert. TRIAL REGISTRATION Clinicaltrials.gov: NCT04525690.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Jessie Torgersen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Dylan S. Small
- The Wharton School, University of Pennsylvania, Philadelphia
| | - Colleen P. Mallozzi
- University of Pennsylvania Health System, University of Pennsylvania, Philadelphia
- Center for Applied Health Informatics, University of Pennsylvania Health System, Philadelphia
| | - John D. McGreevey
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- University of Pennsylvania Health System, University of Pennsylvania, Philadelphia
- Center for Applied Health Informatics, University of Pennsylvania Health System, Philadelphia
| | - Charles A.L. Rareshide
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia
| | - Chalanda N. Evans
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia
| | - Mika Epps
- University of Pennsylvania Health System, University of Pennsylvania, Philadelphia
| | - David Stabile
- University of Pennsylvania Health System, University of Pennsylvania, Philadelphia
| | - Christopher K. Snider
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia
| | - Mitesh S. Patel
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- The Wharton School, University of Pennsylvania, Philadelphia
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia
- Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Ascension Health, St Louis, Missouri
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21
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Bosi A, Xu Y, Gasparini A, Wettermark B, Barany P, Bellocco R, Inker LA, Chang AR, McAdams-DeMarco M, Grams ME, Shin JI, Carrero JJ. Use of nephrotoxic medications in adults with chronic kidney disease in Swedish and US routine care. Clin Kidney J 2021; 15:442-451. [PMID: 35296039 PMCID: PMC8922703 DOI: 10.1093/ckj/sfab210] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Indexed: 12/16/2022] Open
Abstract
Background To characterize the use of nephrotoxic medications in patients with chronic kidney
disease (CKD) Stages G3–5 in routine care. Methods We studied cohorts of adults with confirmed CKD G3–5 undergoing routine care
from 1 January 2016 through 31 December 2018 in two health systems [Stockholm
CREAtinine Measurements (SCREAM), Stockholm, Sweden
(N = 57 880) and Geisinger, PA, USA
(N = 16 255)]. We evaluated the
proportion of patients receiving nephrotoxic medications within 1 year overall and by
baseline kidney function, ranked main contributors and examined the association between
receipt of nephrotoxic medication and age, sex, CKD G-stages comorbidities and provider
awareness of the patient's CKD using multivariable logistic regression. Results During a 1-year period, 20% (SCREAM) and 17% (Geisinger) of patients with
CKD received at least one nephrotoxic medication. Among the top nephrotoxic medications
identified in both cohorts were non-steroidal anti-inflammatory drugs (given to
11% and 9% of patients in SCREAM and Geisinger, respectively), antivirals
(2.5% and 2.0%) and immunosuppressants (2.7% and 1.5%).
Bisphosphonate use was common in SCREAM (3.3%) and fenofibrates in Geisinger
(3.6%). Patients <65 years of age, women and those with CKD G3 were
at higher risk of receiving nephrotoxic medications in both cohorts. Notably, provider
awareness of a patient's CKD was associated with lower odds of nephrotoxic
medication use {odds ratios [OR] 0.85[95% confidence
interval (CI) 0.80–0.90] in SCREAM and OR 0.80 [95% CI
0.72–0.89] in Geisinger}. Conclusions One in five patients with CKD received nephrotoxic medications in two distinct health
systems. Strategies to increase physician's awareness of patients’ CKD and
knowledge of drug nephrotoxicity may reduce prescribing nephrotoxic medications and
prevent iatrogenic kidney injury.
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Affiliation(s)
- Alessandro Bosi
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Yunwen Xu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alessandro Gasparini
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Björn Wettermark
- Department of Pharmacy, Disciplinary Domain of Medicine and Pharmacy, Uppsala University, Uppsala, Sweden
| | - Peter Barany
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Rino Bellocco
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Lesley A Inker
- Division of Nephrology, Department of Internal Medicine, Tufts Medical Center, Boston, MA, USA
| | - Alex R Chang
- Division of Nephrology, Geisinger Health System, Danville, PA, USA
| | - Mara McAdams-DeMarco
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jung-Im Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
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22
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Chew CKT, Hogan H, Jani Y. Scoping review exploring the impact of digital systems on processes and outcomes in the care management of acute kidney injury and progress towards establishing learning healthcare systems. BMJ Health Care Inform 2021; 28:e100345. [PMID: 34233898 PMCID: PMC8264899 DOI: 10.1136/bmjhci-2021-100345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/08/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Digital systems have long been used to improve the quality and safety of care when managing acute kidney injury (AKI). The availability of digitised clinical data can also turn organisations and their networks into learning healthcare systems (LHSs) if used across all levels of health and care. This review explores the impact of digital systems i.e. on patients with AKI care, to gauge progress towards establishing LHSs and to identify existing gaps in the research. METHODS Embase, PubMed, MEDLINE, Cochrane, Scopus and Web of Science databases were searched. Studies of real-time or near real-time digital AKI management systems which reported process and outcome measures were included. RESULTS Thematic analysis of 43 studies showed that most interventions used real-time serum creatinine levels to trigger responses to enable risk prediction, early recognition of AKI or harm prevention by individual clinicians (micro level) or specialist teams (meso level). Interventions at system (macro level) were rare. There was limited evidence of change in outcomes. DISCUSSION While the benefits of real-time digital clinical data at micro level for AKI management have been evident for some time, their application at meso and macro levels is emergent therefore limiting progress towards establishing LHSs. Lack of progress is due to digital maturity, system design, human factors and policy levers. CONCLUSION Future approaches need to harness the potential of interoperability, data analytical advances and include multiple stakeholder perspectives to develop effective digital LHSs in order to gain benefits across the system.
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Affiliation(s)
- Clair Ka Tze Chew
- Transformation and Innovation Team, University College London Hospitals NHS Foundation Trust, London, UK
| | - Helen Hogan
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Yogini Jani
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
- UCL School of Pharmacy, University College London, London, UK
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Hirsch JS, Brar R, Forrer C, Sung C, Roycroft R, Seelamneni P, Dabir H, Naseer A, Gautam-Goyal P, Bock KR, Oppenheim MI. Design, development, and deployment of an indication- and kidney function-based decision support tool to optimize treatment and reduce medication dosing errors. JAMIA Open 2021; 4:ooab039. [PMID: 34222830 PMCID: PMC8242134 DOI: 10.1093/jamiaopen/ooab039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/13/2021] [Accepted: 04/26/2021] [Indexed: 11/19/2022] Open
Abstract
Delivering clinical decision support (CDS) at the point of care has long been considered a major advantage of computerized physician order entry (CPOE). Despite the widespread implementation of CPOE, medication ordering errors and associated adverse events still occur at an unacceptable level. Previous attempts at indication- and kidney function-based dosing have mostly employed intrusive CDS, including interruptive alerts with poor usability. This descriptive work describes the design, development, and deployment of the Adult Dosing Methodology (ADM) module, a novel CDS tool that provides indication- and kidney-based dosing at the time of order entry. Inclusion of several antimicrobials in the initial set of medications allowed for the additional goal of optimizing therapy duration for appropriate antimicrobial stewardship. The CDS aims to decrease order entry errors and burden on providers by offering automatic dose and frequency recommendations, integration within the native electronic health record, and reasonable knowledge maintenance requirements. Following implementation, early utilization demonstrated high acceptance of automated recommendations, with up to 96% of provided automated recommendations accepted by users.
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Affiliation(s)
- Jamie S Hirsch
- Department of Information Services, Northwell Health, New Hyde Park, New York, USA.,Division of Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA.,Center for Health Innovations and Outcomes Research, Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Rajdeep Brar
- Department of Information Services, Northwell Health, New Hyde Park, New York, USA
| | - Christopher Forrer
- Department of Information Services, Northwell Health, New Hyde Park, New York, USA
| | - Christine Sung
- Department of Information Services, Northwell Health, New Hyde Park, New York, USA
| | - Richard Roycroft
- Department of Information Services, Northwell Health, New Hyde Park, New York, USA
| | - Pradeep Seelamneni
- Department of Information Services, Northwell Health, New Hyde Park, New York, USA
| | - Hemala Dabir
- Department of Information Services, Northwell Health, New Hyde Park, New York, USA
| | - Ambareen Naseer
- Department of Information Services, Northwell Health, New Hyde Park, New York, USA
| | - Pranisha Gautam-Goyal
- Division of Infectious Diseases, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Kevin R Bock
- Department of Information Services, Northwell Health, New Hyde Park, New York, USA.,Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Michael I Oppenheim
- Department of Information Services, Northwell Health, New Hyde Park, New York, USA.,Division of Infectious Diseases, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
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24
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Shah SN, Amato MG, Garlo KG, Seger DL, Bates DW. Renal medication-related clinical decision support (CDS) alerts and overrides in the inpatient setting following implementation of a commercial electronic health record: implications for designing more effective alerts. J Am Med Inform Assoc 2021; 28:1081-1087. [PMID: 33517413 PMCID: PMC8661393 DOI: 10.1093/jamia/ocaa222] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 09/04/2020] [Indexed: 11/12/2022] Open
Abstract
Objective To assess the appropriateness of medication-related clinical decision support (CDS) alerts associated with renal insufficiency and the potential/actual harm from overriding the alerts. Materials and Methods Override rate frequency was recorded for all inpatients who had a renal CDS alert trigger between 05/2017 and 04/2018. Two random samples of 300 for each of 2 types of medication-related CDS alerts associated with renal insufficiency—“dose change” and “avoid medication”—were evaluated by 2 independent reviewers using predetermined criteria for appropriateness of alert trigger, appropriateness of override, and patient harm. Results We identified 37 100 “dose change” and 5095 “avoid medication” alerts in the population evaluated, and 100% of each were overridden. Dose change triggers were classified as 12.5% appropriate and overrides of these alerts classified as 90.5% appropriate. Avoid medication triggers were classified as 29.6% appropriate and overrides 76.5% appropriate. We identified 5 adverse drug events, and, of these, 4 of the 5 were due to inappropriately overridden alerts. Conclusion Alerts were nearly always presented inappropriately and were all overridden during the 1-year period studied. Alert fatigue resulting from receiving too many poor-quality alerts may result in failure to recognize errors that could lead to patient harm. Although medication-related CDS alerts associated with renal insufficiency had previously been found to be the most clinically beneficial alerts in a legacy system, in this system they were ineffective. These findings underscore the need for improvements in alert design, implementation, and monitoring of alert performance to make alerts more patient-specific and clinically appropriate.
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Affiliation(s)
- Sonam N Shah
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,MCPHS University, Boston, Massachusetts, USA
| | - Mary G Amato
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,MCPHS University, Boston, Massachusetts, USA
| | - Katherine G Garlo
- Division of Nephrology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Diane L Seger
- Clinical and Quality Analysis, Partners HealthCare, Somerville, Massachusetts, USA
| | - David W Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Clinical and Quality Analysis, Partners HealthCare, Somerville, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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25
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Daniel JW, Kramer J, Burgess LH. Assessment of Oral Anticoagulant Adverse Drug Events Before and After Implementation of a Real-Time Clinical Surveillance Tool. J Patient Saf 2021; 17:e350-e354. [PMID: 31045622 DOI: 10.1097/pts.0000000000000607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to determine the effect on occurrence of oral anticoagulant adverse drug events (ADEs) after implementation of a real-time clinical surveillance tool in a large health system. METHODS Records of patients receiving an oral anticoagulant during a 6-month period before and after implementation of a real-time clinical surveillance tool were reviewed for 31 hospitals within a nationwide health system. The real-time clinical surveillance tool analyzed clinical data from the electronic medical record and alerted the pharmacist of potential opportunities for patient clinical intervention. Oral anticoagulant administration data, International Classification of Diseases, Ninth Edition code documentation of ADEs caused by oral anticoagulants, and alert notification data from the real-time clinical surveillance tool were evaluated. RESULTS A total of 56,761 patients were included in the study. The oral anticoagulant ADE ratio decreased from 0.69% during the period before implementation of the real-time clinical surveillance tool to 0.41% during the period after implementation (P < 0.001). Most alert notifications and greatest impact on ADE ratio occurred in patients administered a single oral anticoagulant during hospitalization. CONCLUSIONS Implementation of a real-time clinical surveillance tool prompting pharmacist intervention reduced the oral anticoagulant ADE ratio for the health system.
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Affiliation(s)
| | - Joan Kramer
- Clinical Services Group, HCA Healthcare, Nashville, Tennessee
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26
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Kane-Gill SL, Barreto EF, Bihorac A, Kellum JA. Development of a Theory-Informed Behavior Change Intervention to Reduce Inappropriate Prescribing of Nephrotoxins and Renally Eliminated Drugs. Ann Pharmacother 2021; 55:1474-1485. [PMID: 33855858 DOI: 10.1177/10600280211009567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Goals of managing patients with acute kidney injury (AKI) are mitigating disease progression and ensuring safety while providing supportive care because no effective treatment exists. One strategy recommended in guidelines to meet these goals is optimizing medication management. Unfortunately, guideline implementation appears to be lacking as observed by the frequent occurrence of medication errors and adverse drug events. OBJECTIVE To address this performance gap in the care of hospitalized patients receiving nephrotoxins and renally eliminated drugs, we sought to provide a potential intervention based on theory-informed behavior change. METHODS Formative research with a qualitative analysis identifying what needs to change in patient care was completed by obtaining clinician opinion and expert opinion and reviewing the published literature. Frontline providers, including 8 physicians, 4 pharmacists, and a multiprofessional group of authors, provided insight into possible barriers to appropriate prescribing. Capability, Opportunity, Motivation and Behavior model and Theoretical Domain Framework were applied to characterize behavior change interventions and inform a potential implementation intervention for changing inappropriate prescribing behaviors. RESULTS Lack of knowledge about appropriate drug management in patients at risk for adverse outcomes was provided as a major barrier. Other reported barriers included a lack of: (1) tools to assist with drug management, (2) motivation to make changes, (3) routinization, and (4) an accountable clinician. CONCLUSIONS AND RELEVANCE Assigning a designated clinician to execute a stepwise, routine care process following the checklist provided is a recommended intervention to overcome barriers. The intended impact is behavior change that reduces inappropriate prescribing.
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Affiliation(s)
- Sandra L Kane-Gill
- School of Pharmacy, Pittsburgh, PA, USA.,University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | - John A Kellum
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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27
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Taheri Moghadam S, Sadoughi F, Velayati F, Ehsanzadeh SJ, Poursharif S. The effects of clinical decision support system for prescribing medication on patient outcomes and physician practice performance: a systematic review and meta-analysis. BMC Med Inform Decis Mak 2021; 21:98. [PMID: 33691690 PMCID: PMC7944637 DOI: 10.1186/s12911-020-01376-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 12/18/2020] [Indexed: 12/14/2022] Open
Abstract
Background Clinical Decision Support Systems (CDSSs) for Prescribing are one of the innovations designed to improve physician practice performance and patient outcomes by reducing prescription errors. This study was therefore conducted to examine the effects of various CDSSs on physician practice performance and patient outcomes. Methods This systematic review was carried out by searching PubMed, Embase, Web of Science, Scopus, and Cochrane Library from 2005 to 2019. The studies were independently reviewed by two researchers. Any discrepancies in the eligibility of the studies between the two researchers were then resolved by consulting the third researcher. In the next step, we performed a meta-analysis based on medication subgroups, CDSS-type subgroups, and outcome categories. Also, we provided the narrative style of the findings. In the meantime, we used a random-effects model to estimate the effects of CDSS on patient outcomes and physician practice performance with a 95% confidence interval. Q statistics and I2 were then used to calculate heterogeneity. Results On the basis of the inclusion criteria, 45 studies were qualified for analysis in this study. CDSS for prescription drugs/COPE has been used for various diseases such as cardiovascular diseases, hypertension, diabetes, gastrointestinal and respiratory diseases, AIDS, appendicitis, kidney disease, malaria, high blood potassium, and mental diseases. In the meantime, other cases such as concurrent prescribing of multiple medications for patients and their effects on the above-mentioned results have been analyzed. The study shows that in some cases the use of CDSS has beneficial effects on patient outcomes and physician practice performance (std diff in means = 0.084, 95% CI 0.067 to 0.102). It was also statistically significant for outcome categories such as those demonstrating better results for physician practice performance and patient outcomes or both. However, there was no significant difference between some other cases and traditional approaches. We assume that this may be due to the disease type, the quantity, and the type of CDSS criteria that affected the comparison. Overall, the results of this study show positive effects on performance for all forms of CDSSs. Conclusions Our results indicate that the positive effects of the CDSS can be due to factors such as user-friendliness, compliance with clinical guidelines, patient and physician cooperation, integration of electronic health records, CDSS, and pharmaceutical systems, consideration of the views of physicians in assessing the importance of CDSS alerts, and the real-time alerts in the prescription.
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Affiliation(s)
- Sharare Taheri Moghadam
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Farahnaz Sadoughi
- Health Management and Economics Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Rashid Yasemi Street, Vali-e Asr Avenue, Tehran, 1996713883, Iran.
| | - Farnia Velayati
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Jafar Ehsanzadeh
- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
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28
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Usability assessment of drug-linking laboratory data listed on prescriptions for outpatients of chiba university hospital. Sci Rep 2021; 11:1715. [PMID: 33462322 PMCID: PMC7814059 DOI: 10.1038/s41598-021-81344-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/05/2021] [Indexed: 11/25/2022] Open
Abstract
To evaluate the impact of pharmacotherapy on efficacy and safety by providing laboratory data information linked to medicines on outpatient prescriptions from the hospital to the community pharmacy. Beginning on October 28, 2014, standardized laboratory data and drug-linking laboratory data were included with outpatient prescriptions at our hospital. We have created a database of drug-linking laboratory data for all drugs that can be prescribed in Japan. We counted the number of prescription inquiries related to laboratory data from community pharmacies, including those leading to prescription changes. Before laboratory data were listed on outpatient prescriptions, 4 prescription inquiries from community pharmacies per year were related to laboratory data. After our hospital started to list laboratory data, this number rose to 643, 576, 563, and 847 in the first, second, third, and fourth year (P < .05). Of these, 132, 143, 152, and 224 inquiries resulted in prescription changes. Listing laboratory data on outpatient prescriptions avoided 153 contraindications and 84 exacerbations of adverse drug reactions in four years by a prescription inquiry that had never been done before. The efficacy and safety of pharmacotherapy can be improved by listing relevant laboratory data on outpatient prescriptions.
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30
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Wada R, Takeuchi J, Nakamura T, Sonoyama T, Kosaka S, Matsumoto C, Sakuma M, Ohta Y, Morimoto T. Clinical Decision Support System with Renal Dose Adjustment Did Not Improve Subsequent Renal and Hepatic Function among Inpatients: The Japan Adverse Drug Event Study. Appl Clin Inform 2020; 11:846-856. [PMID: 33368060 PMCID: PMC7758157 DOI: 10.1055/s-0040-1721056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background
Medication dose adjustment is crucial for patients with renal dysfunction (RD). The assessment of renal function is generally mandatory; however, the renal function may change during the hospital stay and the manual assessment is sometimes challenging.
Objective
We developed the clinical decision support system (CDSS) that provided a recommended dose based on automated calculated renal function.
Methods
We conducted a prospective cohort study in a single teaching hospital in Japan. All hospitalized patients were included except for obstetrics/gynecology and pediatric wards between September 2013 and February 2015. The CDSS was implemented on December 2013. Renal and hepatic dysfunction (HD) were defined as changes in the estimated glomerular filtration rate (eGFR) and alanine aminotransferase or alkaline phosphatase levels based on these measurements during hospital stay. These measurements were obtained before (phase I), after (phase II), and 1 year after (phase III) the CDSS implementation.
Results
We included 6,767 patients (phase I: 2,205; phase II: 2,279; phase III: 2,283). The patients' characteristics were similar among phases. Changes in eGFR were similar among phases, but the incidence of RD increased in phase III (phase I: 228 [10.3%]; phase II: 260 [11.4%]; phase III: 296 [13.0%],
p
= 0.02). However, the differences in incidences of RD were not statistically significant after adjusting for eGFR at baseline and age. The incidences of HD were also similar among phases (phase I: 175 [13.2%]; phase II: 171 [12.9%]; phase III: 167 [12.2%],
p
= 0.72).
Conclusion
The CDSS implementation did not affect the incidence of renal and HD and changes in renal and hepatic function among hospitalized patients. The effectiveness of the CDSS with renal-guided doses should be investigated with respect to other endpoints.
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Affiliation(s)
- Ryuhei Wada
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Jiro Takeuchi
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Tsukasa Nakamura
- Department of Infectious Diseases, Shimane Prefectural Central Hospital, Izumo, Shimane, Japan
| | - Tomohiro Sonoyama
- Department of Pharmacy, Shimane Prefectural Central Hospital, Izumo, Shimane, Japan
| | - Shinji Kosaka
- Shimane Prefectural Central Hospital, Izumo, Shimane, Japan
| | - Chisa Matsumoto
- Center for Health Surveillance & Preventive Medicine, Tokyo Medical University, Tokyo, Japan
| | - Mio Sakuma
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yoshinori Ohta
- Education and Training Center for Students and Professionals in Healthcare, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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31
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Trinkley KE, Kahn MG, Bennett TD, Glasgow RE, Haugen H, Kao DP, Kroehl ME, Lin CT, Malone DC, Matlock DD. Integrating the Practical Robust Implementation and Sustainability Model With Best Practices in Clinical Decision Support Design: Implementation Science Approach. J Med Internet Res 2020; 22:e19676. [PMID: 33118943 PMCID: PMC7661234 DOI: 10.2196/19676] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/18/2020] [Accepted: 09/15/2020] [Indexed: 11/13/2022] Open
Abstract
Background Clinical decision support (CDS) design best practices are intended to provide a narrative representation of factors that influence the success of CDS tools. However, they provide incomplete direction on evidence-based implementation principles. Objective This study aims to describe an integrated approach toward applying an existing implementation science (IS) framework with CDS design best practices to improve the effectiveness, sustainability, and reproducibility of CDS implementations. Methods We selected the Practical Robust Implementation and Sustainability Model (PRISM) IS framework. We identified areas where PRISM and CDS design best practices complemented each other and defined methods to address each. Lessons learned from applying these methods were then used to further refine the integrated approach. Results Our integrated approach to applying PRISM with CDS design best practices consists of 5 key phases that iteratively interact and inform each other: multilevel stakeholder engagement, designing the CDS, design and usability testing, thoughtful deployment, and performance evaluation and maintenance. The approach is led by a dedicated implementation team that includes clinical informatics and analyst builder expertise. Conclusions Integrating PRISM with CDS design best practices extends user-centered design and accounts for the multilevel, interacting, and dynamic factors that influence CDS implementation in health care. Integrating PRISM with CDS design best practices synthesizes the many known contextual factors that can influence the success of CDS tools, thereby enhancing the reproducibility and sustainability of CDS implementations. Others can adapt this approach to their situation to maximize and sustain CDS implementation success.
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Affiliation(s)
- Katy E Trinkley
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Clinical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, CO, United States
| | - Michael G Kahn
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Tellen D Bennett
- Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, CO, United States.,Section of Informatics and Data Science, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Russell E Glasgow
- Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, CO, United States.,Department of Family Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Heather Haugen
- Colorado Clinical and Translational Sciences Institute, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - David P Kao
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Clinical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Miranda E Kroehl
- Charter Communications Corporation, Greenwood Village, CO, United States
| | - Chen-Tan Lin
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Clinical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Daniel C Malone
- Department of Pharmacotherapy, Skaggs College of Pharmacy, University of Utah, Salt Lake City, UT, United States
| | - Daniel D Matlock
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, CO, United States.,VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, CO, United States
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Kwan JL, Lo L, Ferguson J, Goldberg H, Diaz-Martinez JP, Tomlinson G, Grimshaw JM, Shojania KG. Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials. BMJ 2020; 370:m3216. [PMID: 32943437 PMCID: PMC7495041 DOI: 10.1136/bmj.m3216] [Citation(s) in RCA: 151] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To report the improvements achieved with clinical decision support systems and examine the heterogeneity from pooling effects across diverse clinical settings and intervention targets. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline up to August 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES AND METHODS Randomised or quasi-randomised controlled trials reporting absolute improvements in the percentage of patients receiving care recommended by clinical decision support systems. Multilevel meta-analysis accounted for within study clustering. Meta-regression was used to assess the degree to which the features of clinical decision support systems and study characteristics reduced heterogeneity in effect sizes. Where reported, clinical endpoints were also captured. RESULTS In 108 studies (94 randomised, 14 quasi-randomised), reporting 122 trials that provided analysable data from 1 203 053 patients and 10 790 providers, clinical decision support systems increased the proportion of patients receiving desired care by 5.8% (95% confidence interval 4.0% to 7.6%). This pooled effect exhibited substantial heterogeneity (I2=76%), with the top quartile of reported improvements ranging from 10% to 62%. In 30 trials reporting clinical endpoints, clinical decision support systems increased the proportion of patients achieving guideline based targets (eg, blood pressure or lipid control) by a median of 0.3% (interquartile range -0.7% to 1.9%). Two study characteristics (low baseline adherence and paediatric settings) were associated with significantly larger effects. Inclusion of these covariates in the multivariable meta-regression, however, did not reduce heterogeneity. CONCLUSIONS Most interventions with clinical decision support systems appear to achieve small to moderate improvements in targeted processes of care, a finding confirmed by the small changes in clinical endpoints found in studies that reported them. A minority of studies achieved substantial increases in the delivery of recommended care, but predictors of these more meaningful improvements remain undefined.
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Affiliation(s)
- Janice L Kwan
- Sinai Health System, Department of Medicine, 600 University Avenue, Toronto, ON M5G 1X5, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lisha Lo
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, ON, Canada
| | - Jacob Ferguson
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Hanna Goldberg
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Juan Pablo Diaz-Martinez
- Biostatistics Research Unit, University Health Network and Sinai Health System, Toronto, ON, Canada
| | - George Tomlinson
- Biostatistics Research Unit, University Health Network and Sinai Health System, Toronto, ON, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kaveh G Shojania
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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33
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Teaford HR, Rule AD, Mara KC, Kashani KB, Lieske JC, Schreier DJ, Wieruszewski PM, Barreto EF. Patterns of Cystatin C Uptake and Use Across and Within Hospitals. Mayo Clin Proc 2020; 95:1649-1659. [PMID: 32753139 PMCID: PMC7412578 DOI: 10.1016/j.mayocp.2020.03.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 02/23/2020] [Accepted: 03/04/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To characterize the use of cystatin C (cysC) across and within hospitals. PATIENTS AND METHODS This 2-part study first evaluated access to cysC testing across 129 hospitals in the state of Minnesota, using a telephone-based survey. Second, granular data from a single center (Mayo Clinic) with on-site, rapid-turnaround testing (<1 day) and automated estimated glomerular filtration rate (eGFR) reporting was used to describe temporal patterns. The characteristics of hospitals that offered cysC testing and of patients who underwent rapid cysC testing at Mayo Clinic between January 1, 2011, and March 31, 2018, were described. Poisson regression analyzed temporal trends in cysC testing. RESULTS Of the 114 hospitals (88%) that responded to the statewide survey, cysC was available in 91 (80%), but only 3 of 91 (3%) reported a turnaround time of <1 day. At Mayo Clinic, cysC use increased from 0.74 tests per 1000 patient-days in 2011 to 14 tests per 1000 patient-days in 2018 (P=.004). Of the 3774 patients with cysC tests, the mean first available eGFR was 46 mL/min per 1.73 m2 using cysC and 59 mL/min per 1.73 m2 using serum creatinine (P<.001). CysC testing was used across all intensities of care and was ordered by a variety of specialties. Nephrology was consulted in only 42% of cases. CONCLUSION In the hospital, rapid-turnaround cysC testing is necessary for practical use but was not widely available in Minnesota. When available, a marked increase in cysC testing was observed over the study timeframe. Additional research is needed to determine optimal strategies for implementation of cysC within hospitals.
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Affiliation(s)
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Division of Epidemiology, Mayo Clinic, Rochester, MN
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | | | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
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34
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Miyazaki M, Matsuo K, Uchiyama M, Nakamura Y, Sakamoto Y, Misaki M, Tokura K, Jimi S, Okamura K, Adachi S, Yamamoto T, Shirai K, Urata H, Imakyure O. Inappropriate direct oral anticoagulant dosing in atrial fibrillation patients is associated with prescriptions for outpatients rather than inpatients: a single-center retrospective cohort study. J Pharm Health Care Sci 2020; 6:2. [PMID: 32071730 PMCID: PMC7014592 DOI: 10.1186/s40780-020-0157-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/20/2020] [Indexed: 02/05/2023] Open
Abstract
Background Inappropriate dosing of direct oral anticoagulants (DOACs) has been associated with clinical safety and efficacy; however, little is known about clinical data associated with an inappropriate DOAC dosing in Japan. In addition, there is no report in which the appropriateness of DOAC dosing between prescription for inpatients and for outpatients was examined. In this study, we aimed to investigate the prevalence and factors associated in the inappropriate dosing of DOACs in patients with atrial fibrillation (AF). Methods The retrospective cohort study was conducted at a single Japanese university hospital. Both inpatients and outpatients, who were diagnosed with AF and for whom treatment with either dabigatran, rivaroxaban, apixaban, or edoxaban was initiated between April 1, 2014 and March 31, 2018, were enrolled in the study. Appropriateness of DOAC dosing was assessed according to the manufacturer’s labeling recommendations (dose reduction criteria) of each DOAC. Inappropriate reduced dose, namely, underdosing, was defined as prescription of a reduced dose of DOAC despite the patient not meeting the dose reduction criteria. Inappropriate standard dose, namely, overdosing, was defined as prescription of a standard dose of DOAC despite the patient meeting the dose reduction criteria. Inappropriate DOAC dosing was defined as a deviation of the recommended dose (both underdosing and overdosing). Results A total of 316 patients (dabigatran, 28; rivaroxaban, 107; apixaban, 116; and edoxaban, 65) were included, with a median (interquartile range) age of 75 (66–81) years and 62.3% male. DOACs were prescribed at an appropriate standard dose in 39.2% of patients, an appropriate reduced dose in 36.7%, an inappropriate standard dose in 2.5%, and an inappropriate reduced dose in 19.3%. Multivariate analysis revealed that the inappropriate dosing of DOACs was significantly associated with prescriptions for outpatients (vs. inpatients; odds ratio [OR] 2.87, 95% confidence interval [CI] 1.53–5.62, p < 0.001) and those with higher HAS-BLED scores (OR 1.87, 95% CI 1.42–2.51, p < 0.001). Conclusions Our results demonstrated that the inappropriate dosing of DOACs occurred in approximately 20% of AF patients, and was more frequent in outpatients (vs. inpatients) and in those with a higher risk of bleeding. It is recommended that pharmacists play a greater role in assisting in the prescription process to help physicians make better decisions.
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Affiliation(s)
- Motoyasu Miyazaki
- 1Department of Pharmacy, Fukuoka University Chikushi Hospital, Fukuoka Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Koichi Matsuo
- 1Department of Pharmacy, Fukuoka University Chikushi Hospital, Fukuoka Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Masanobu Uchiyama
- 1Department of Pharmacy, Fukuoka University Chikushi Hospital, Fukuoka Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Yoshihiko Nakamura
- 2Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan; 7-45-1, Nanakuma, Jonan-ku, Fukuoka, 814-0180 Japan
| | - Yuya Sakamoto
- 1Department of Pharmacy, Fukuoka University Chikushi Hospital, Fukuoka Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Momoko Misaki
- 1Department of Pharmacy, Fukuoka University Chikushi Hospital, Fukuoka Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Kaoko Tokura
- 1Department of Pharmacy, Fukuoka University Chikushi Hospital, Fukuoka Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Shiro Jimi
- 3Central Laboratory for Pathology and Morphology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan; 7-45-1, Nanakuma, Jonan-ku, Fukuoka, 814-0180 Japan
| | - Keisuke Okamura
- 4Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Fukuoka, Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Sen Adachi
- 4Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Fukuoka, Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Tomohiko Yamamoto
- 4Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Fukuoka, Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Kazuyuki Shirai
- 4Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Fukuoka, Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Hidenori Urata
- 4Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Fukuoka, Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
| | - Osamu Imakyure
- 1Department of Pharmacy, Fukuoka University Chikushi Hospital, Fukuoka Japan; 1-1-1, Zokumyoin, Chikushino-shi, Fukuoka, 818-8502 Japan
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Slight SP, Seger DL, Franz C, Wong A, Bates DW. The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States. J Am Med Inform Assoc 2019; 25:1183-1188. [PMID: 29939271 DOI: 10.1093/jamia/ocy066] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 05/24/2018] [Indexed: 11/14/2022] Open
Abstract
Objective To estimate the national cost of ADEs resulting from inappropriate medication-related alert overrides in the U.S. inpatient setting. Materials and Methods We used three different regression models (Basic, Model 1, Model 2) with model inputs taken from the medical literature. A random sample of 40 990 adult inpatients at the Brigham and Women's Hospital (BWH) in Boston with a total of 1 639 294 medication orders was taken. We extrapolated BWH medication orders using 2014 National Inpatient Sample (NIS) data. Results Using three regression models, we estimated that 29.7 million adult inpatient discharges in 2014 resulted in between 1.02 billion and 1.07 billion medication orders, which in turn generated between 75.1 million and 78.8 million medication alerts, respectively. Taking the basic model (78.8 million), we estimated that 5.5 million medication-related alerts might have been inappropriately overridden, resulting in approximately 196 600 ADEs nationally. This was projected to cost between $871 million and $1.8 billion for treating preventable ADEs. We also estimated that clinicians and pharmacists would have jointly spent 175 000 hours responding to 78.8 million alerts with an opportunity cost of $16.9 million. Discussion and Conclusion These data suggest that further optimization of hospitals computerized provider order entry systems and their associated clinical decision support is needed and would result in substantial savings. We have erred on the side of caution in developing this range, taking two conservative cost estimates for a preventable ADE that did not include malpractice or litigation costs, or costs of injuries to patients.
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Affiliation(s)
- Sarah P Slight
- School of Pharmacy, King George VI Building, Newcastle University, Newcastle, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK.,The Centre for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Diane L Seger
- The Centre for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Partners HealthCare, Somerville, Massachusetts, USA
| | - Calvin Franz
- Eastern Research Group, Inc., Lexington, Massachusetts, USA
| | - Adrian Wong
- The Centre for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - David W Bates
- The Centre for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Harvard School of Public Health, Boston, Massachusetts, USA
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Moja L, Polo Friz H, Capobussi M, Kwag K, Banzi R, Ruggiero F, González-Lorenzo M, Liberati EG, Mangia M, Nyberg P, Kunnamo I, Cimminiello C, Vighi G, Grimshaw JM, Delgrossi G, Bonovas S. Effectiveness of a Hospital-Based Computerized Decision Support System on Clinician Recommendations and Patient Outcomes: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e1917094. [PMID: 31825499 PMCID: PMC6991299 DOI: 10.1001/jamanetworkopen.2019.17094] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Sophisticated evidence-based information resources can filter medical evidence from the literature, integrate it into electronic health records, and generate recommendations tailored to individual patients. OBJECTIVE To assess the effectiveness of a computerized clinical decision support system (CDSS) that preappraises evidence and provides health professionals with actionable, patient-specific recommendations at the point of care. DESIGN, SETTING, AND PARTICIPANTS Open-label, parallel-group, randomized clinical trial among internal medicine wards of a large Italian general hospital. All analyses in this randomized clinical trial followed the intent-to-treat principle. Between November 1, 2015, and December 31, 2016, patients were randomly assigned to the intervention group, in which CDSS-generated reminders were displayed to physicians, or to the control group, in which reminders were generated but not shown. Data were analyzed between February 1 and July 31, 2018. INTERVENTIONS Evidence-Based Medicine Electronic Decision Support (EBMEDS), a commercial CDSS covering a wide array of health conditions across specialties, was integrated into the hospital electronic health records to generate patient-specific recommendations. MAIN OUTCOMES AND MEASURES The primary outcome was the resolution rate, the rate at which medical problems identified and alerted by the CDSS were addressed by a change in practice. Secondary outcomes included the length of hospital stay and in-hospital all-cause mortality. RESULTS In this randomized clinical trial, 20 563 patients were admitted to the hospital. Of these, 6480 (31.5%) were admitted to the internal medicine wards (study population) and randomized (3242 to CDSS and 3238 to control). The mean (SD) age of patients was 70.5 (17.3) years, and 54.5% were men. In total, 28 394 reminders were generated throughout the course of the trial (median, 3 reminders per patient per hospital stay; interquartile range [IQR], 1-6). These messages led to a change in practice in approximately 4 of 100 patients. The resolution rate was 38.0% (95% CI, 37.2%-38.8%) in the intervention group and 33.7% (95% CI, 32.9%-34.4%) in the control group, corresponding to an odds ratio of 1.21 (95% CI, 1.11-1.32; P < .001). The length of hospital stay did not differ between the groups, with a median time of 8 days (IQR, 5-13 days) for the intervention group and a median time of 8 days (IQR, 5-14 days) for the control group (P = .36). In-hospital all-cause mortality also did not differ between groups (odds ratio, 0.95; 95% CI, 0.77-1.17; P = .59). Alert fatigue did not differ between early and late study periods. CONCLUSIONS AND RELEVANCE An international commercial CDSS intervention marginally influenced routine practice in a general hospital, although the change did not statistically significantly affect patient outcomes. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02577198.
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Affiliation(s)
- Lorenzo Moja
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Clinical Epidemiology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Orthopedic Institute Galeazzi, Milan, Italy
| | - Hernan Polo Friz
- Internal Medicine Division, Medical Department, Vimercate Hospital, Vimercate, Italy
| | - Matteo Capobussi
- Clinical Epidemiology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Orthopedic Institute Galeazzi, Milan, Italy
| | - Koren Kwag
- Medical School of International Health, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Rita Banzi
- IRCCS Mario Negri Institute for Pharmacological Research, Milan, Italy
| | - Francesca Ruggiero
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Clinical Epidemiology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Orthopedic Institute Galeazzi, Milan, Italy
| | - Marien González-Lorenzo
- Humanitas Clinical and Research Center, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Elisa G. Liberati
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, United Kingdom
| | | | - Peter Nyberg
- Duodecim Medical Publications Ltd, Helsinki, Finland
| | - Ilkka Kunnamo
- Duodecim Medical Publications Ltd, Helsinki, Finland
| | - Claudio Cimminiello
- Internal Medicine Division, Medical Department, Vimercate Hospital, Vimercate, Italy
| | - Giuseppe Vighi
- Internal Medicine Division, Medical Department, Vimercate Hospital, Vimercate, Italy
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and the Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Giovanni Delgrossi
- Internal Medicine Division, Medical Department, Vimercate Hospital, Vimercate, Italy
| | - Stefanos Bonovas
- Humanitas Clinical and Research Center, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Garlo KG, Bates DW, Seger DL, Fiskio JM, Charytan DM. Lab monitoring and acute care utilization during initiation of renin angiotensin aldosterone inhibitors or diuretics in chronic kidney disease. Medicine (Baltimore) 2019; 98:e17963. [PMID: 31804307 PMCID: PMC6919529 DOI: 10.1097/md.0000000000017963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Renin angiotensin aldosterone system inhibitors (RAASi) and diuretics are among the most frequently prescribed anti-hypertensives. Individuals with chronic kidney disease (CKD) are particularly at risk for electrolyte disturbances and kidney injury but the appropriate use of lab monitoring following RAASi or diuretic initiation is uncertain in CKD.We describe the frequency and time interval of lab monitoring during initiation of RAASi and diuretics in CKD and assess whether close lab monitoring associates with one-year risk of emergency department (ED) visit or hospitalization.We evaluated an observational cohort of 8,217 individuals with stage 3-5 non-dialysis CKD newly prescribed a RAASi (52.3%) or diuretic (47.7%) from thirty-six primary care offices affiliated with Brigham and Women's Hospital and Massachusetts General Hospital between 2009 and 2011.Overall, 3306 (40.2%) individuals did not have pre-prescription labs done within 2 weeks, and 5957 (72.5%) did not have post-prescription labs done within 2 weeks which includes 524 (6.4%) individuals without post-prescription within 1 year. Close monitoring occurred in only 1547 (20.1%) and was more likely in individuals prescribed diuretics compared to RAASi (adjusted OR 1.39; 95%CI 1.20-1.62), with CKD stage 4,5 compared with stage 3 (adjusted OR 1.47; 95%CI 1.16-1.86) and with cardiovascular disease (adjusted OR 1.42; 95%CI 1.21-1.66). Close monitoring was not associated with decreased risk of ED visit or hospitalization.Close lab monitoring during initiation of RAASi or diuretics was more common in participants with cardiovascular disease and advanced CKD suggesting physicians selected high-risk individuals for close monitoring. As nearly 80% of individuals did not receive close lab monitoring there may be value in future research on electronic physician decision tools targeted at lab monitoring.
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Affiliation(s)
| | - David W. Bates
- The Center for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Boston
- Clinical & Quality Analysis, Partners HealthCare, Somerville, MA
| | - Diane L. Seger
- The Center for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Boston
- Clinical & Quality Analysis, Partners HealthCare, Somerville, MA
| | - Julie M. Fiskio
- The Center for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Boston
- Clinical & Quality Analysis, Partners HealthCare, Somerville, MA
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Casanova AG, Hernández-Sánchez MT, López-Hernández FJ, Martínez-Salgado C, Prieto M, Vicente-Vicente L, Morales AI. Systematic review and meta-analysis of the efficacy of clinically tested protectants of cisplatin nephrotoxicity. Eur J Clin Pharmacol 2019; 76:23-33. [PMID: 31677116 DOI: 10.1007/s00228-019-02771-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/24/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Cisplatin is a potent antineoplastic drug that has been widely used to treat a number of solid tumors. However, a high incidence of renal damage observed in patients has led researchers to search for alternate strategies that prevent or at least reduce the cisplatin-induced nephrotoxicity. The objective of the present study was to conduct a systematic review and a subsequent meta-analysis to evaluate and identify compounds with effective antitumor activity and lesser side effects that could provide protection against cisplatin-induced nephrotoxicity. METHODS The study included all placebo-controlled trials published up to December 2017 that met the inclusion criteria. A total of 22 articles were finally included to extract the following information: number of patients, doses of cisplatin and protectant, qualitative (acute kidney injury incidence) and quantitative (plasma creatinine, blood urea nitrogen, and creatinine clearance) indicators of renal function. The odds ratio or the mean difference (95% confidence interval) of each parameter was calculated for each study and group of studies. RESULTS The results of this meta-analysis show that there is great variability in the nephroprotective capacity of a variety of products evaluated. Of all the compounds tested, only magnesium sulfate and cystone were found to exert protective effects. However, more studies need to be conducted to confirm these results. CONCLUSIONS The administration of 1 g of Mg i.v. seems to be the best strategy for the prevention of cisplatin nephrotoxicity.
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Affiliation(s)
- Alfredo G Casanova
- Unidad de Toxicología, Departamento de Fisiología y Farmacología, University of Salamanca, Laboratorio 223-226, Campus Miguel de Unamuno, 37007, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL)-Instituto de Estudios de Ciencias de la Salud de Castilla y León (IESCYL), Salamanca, Spain
- Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain
- Grupo de Investigación Biomédica en Cuidados Críticos (BioCritic), Valladolid, Spain
| | - María Teresa Hernández-Sánchez
- Unidad de Toxicología, Departamento de Fisiología y Farmacología, University of Salamanca, Laboratorio 223-226, Campus Miguel de Unamuno, 37007, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL)-Instituto de Estudios de Ciencias de la Salud de Castilla y León (IESCYL), Salamanca, Spain
- Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain
- Grupo de Investigación Biomédica en Cuidados Críticos (BioCritic), Valladolid, Spain
| | - Francisco J López-Hernández
- Unidad de Toxicología, Departamento de Fisiología y Farmacología, University of Salamanca, Laboratorio 223-226, Campus Miguel de Unamuno, 37007, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL)-Instituto de Estudios de Ciencias de la Salud de Castilla y León (IESCYL), Salamanca, Spain
- Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain
- Grupo de Investigación Biomédica en Cuidados Críticos (BioCritic), Valladolid, Spain
| | - Carlos Martínez-Salgado
- Unidad de Toxicología, Departamento de Fisiología y Farmacología, University of Salamanca, Laboratorio 223-226, Campus Miguel de Unamuno, 37007, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL)-Instituto de Estudios de Ciencias de la Salud de Castilla y León (IESCYL), Salamanca, Spain
- Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain
- Grupo de Investigación Biomédica en Cuidados Críticos (BioCritic), Valladolid, Spain
| | - Marta Prieto
- Unidad de Toxicología, Departamento de Fisiología y Farmacología, University of Salamanca, Laboratorio 223-226, Campus Miguel de Unamuno, 37007, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL)-Instituto de Estudios de Ciencias de la Salud de Castilla y León (IESCYL), Salamanca, Spain
- Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain
- Grupo de Investigación Biomédica en Cuidados Críticos (BioCritic), Valladolid, Spain
| | - Laura Vicente-Vicente
- Unidad de Toxicología, Departamento de Fisiología y Farmacología, University of Salamanca, Laboratorio 223-226, Campus Miguel de Unamuno, 37007, Salamanca, Spain.
- Instituto de Investigación Biomédica de Salamanca (IBSAL)-Instituto de Estudios de Ciencias de la Salud de Castilla y León (IESCYL), Salamanca, Spain.
- Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain.
- Grupo de Investigación Biomédica en Cuidados Críticos (BioCritic), Valladolid, Spain.
| | - Ana Isabel Morales
- Unidad de Toxicología, Departamento de Fisiología y Farmacología, University of Salamanca, Laboratorio 223-226, Campus Miguel de Unamuno, 37007, Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL)-Instituto de Estudios de Ciencias de la Salud de Castilla y León (IESCYL), Salamanca, Spain
- Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain
- Grupo de Investigación Biomédica en Cuidados Críticos (BioCritic), Valladolid, Spain
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Garber A, Nowacki AS, Chaitoff A, Brateanu A, Colbert CY, Bauer SR, Arora Z, Mehdi A, Lam S, Spencer A, Rothberg MB. Frequency, Timing, and Types of Medication Ordering Errors Made by Residents in the Electronic Medical Records Era. South Med J 2019; 112:25-31. [PMID: 30608627 DOI: 10.14423/smj.0000000000000923] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To describe associations between resident level of training, timing of medication orders, and the types of inpatient medication ordering errors made by internal medicine residents. METHODS This study reviewed all inpatient medication orders placed by internal medicine residents at a tertiary care academic medical center from July 2011 to June 2015. Medication order errors were measured by pharmacists' reporting of an error via the electronic medical record during real-time surveillance of orders. Multivariable regression models were constructed to assess associations between resident training level (postgraduate year [PGY]), medication order timing (time of day and month of year), and rates of medication ordering errors. RESULTS Of 1,772,462 medication orders placed by 335 residents, 68,545 (3.9%) triggered a pharmacist intervention in the electronic medical record. Overall and for each PGY level, renal dose monitoring/adjustment was the most common order error (40%). Ordering errors were less frequent during the night and transition periods versus daytime (adjusted odds ratio [aOR] 0.93, 95% confidence interval [CI] 0.91-0.96, and aOR 0.93, 95% CI 0.90-0.95, respectively). Errors were more common in July and August compared with other months (aOR 1.05, 95% CI 1.01-1.09). Compared with PGY2 residents, both PGY1 (aOR 1.06, 95% CI 1.03-1.10), and PGY3 residents (aOR 1.07, 95% CI, 1.03-1.10) were more likely to make medication ordering errors. Throughout the course of the academic year, the odds of a medication ordering error decreased by 16% (aOR 0.84, 95% CI 0.80-0.89). CONCLUSIONS Despite electronic medical records, medication ordering errors by trainees remain common. Additional supervision and resident education regarding medication orders may be necessary.
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Affiliation(s)
- Ari Garber
- From the Departments of Gastroenterology and Hepatology, Quantitative Health Sciences in the Lerner Research Institute, Internal Medicine, and Pharmacy, and the Center for Value Based Care Research, Cleveland Clinic, and the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Amy S Nowacki
- From the Departments of Gastroenterology and Hepatology, Quantitative Health Sciences in the Lerner Research Institute, Internal Medicine, and Pharmacy, and the Center for Value Based Care Research, Cleveland Clinic, and the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Alexander Chaitoff
- From the Departments of Gastroenterology and Hepatology, Quantitative Health Sciences in the Lerner Research Institute, Internal Medicine, and Pharmacy, and the Center for Value Based Care Research, Cleveland Clinic, and the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Andrei Brateanu
- From the Departments of Gastroenterology and Hepatology, Quantitative Health Sciences in the Lerner Research Institute, Internal Medicine, and Pharmacy, and the Center for Value Based Care Research, Cleveland Clinic, and the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Colleen Y Colbert
- From the Departments of Gastroenterology and Hepatology, Quantitative Health Sciences in the Lerner Research Institute, Internal Medicine, and Pharmacy, and the Center for Value Based Care Research, Cleveland Clinic, and the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Seth R Bauer
- From the Departments of Gastroenterology and Hepatology, Quantitative Health Sciences in the Lerner Research Institute, Internal Medicine, and Pharmacy, and the Center for Value Based Care Research, Cleveland Clinic, and the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Zubin Arora
- From the Departments of Gastroenterology and Hepatology, Quantitative Health Sciences in the Lerner Research Institute, Internal Medicine, and Pharmacy, and the Center for Value Based Care Research, Cleveland Clinic, and the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Ali Mehdi
- From the Departments of Gastroenterology and Hepatology, Quantitative Health Sciences in the Lerner Research Institute, Internal Medicine, and Pharmacy, and the Center for Value Based Care Research, Cleveland Clinic, and the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Simon Lam
- From the Departments of Gastroenterology and Hepatology, Quantitative Health Sciences in the Lerner Research Institute, Internal Medicine, and Pharmacy, and the Center for Value Based Care Research, Cleveland Clinic, and the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Abby Spencer
- From the Departments of Gastroenterology and Hepatology, Quantitative Health Sciences in the Lerner Research Institute, Internal Medicine, and Pharmacy, and the Center for Value Based Care Research, Cleveland Clinic, and the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Michael B Rothberg
- From the Departments of Gastroenterology and Hepatology, Quantitative Health Sciences in the Lerner Research Institute, Internal Medicine, and Pharmacy, and the Center for Value Based Care Research, Cleveland Clinic, and the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
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Trinkley KE, Blakeslee WW, Matlock DD, Kao DP, Van Matre AG, Harrison R, Larson CL, Kostman N, Nelson JA, Lin CT, Malone DC. Clinician preferences for computerised clinical decision support for medications in primary care: a focus group study. BMJ Health Care Inform 2019; 26:0. [PMID: 31039120 PMCID: PMC7062316 DOI: 10.1136/bmjhci-2019-000015] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/14/2019] [Accepted: 02/27/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND To improve user-centred design efforts and efficiency; there is a need to disseminate information on modern day clinician preferences for technologies such as computerised clinical decision support (CDS). OBJECTIVE To describe clinician perceptions regarding beneficial features of CDS for chronic medications in primary care. METHODS This study included focus groups and clinicians individually describing their ideal CDS. Three focus groups were conducted including prescribing clinicians from a variety of disciplines. Outcome measures included identification of favourable features and unintended consequences of CDS for chronic medication management in primary care. We transcribed recordings, performed thematic qualitative analysis and generated counts when possible. RESULTS There were 21 participants who identified four categories of beneficial CDS features during the group discussion: non-interruptive alerts, clinically relevant and customisable support, presentation of pertinent clinical information and optimises workflow. Non-interruptive alerts were broadly defined as passive alerts that a user chooses to review, whereas interruptive were active or disruptive alerts that interrupted workflow and one is forced to review before completing a task. The CDS features identified in the individual descriptions were consistent with the focus group discussion, with the exception of non-interruptive alerts. In the individual descriptions, 12 clinicians preferred interruptive CDS compared with seven clinicians describing non-interruptive CDS. CONCLUSION Clinicians identified CDS for chronic medications beneficial when they are clinically relevant and customisable, present pertinent clinical information (eg, labs, vitals) and improve their workflow. Although clinicians preferred passive, non-interruptive alerts, most acknowledged that these may not be widely seen and may be less effective. These features align with literature describing best practices in CDS design and emphasise those features clinicians prioritise, which should be considered when designing CDS for medication management in primary care. These findings highlight the disparity between the current state of CDS design and clinician-stated design features associated with beneficial CDS.
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Affiliation(s)
- Katy E Trinkley
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine Department of Medicine, Aurora, Colorado, USA
- Department of Clinical Informatics, University of Colorado Health, Aurora, Colorado, USA
| | | | - Daniel D Matlock
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Adult and Child Consortium for Outcomes Research and Delivery Science, Aurora, Colorado, USA
| | - David P Kao
- Department of Clinical Informatics, University of Colorado Health, Aurora, Colorado, USA
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine Department of Medicine, Aurora, Colorado, USA
| | - Amanda G Van Matre
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Robert Harrison
- Department of Clinical Informatics, University of Colorado Health, Aurora, Colorado, USA
| | - Cynthia L Larson
- Department of Clinical Informatics, University of Colorado Health, Aurora, Colorado, USA
| | | | - Jennifer A Nelson
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Chen-Tan Lin
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine Department of Medicine, Aurora, Colorado, USA
- Department of Clinical Informatics, University of Colorado Health, Aurora, Colorado, USA
| | - Daniel C Malone
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, Arizona, USA
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver, Colorado, USA
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Mutter M, Martin M, Yamamoto Y, Biswas A, Etropolski B, Feldman H, Garg A, Gourlie N, Latham S, Lin H, Palevsky PM, Parikh C, Moreira E, Ugwuowo U, Wilson FP. Electronic Alerts for Acute Kidney Injury Amelioration (ELAIA-1): a completely electronic, multicentre, randomised controlled trial: design and rationale. BMJ Open 2019; 9:e025117. [PMID: 31154298 PMCID: PMC6549649 DOI: 10.1136/bmjopen-2018-025117] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) is common among hospitalised patients and under-recognised by providers and yet carries a significant risk of morbidity and mortality. Electronic alerts for AKI have become more common despite a lack of strong evidence of their benefits. We designed a multicentre, randomised, controlled trial to evaluate the effectiveness of AKI alerts. Our aim is to highlight several challenges faced in the design of this trial, which uses electronic screening, enrolment, randomisation, intervention and data collection. METHODS AND ANALYSIS The design and implementation of an electronic alert system for AKI was a reiterative process involving several challenges and limitations set by the confines of the electronic medical record system. The trial will electronically identify and randomise 6030 adults with AKI at six hospitals over a 1.5-2 year period to usual care versus an electronic alert containing an AKI-specific order set. Our primary outcome will be a composite of AKI progression, inpatient dialysis and inpatient death within 14 days of randomisation. During a 1-month pilot in the medical intensive care unit of Yale New Haven Hospital, we have demonstrated feasibility of automating enrolment and data collection. Feedback from providers exposed to the alerts was used to continually improve alert clarity, user friendliness and alert specificity through refined inclusion and exclusion criteria. ETHICS AND DISSEMINATION This study has been approved by the appropriate ethics committees for each of our study sites. Our study qualified for a waiver of informed consent as it presents no more than minimal risk and cannot be feasibly conducted in the absence of a waiver. We are committed to open dissemination of our data through clinicaltrials.gov and submission of results to the NIH data sharing repository. Results of our trial will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02753751; Pre-results.
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Affiliation(s)
- Marina Mutter
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Melissa Martin
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Yu Yamamoto
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Aditya Biswas
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Boian Etropolski
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Harold Feldman
- Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amit Garg
- Department of Medcine, University of Western Ontario, London, Ontario, Canada
| | - Noah Gourlie
- Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Stephen Latham
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Haiqun Lin
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Paul M Palevsky
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Chirag Parikh
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Erica Moreira
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ugochukwu Ugwuowo
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Francis P Wilson
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Medicine, Yale University, New Haven, Connecticut, USA
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Stanski N, Menon S, Goldstein SL, Basu RK. Integration of urinary neutrophil gelatinase-associated lipocalin with serum creatinine delineates acute kidney injury phenotypes in critically ill children. J Crit Care 2019; 53:1-7. [PMID: 31174170 DOI: 10.1016/j.jcrc.2019.05.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/10/2019] [Accepted: 05/27/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Acute kidney injury (AKI) is prevalent in critically ill patients and associated with poor outcomes. Current AKI diagnostics- changes to serum creatinine (SCr) and urine output- are imprecise. Integration of injury biomarkers with SCr may improve diagnostic precision. METHODS We performed a secondary analysis of a study of critically ill children. Measurements of urine neutrophil gelatinase-associated lipocalin (uNGAL) and SCr samples from ICU admission facilitated the creation of four groups for comparison, based on elevation of SCr from baseline and reference NGAL cut-off value: uNGAL-/SCr-, uNGAL+/SCr-, uNGAL-/SCr + and uNGAL+/SCr+. The primary outcome assessed was AKI severity on Day 3. RESULTS 178 children were studied. Compared to uNGAL-/SCr-, uNGAL+/SCr- patients had increased risk for all-stage Day 3 AKI (≥ KDIGO stage 1) (OR 3.83, [1.3-11.3], p = .025). Compared to uNGAL-/SCr+, uNGAL+/SCr + patients had increased risk for severe Day 3 AKI (≥ KDIGO stage 2) (OR 12, [1.4-102], p = .018). The only patients to suffer all-stage Day 3 AKI and mortality were uNGAL+ (3.2% uNGAL+/SCr-; 6.5% uNGAL+/SCr+). CONCLUSIONS Unique biomarker combinations on admission are predictive of distinct Day 3 AKI severity phenotypes. These classifications may enable a more personalized approach to the early management of AKI. Expanded study in larger populations is warranted.
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Affiliation(s)
- Natalja Stanski
- Cincinnati Children's Hospital Medical Center, Division of Critical Care Medicine, 3333 Burnet Avenue, MLC 2005, Cincinnati, OH 45229, United States of America.
| | - Shina Menon
- University of Washington School of Medicine, Division of Nephrology, Seattle Children's Hospital, Seattle, WA, United States of America.
| | - Stuart L Goldstein
- Cincinnati Children's Hospital Medical Center, Center for Acute Care Nephrology, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 7022, Cincinnati, OH 45229, United States of America.
| | - Rajit K Basu
- Children's Healthcare of Atlanta, Division of Critical Care Medicine, United States of America.
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43
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The use of nephrotoxic drugs in patients with chronic kidney disease. Int J Clin Pharm 2019; 41:767-775. [DOI: 10.1007/s11096-019-00811-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 03/07/2019] [Indexed: 11/26/2022]
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44
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Khreba NA, Abdelsalam M, Wahab AM, Sanad M, Elhelaly R, Adel M, El-Kannishy G. Kidney Injury Molecule 1 (KIM-1) as an Early Predictor for Acute Kidney Injury in Post-Cardiopulmonary Bypass (CPB) in Open Heart Surgery Patients. Int J Nephrol 2019; 2019:6265307. [PMID: 30993020 PMCID: PMC6434264 DOI: 10.1155/2019/6265307] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 02/16/2019] [Accepted: 02/19/2019] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Postoperative acute kidney injury is associated with a higher mortality, a more complicated hospital course with longer hospital stay. Urinary kidney injury molecule 1 may play an important role as an early predictor of acute kidney injury post-cardiopulmonary in open heart surgery. METHODS We evaluated 45 patients who underwent open heart surgery from January 2016 to June 2016. Both urinary kidney injury molecule 1 and serum creatinine were evaluated before operation and 3hs and 24hs after operation. Acute kidney injury was diagnosed according to Kidney Disease: Improving Global Outcomes, 2012 guidelines. RESULTS In this study, 27 patients developed acute kidney injury. The three hour-post-surgery urinary kidney injury molecule 1 was significantly higher in the acute kidney injury group (P<0.015) and, at the same time, we did not find any significant difference in the serum creatinine levels between the two groups. CONCLUSION Although serum creatinine is still the gold standard for diagnosis of acute kidney injury searching for other new markers is mandatory. Urinary kidney injury molecule 1 can be used as simple noninvasive and specific biomarker for early diagnosis of acute kidney injury.
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Affiliation(s)
- Nora A. Khreba
- Mansoura Nephrology and Dialysis Unit, Internal Medicine Department, Mansoura University, Egypt
| | - Mostafa Abdelsalam
- Mansoura Nephrology and Dialysis Unit, Internal Medicine Department, Mansoura University, Egypt
| | - A. M. Wahab
- Mansoura Nephrology and Dialysis Unit, Internal Medicine Department, Mansoura University, Egypt
| | - Mohammed Sanad
- Cardiothoracic Surgery Department, Mansoura University, Egypt
| | - Rania Elhelaly
- Clinical Pathology Department, Mansoura University, Egypt
| | - Mohammed Adel
- Anesthesia and Surgical Intensive Care, Mansoura University, Egypt
| | - Ghada El-Kannishy
- Mansoura Nephrology and Dialysis Unit, Internal Medicine Department, Mansoura University, Egypt
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45
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Whitehead NS, Williams L, Meleth S, Kennedy S, Ubaka-Blackmoore N, Kanter M, O'Leary KJ, Classen D, Jackson B, Murphy DR, Nichols J, Stockwell D, Lorey T, Epner P, Taylor J, Graber ML. The Effect of Laboratory Test-Based Clinical Decision Support Tools on Medication Errors and Adverse Drug Events: A Laboratory Medicine Best Practices Systematic Review. J Appl Lab Med 2019; 3:1035-1048. [PMID: 31639695 DOI: 10.1373/jalm.2018.028019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 12/27/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Laboratory and medication data in electronic health records create opportunities for clinical decision support (CDS) tools to improve medication dosing, laboratory monitoring, and detection of side effects. This systematic review evaluates the effectiveness of such tools in preventing medication-related harm. METHODS We followed the Laboratory Medicine Best Practice (LMBP) initiative's A-6 methodology. Searches of 6 bibliographic databases retrieved 8508 abstracts. Fifteen articles examined the effect of CDS tools on (a) appropriate dose or medication (n = 5), (b) laboratory monitoring (n = 4), (c) compliance with guidelines (n = 2), and (d) adverse drug events (n = 5). We conducted meta-analyses by using random-effects modeling. RESULTS We found moderate and consistent evidence that CDS tools applied at medication ordering or dispensing can increase prescriptions of appropriate medications or dosages [6 results, pooled risk ratio (RR), 1.48; 95% CI, 1.27-1.74]. CDS tools also improve receipt of recommended laboratory monitoring and appropriate treatment in response to abnormal test results (6 results, pooled RR, 1.40; 95% CI, 1.05-1.87). The evidence that CDS tools reduced adverse drug events was inconsistent (5 results, pooled RR, 0.69; 95% CI, 0.46-1.03). CONCLUSIONS The findings support the practice of healthcare systems with the technological capability incorporating test-based CDS tools into their computerized physician ordering systems to (a) identify and flag prescription orders of inappropriate dose or medications at the time of ordering or dispensing and (b) alert providers to missing laboratory tests for medication monitoring or results that warrant a change in treatment. More research is needed to determine the ability of these tools to prevent adverse drug events.
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Affiliation(s)
| | | | | | | | | | - Michael Kanter
- Permanente Federation and Regional Medical Director of Quality and Clinical Analysis, Kaiser Permanente Southern California, Pasadena, CA
| | - Kevin J O'Leary
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - David Classen
- Pascal Metrics, Washington, DC.,University of Utah School of Medicine, Salt Lake City, UT
| | - Brian Jackson
- University of Utah School of Medicine, Salt Lake City, UT.,ARUP Laboratories, Salt Lake City, UT
| | - Daniel R Murphy
- Houston VA Center of Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.,Department of Medicine, Baylor College of Medicine, Houston, TX
| | - James Nichols
- Vanderbilt University School of Medicine, Nashville, TN
| | - David Stockwell
- Pascal Metrics, Washington, DC.,Division of Critical Care Medicine, Children's National Medical Center, Washington, DC.,Department of Pediatrics, George Washington University School of Medicine, Washington, DC
| | - Thomas Lorey
- TPMG Regional Reference Laboratory, Kaiser Permanente Northern California, Berkeley, CA
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46
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Whittaker CF, Miklich MA, Patel RS, Fink JC. Medication Safety Principles and Practice in CKD. Clin J Am Soc Nephrol 2018; 13:1738-1746. [PMID: 29915131 PMCID: PMC6237057 DOI: 10.2215/cjn.00580118] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Ensuring patient safety is a priority of medical care because iatrogenic injury has been a primary concern. Medications are an important source of medical errors, and kidney disease is a thoroughfare of factors threatening safe administration of medicines. Principal among these is reduced kidney function because almost half of all medications used are eliminated via the kidney. Additionally, kidney patients often suffer from multimorbidity, including diabetes, hypertension, and heart failure, with a range of prescribers who often do not coordinate treatments. Patients with kidney disease are also susceptible to further kidney injury and metabolic derangements from medications, which can worsen the disease. In this review, we will present the key issues and threats to safe medication use in kidney disease, with a focus on predialysis CKD, as the scope of medication safety in ESKD and transplantation are unique and deserve their own consideration. We discuss drugs that need to be avoided or dose modified, and review the complications of a range of medications routinely administered in CKD, as these also call for cautious use.
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Affiliation(s)
- Chanel F. Whittaker
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Margaret A. Miklich
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, Pennsylvania
| | - Roshni S. Patel
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Philadelphia, Pennsylvania; and
| | - Jeffrey C. Fink
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Kidney Function, Polypharmacy, and Potentially Inappropriate Medication Use in a Community-Based Cohort of Older Adults. Drugs Aging 2018; 35:735-750. [PMID: 30039344 DOI: 10.1007/s40266-018-0563-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) afflicts many older adults and increases the risk for medication-related adverse events. OBJECTIVE The aim of this study was to assess the prevalence and associated morbidity and mortality of polypharmacy (use of several medications concurrently), and potentially inappropriate medication (PIM) use in older adults, looking for differences by CKD status. METHODS We quantified medication and PIM use (from Beers criteria, the Screening Tool of Older People's Prescriptions, and Micromedex®) by level of estimated glomerular filtration rate (eGFR) for participants aged 65 years or older attending a baseline study visit in the Atherosclerosis Risk in Communities study (n =6392). We used zero-inflated negative binomial and Cox proportional hazards regressions to assess the relationship between baseline polypharmacy, PIM use, and subsequent hospitalization and death. RESULTS Mean age at baseline was 76 (± 5) years, 59% were female, and 29% had CKD (eGFR < 60 ml/min/1.73 m2). Overall, participants reported 6.1 (± 3.5) medications and 2.3 (± 2.2) vitamins/supplements; 16% reported ≥ 10 medications; 31% reported a PIM based on their age. On average, participants with CKD reported more medications. A PIM based on kidney function was used by 36% of those with eGFR < 30 ml/min/1.73 m2. Over a median of 2.6 years, more concurrent medications were associated with higher risk of hospitalization and death, but PIM use was not. While those with CKD had higher absolute risks, there was no difference in the relative risks associated with greater numbers of medications by CKD status. CONCLUSION Polypharmacy and PIM use were common, with greater numbers of medications associated with higher risk of hospitalization and death; relative risks were similar for those with and without CKD.
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48
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Tolley CL, Slight SP, Husband AK, Watson N, Bates DW. Improving medication-related clinical decision support. Am J Health Syst Pharm 2018; 75:239-246. [PMID: 29436470 DOI: 10.2146/ajhp160830] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Current uses of medication-related clinical decision support (CDS) and recommendations for improving these systems are reviewed. SUMMARY Using a systematic approach, articles published from 2007 through 2014 were identified in MEDLINE and EMBASE using MeSH terms and keywords relating to the 5 basic medication-related CDS functionalities. A total of 156 full-text articles and 28 conference abstracts were reviewed across each of the 5 areas: drug-drug interaction (DDI) checks (n = 78), drug allergy checks (n = 20), drug dose support (n = 55), drug duplication checks (n = 11), and drug formulary support (n = 20). The success of medication-related CDS depends on users finding the alerts valuable and acting on the information received. Improving alert specificity and sensitivity is important for all domains. Tiering is important for improving the acceptance of DDI alerts. The ability to perform appropriate cross-sensitivity checks is key to producing appropriate drug allergy checks. Drug dosage alerts should be individualized and deliver practical recommendations. How the system is configured to identify certain drug duplications is important to prevent possible patient toxicity. Accurate knowledge databases are needed to produce relevant drug formulary alerts and encourage formulary adherence. Medication-related CDS is still relatively immature in some organizations and has substantial room for improvement. For example, decision support should consider more patient-specific factors, human factors principles should always be considered, and alert specificity must be improved in order to reduce alert fatigue. CONCLUSION Standardization, integration of patient-specific parameters, and consideration of human factors design principles are central to realizing the potential benefits of medication-related CDS.
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Affiliation(s)
- Clare L Tolley
- Institute of Health and Society, Sir James Spence Institute, Newcastle University, Newcastle upon Tyne, United Kingdom, United Kingdom
| | - Sarah P Slight
- School of Pharmacy, Newcastle Univesity, Newcastle upon Tyne, United Kingdom .,Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Andrew K Husband
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Neil Watson
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - David W Bates
- Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
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49
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Sykes L, Nipah R, Kalra P, Green D. A narrative review of the impact of interventions in acute kidney injury. J Nephrol 2018; 31:523-535. [PMID: 29188454 PMCID: PMC6061256 DOI: 10.1007/s40620-017-0454-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 10/27/2017] [Indexed: 10/25/2022]
Abstract
Acute kidney injury (AKI) is independently associated with significant morbidity and mortality, and is thus an important challenge facing physicians in modern healthcare. This narrative review assesses the impact of strategies employed to tackle AKI following the 2009 NCEPOD report on acute kidney injury (Sterwart et al. Acute kidney injury: adding insult to injury, pp 1-22, 2009). There is scarce and heterogeneous research into hard end points such as mortality and AKI progression for AKI interventions. This review found that e-alerts have varying effects on mortality and AKI progression, but decrease the incidence of contrast-induced AKI. The use of AKI bundles delivers statistically significant improvements in mortality and AKI progression. Similarly, AKI nurses generate statistically significant improvements on hospital acquired AKI and mortality. As yet there is no evidence base for the effects of education, sick day rules and smart phone apps. Overall, a combination of e-alerts and AKI bundles supported by education yielded the most effective and statistically significant results. Current practice revolves around reactive rather than preventative behaviour. This narrative review discusses reactive interventions and their impact on the progression and severity of AKI, and on mortality from it. Preventative behaviour, such as risk stratification and early intervention in the deteriorating patient, may be influential in decreasing AKI incidence.
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Affiliation(s)
- Lynne Sykes
- Emergency Assessment Unit, Salford Royal NHS Foundation Trust, MAHSC, Stott Lane, Salford, M6 8HD, UK.
- Division of Cardiovascular Sciences, University of Manchester, MAHSC, Manchester, UK.
| | - Rob Nipah
- Emergency Assessment Unit, Salford Royal NHS Foundation Trust, MAHSC, Stott Lane, Salford, M6 8HD, UK
- Division of Cardiovascular Sciences, University of Manchester, MAHSC, Manchester, UK
| | - Philip Kalra
- Division of Cardiovascular Sciences, University of Manchester, MAHSC, Manchester, UK
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, MAHSC, Salford, UK
| | - Darren Green
- Emergency Assessment Unit, Salford Royal NHS Foundation Trust, MAHSC, Stott Lane, Salford, M6 8HD, UK
- Division of Cardiovascular Sciences, University of Manchester, MAHSC, Manchester, UK
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, MAHSC, Salford, UK
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50
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Impact of a clinical decision support system for drug dosage in patients with renal failure. Int J Clin Pharm 2018; 40:1225-1233. [PMID: 29785684 DOI: 10.1007/s11096-018-0612-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 03/02/2018] [Indexed: 01/27/2023]
Abstract
Background A clinical decision support system (CDSS) linked to the computerized physician order entry may help improve prescription appropriateness in inpatients with renal insufficiency. Objective To evaluate the impact on prescription appropriateness of a CDSS prescriber alert for 85 drugs in renal failure patients. Setting Before-after study in a 975-bed academic hospital. Method Prescriptions of patients with renal failure were reviewed during two comparable periods of 6 days each, before and after the implementation of the CDSS (September 2009 and 2010). Main outcome measure The proportion of inappropriate dosages of 85 drugs included in the CDSS was compared in the pre- and post-implementation group. Results Six hundred and fifteen patients were included in the study (301 in pre- and 314 in post-implementation periods). In the pre- and post-implementation period, respectively 2882 and 3485 prescriptions were evaluated, of which 14.9 and 16.6% triggered an alert. Among these, the dosage was inappropriate in respectively 25.4 and 24.6% of prescriptions in the pre- and post-implementation periods (OR 0.97; 95% CI 0.72-1.29). The most frequently involved drugs were paracetamol, perindopril, tramadol and allopurinol. Conclusion The implementation of a CDSS did not significantly reduce the proportion of inappropriate drug dosages in patients with renal failure. Further research is required to investigate the reasons why prescribers override alerts. Collaboration with clinical pharmacists might improve compliance with the CDSS recommendations.
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