Renal Drug Dosing

Erin A. Vogel; Sarah J. Billups; Sheryl J. Herner; Thomas Delate

doi:10.4338/ACI-2016-01-RA-0010

Applied Clinical Informatics, Inhaltsverzeichnis

Appl Clin Inform 2016; 07(03): 731-744
DOI: 10.4338/ACI-2016-01-RA-0010

Research Article

Schattauer GmbH

Renal Drug Dosing

Effectiveness of Outpatient Pharmacist-Based vs. Prescriber-Based Clinical Decision Support Systems

Erin A. Vogel

¹Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO

²Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO

,

Sarah J. Billups

¹Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO

²Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO

,

Sheryl J. Herner

¹Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO

²Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO

,

Thomas Delate

¹Pharmacy Department, Kaiser Permanente Colorado, Aurora, CO

²Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO

› Institutsangaben

Abstract

Summary

Objective

The purpose of this study was to compare the effectiveness of an outpatient renal dose adjustment alert via a computerized provider order entry (CPOE) clinical decision support system (CDSS) versus a CDSS with alerts made to dispensing pharmacists.

Methods

This was a retrospective analysis of patients with renal impairment and 30 medications that are contraindicated or require dose-adjustment in such patients. The primary outcome was the rate of renal dosing errors for study medications that were dispensed between August and December 2013, when a pharmacist-based CDSS was in place, versus August through December 2014, when a prescriber-based CDSS was in place. A dosing error was defined as a prescription for one of the study medications dispensed to a patient where the medication was contraindicated or improperly dosed based on the patient’s renal function. The denominator was all prescriptions for the study medications dispensed during each respective study period.

Results

During the pharmacist-and prescriber-based CDSS study periods, 49,054 and 50,678 prescriptions, respectively, were dispensed for one of the included medications. Of these, 878 (1.8%) and 758 (1.5%) prescriptions were dispensed to patients with renal impairment in the respective study periods. Patients in each group were similar with respect to age, sex, and renal function stage. Overall, the five-month error rate was 0.38%. Error rates were similar between the two groups: 0.36% and 0.40% in the pharmacist-and prescriber-based CDSS, respectively (p=0.523). The medication with the highest error rate was dofetilide (0.51% overall) while the medications with the lowest error rate were dabigatran, fondaparinux, and spironolactone (0.00% overall).

Conclusions

Prescriber-and pharmacist-based CDSS provided comparable, low rates of potential medication errors. Future studies should be undertaken to examine patient benefits of the prescriber-based CDSS.

Citation: Vogel EA, Billups SJ, Herner SJ, Delate T. Renal drug dosing: Effectiveness of outpatient pharmacist-based vs. prescriber-based clinical decision support systems.

Keywords

Renal insufficiency - clinical decision support systems - computerized provider order entry - medication errors - pharmacists

Volltext

Referenzen

References
1 Joosten H, Drion L, Boogerd K, Van der Pijl EV, Slingerland RJ, Slaets JP, Jansen TJ, Schwantje, Gans RO, Bilo HJ. Optimizing drug prescribing and dispensing in subjects at risk for drug errors due to renal impairment: improving drug safety in primary healthcare by low eGFR alerts. BMJ Open 2013; 03: 1-10.
2 Yap C, Dunhan D, Thompson J, Baker D. Medication dosing errors for patients with renal insufficiency in ambulatory care. Jt Comm J Qual Patient Saf 2005; 31: 514-521.
3 Farag A, Garg A, Li L, Jain AK. Dosing errors in prescribed antibiotics for older persons with CKD: a retrospective time series analysis. Am J Kidney Dis 2014; 63: 422-428.
4 Bhardwaja B, Carroll N, Raebel M, Chester EA, Korner EJ, Rocho BE, Brand DW, Magid DJ. Improving prescribing safety in patients with renal insufficiency in the ambulatory setting: the Drug Renal Alert Pharmacy (DRAP) program. Pharmacotherapy 2011; 31: 346-356.
5 Patel HR, Prunchnicki MC, Hall LE. Assessment for chronic kidney disease service in high-risk patient at community health clinics. Ann Pharmacother 2005; 39: 22-27.
6 Long CL, Rabel MA, Price DW, Magid DJ. Compliance with dosing guidelines in patients with chronic kidney disease. Ann Pharmacother 2004; 38: 853-858.
7 Erler A, Beyer M, Petersen J, Saal K, Rath T, Rochon J, Haefeli WE, Gerlach FM. How to improve drug dosing for patients with renal impairment in primary care – a cluster-randomized controlled trial. BMC Fam Pract 2012; 13: 91.
8 Tawadrous D, Shariff SZ, Haynes RB, Iansavichus AV, Jain AK, Garg AX. Use of clinical decision support systems for kidney-related prescribing: a systematic review. Am J Kidney Dis 2011; 58: 903-914.
9 Boussaid A, Caruba T, Karras A. Validity of a clinical decision rule-based alert system for drug dose adjustments in patients with renal failure intended to improve pharmacist’s’ analysis of medication orders in hospitals. IJMI 2013; 82: 964-972.
10 Terrell KM, Perkins AJ, Hui SL, Callahan CM, Dexter PR, Miller DK. Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial. Ann Emerg Med 2010; 56: 623-629.
11 Nielsen AL, Henriksen DP, Marinakis C, Hellebek A, Birn H, Nybo M, Sondergaard J, Nymark A, Pedersen C. Drug dosing in patients with renal insufficiency in a hospital setting using electronic prescribing and automated reporting of estimated glomerular filtration rate. Basic Clin Pharmacol Toxicol 2014; 114: 407-413.
12 Wang HY, Lu CL, Wu MP, Huang M, Huang Y. Effectiveness of an integrated CPOE decision-supporting system with clinical pharmacist monitoring practice in preventing antibiotic dosing errors. Int J Clin Pharmacol Ther 2012; 50: 375-382.
13 Kuperman GJ, Bobb A, Payne T, Avery A, Gandhi TK, Burns G, Classen DC, Bates DW. Medication – related clinical decision support in computerized provider order entry systems: a review. J Am Med Inform Assoc 2007; 14: 29-40.
14 Cockcroft DW, Gault HM. Prediction of creatinine clearance from serum creatinine. Nephron 1976; 16: 31-41.
15 National Kidney Disease Education Program. CKD and drug dosing: information for providers. 2015 [cited December 2015]; Available from: http://www.niddk.nih.gov/health-information/health-communi cation-programs/nkdep/a-z/ckd-drug-dosing/Documents/ckd-drug-dosing-508.pdf
16 Hudson JQ, Nyman HA. Use of estimated glomerular filtration rate for drug dosing in the chronic kidney disease patient. Curr Opin Nephrol Hypertens 2011; 20: 482-491.
17 Levey A, Bosch JP, Lewis JB, Greene T, Nancy R, Roth D. A more accurate method to estimate glomerular filtration rate. Ann Intern Med 1999; 130: 461-470.
18 Nyman HA, Dowling TC, Hudson JQ, Peter WL, Joy MS, Nolin TD. Comparative evaluation of the Cockcroft-Gault equation and the modification of the diet in renal disease (MDRD) study equation for drug dosing: An opinion of the Nephrology Practice and Research Network of the American College of Clinical Pharmacy. Pharmacotherapy 2011; 31: 1130-1144.
19 Jones G. Estimating renal function for drug dosing decisions. Clin Biochem Rev 2011; 32: 81-88.
20 Stevens LA, Nolin TD, Richardson MM, Feldman HI, Lewis JB, Rodby R, Townsend R, Okparavero A, Zhang YL, Schmid CH, Levey AS. Comparison of drug dosing recommendations based on measured GFR and kidney function estimating equations. Am J Kidney Dis 2009; 54: 33-42.
21 Awdishu L, Coates CR, Lyddane A, Tran K, Daniels CE, Lee J, El-Kareh R. The impact of real-time alerting on appropriate prescribing in kidney disease: a cluster randomized controlled trial. J Am Med Inform Assoc 2016; 23: 609-616.
22 Zand L, McKian KP, Qian Q. Gabapentin toxicity in patients with chronic kidney disease: a preventable cause of mobidity. Am J Med 2010; 123: 367-373.
23 Mounsey JP, DiMarco JP. Dofetilide. Circulation 2000; 102: 2665-2670.
24 Cho I, Slight SP, Nanji KC, Seger DL, Maniam N, Dykes PC, Bates DW. Understanding physicians’ behavior toward alerts about nephrotoxic medications in outpatients: a cross-sectional analysis. BMC Nephrol 2014; 15: 200.
25 Isaac T, Weissman JS, Davis RB, Massagli M, Cyrulik A, Sands DZ, Weingart SN. Overrides of medication alerts in ambulatory care. Arch Intern Med 2009; 169: 305-311.
26 Weingart SN, Toth M, Sands DZ, Aronson MD, Davis RB, Phillips RS. Physicians’ decisions to override computerized drug alerts in primary care. Arch Intern Med 2003; 163: 2625-2631.
27 Galanter WL, Moja J, Lambert BL. Using computerized provider order entry and clinical decision support to improve prescribing in patients with decreased GFR. Am J Kidney Dis 2010; 56: 809-812.
28 The Office of the National Coordinator for Health Information Technology. Self assessment. Computerized provider order entry with decision support. 2014 [cited December 2015]; Available from: https://www.healthit.gov/sites/safer/files/guides/SAFER_CPOE_sg007_form.pdf
29 Garg A, Adhikari N, McDonald H, Rosas-Arellano M, Devereaux PJ, Beyene J, Sam J, Haynes RB. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes. JAMA 2005; 293: 1223-1238.
30 Field TS, Rochon P, Lee M, Gavendo L, Subramanian S, Hoover S, Baril J, Gurwitz J. Costs associated with developing and implementing a computerized clinical decision support system for medication dosing for patients with renal insufficiency in the long-term care setting. J Am Med Inform Assoc 2008; 15: 466-472.
31 Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl 2013; 03: 1-150.