1
|
Frazer A, Rowland J, Mudge A, Barras M, Martin J, Donovan P. Systematic review of interventions to improve safety and quality of anticoagulant prescribing for therapeutic indications for hospital inpatients. Eur J Clin Pharmacol 2019; 75:1645-1657. [PMID: 31511939 DOI: 10.1007/s00228-019-02752-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 08/23/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Anticoagulation-associated adverse drug events are common in hospitalised patients and result in morbidity, mortality, increased length of hospital stay and higher costs of care. Many are preventable. We reviewed the literature to identify and assess interventions intended to improve safety or quality anticoagulant prescribing. METHODS A systematic search of EMBASE, MEDLINE, the Cochrane Library, Pretty Darn Quick-Evidence and Health Systems Evidence was undertaken to identify controlled studies assessing system-level interventions to improve prescribing of oral or parenteral therapeutic anticoagulation for any indication in hospitalised adults. Data were extracted for safety and quality outcomes, with studies grouped by intervention type for meta-analysis and narrative review. RESULTS Of 10,640 records screened, 19 trials evaluating 12,742 participants were included for analysis. No study specifically evaluated prescribing of low molecular weight heparins (LMWHs) or direct acting oral anticoagulants (DOACs). Our findings suggest that physician-led anticoagulation consultation services may reduce bleeding rates in high-risk patients. On meta-analysis, decision supported warfarin dosing resulted in higher proportion of time with international normalised ratio in therapeutic range (p = 0.0007). Studies of other clinical decision support systems and heparin monitoring systems did not demonstrate improved safety, and quality findings were inconsistent. Systematic education and feedback programs were not efficacious. CONCLUSIONS There is currently insufficient high-quality evidence to recommend any reviewed intervention, though several warrant closer evaluation. Adequately powered controlled trials assessing safety outcomes and evidence-based quality markers in high-risk patient groups and studies of interventions to improve safety of LMWH and DOAC prescribing are needed.
Collapse
Affiliation(s)
- Andrew Frazer
- Department of Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia.
| | - James Rowland
- Department of Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| | - Alison Mudge
- Department of Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| | - Michael Barras
- University of Queensland School of Pharmacy, 20 Cornwall Street, Woolloongabba, QLD, 4102, Australia
| | - Jennifer Martin
- Chair of Clinical Pharmacology, University of Newcastle School of Medicine and Public Health, University Drive, Callaghan, NSW, 2308, Australia
| | - Peter Donovan
- Director of Clinical Pharmacology, The Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| |
Collapse
|
2
|
Hubers L, Spyropoulos A, Eikelboom J, Connolly B, Van Spall H, Schulze K, Cuddy S, Stehouwer A, Schulman S, Connolly S, Nieuwlaat R. Randomised comparison of a simple warfarin dosing algorithm versus a computerised anticoagulation management system for control of warfarin maintenance therapy. Thromb Haemost 2017; 108:1228-35. [DOI: 10.1160/th12-06-0433] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 08/31/2012] [Indexed: 11/05/2022]
Abstract
SummaryExcellent control of the international normalised ratio (INR) is associated with improved clinical outcomes in patients receiving warfarin, and can be achieved by anticoagulation clinics but is difficult in general practice. Anticoagulation clinics have often used validated commercial computer systems to manage the INR, but these are not usually available to general practitioners. It was the objective of this study to perform a randomised trial of a simple one-step warfarin dosing algorithm against a widely used computerised dosing system. During the period of introduction of a commercial computerised warfarin dosing system (DAWN AC) to an anticoagulation clinic, patients were randomised to have warfarin dose adjustment done according to recommendations of the existing warfarin dosing algorithm or to those of the computerised system. The study tested if the computerised system was non-inferior to the existing algorithm for the primary outcome of time in therapeutic INR range of 2.0–3.0 (TTR), with a one-sided non-inferiority margin of 4.5%. There were 541 patients randomised to commercial computerised system and 527 to the algorithm. Median follow-up was 159 days. A dose recommendation was provided and followed in 91% of occasions for the computerised system and in 90% for the algorithm (p=0.03). The mean TTR was 71.0% (standard deviation [SD] 23.2) for the computerised system and 71.9% (SD 22.9) for the algorithm (difference 0.9% [95% confidence interval: –1.4% to 4.1%];p-value for noninferiority=0.002;p-value for superiority=0.34). In conclusion, similar maintenance control of the INR was achieved with a simple one-step dosing algorithm and a commercial computerised management system.
Collapse
|
3
|
Delvaux N, Van Thienen K, Heselmans A, de Velde SV, Ramaekers D, Aertgeerts B. The Effects of Computerized Clinical Decision Support Systems on Laboratory Test Ordering: A Systematic Review. Arch Pathol Lab Med 2017; 141:585-595. [PMID: 28353386 DOI: 10.5858/arpa.2016-0115-ra] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT - Inappropriate laboratory test ordering has been shown to be as high as 30%. This can have an important impact on quality of care and costs because of downstream consequences such as additional diagnostics, repeat testing, imaging, prescriptions, surgeries, or hospital stays. OBJECTIVE - To evaluate the effect of computerized clinical decision support systems on appropriateness of laboratory test ordering. DATA SOURCES - We used MEDLINE, Embase, CINAHL, MEDLINE In-Process and Other Non-Indexed Citations, Clinicaltrials.gov, Cochrane Library, and Inspec through December 2015. Investigators independently screened articles to identify randomized trials that assessed a computerized clinical decision support system aimed at improving laboratory test ordering by providing patient-specific information, delivered in the form of an on-screen management option, reminder, or suggestion through a computerized physician order entry using a rule-based or algorithm-based system relying on an evidence-based knowledge resource. Investigators extracted data from 30 papers about study design, various study characteristics, study setting, various intervention characteristics, involvement of the software developers in the evaluation of the computerized clinical decision support system, outcome types, and various outcome characteristics. CONCLUSIONS - Because of heterogeneity of systems and settings, pooled estimates of effect could not be made. Data showed that computerized clinical decision support systems had little or no effect on clinical outcomes but some effect on compliance. Computerized clinical decision support systems targeted at laboratory test ordering for multiple conditions appear to be more effective than those targeted at a single condition.
Collapse
Affiliation(s)
| | | | | | | | | | - Bert Aertgeerts
- From the Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium (Drs Delvaux, Heselmans, Ramaekers, and Aertgeerts).,the Department of Public Health, Vrije University Brussels, Brussels, Belgium (Dr Van Thienen).,the GUIDES project, Norwegian Institute of Public Health, Oslo, Norway (Dr Van de Velde).,and the Centre for Evidence-Based Medicine (CEBAM), Belgian Branch of the Dutch Cochrane Collaboration, Leuven, Belgium (Drs Ramaekers and Aertgeerts)
| |
Collapse
|
4
|
Zhao Y, Liu N, Wang Y, Hickey KT. A rolling-horizon pharmacokinetic pharmacodynamic model for warfarin inpatients in transient clinical states. Per Med 2016; 13:21-32. [DOI: 10.2217/pme.15.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim: To design a pharmacokinetic pharmacodynamic model to make individualized and adaptive international normalized ratio (INR) predictions for warfarin inpatients in changing clinical status. Methods: We tested a new model on 60 inpatients at Columbia University. The model personalizes four submodels and minimizes the number of parameters to be estimated. Prediction accuracy was assessed by prediction error, absolute prediction error and percentage absolute prediction error. Results: The INRs were accurately predicted 5 days into the future. Median prediction error: 0.01–0.12; median absolute prediction error: 0.17–0.5 and median percentage absolute prediction error: 9.85–26.06%. Conclusion: Patients exhibit interindividual and intertemporal variability. The model captures the variability and provides accurate and personalized INR predictions.
Collapse
Affiliation(s)
- Yao Zhao
- Department of Supply Chain Management, Rutgers Business School, Rutgers – the State University of New Jersey, Newark, NJ, USA
| | - Nan Liu
- Department of Health Policy & Management, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Yijun Wang
- Department of Supply Chain Management, Rutgers Business School, Rutgers – the State University of New Jersey, Newark, NJ, USA
| | - Kathleen T Hickey
- Columbia University School of Nursing, Columbia University Medical Center, NY, USA
| |
Collapse
|
5
|
|
6
|
Bayoumi I, Al Balas M, Handler SM, Dolovich L, Hutchison B, Holbrook A. The effectiveness of computerized drug-lab alerts: a systematic review and meta-analysis. Int J Med Inform 2014; 83:406-15. [PMID: 24793784 DOI: 10.1016/j.ijmedinf.2014.03.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 03/17/2014] [Accepted: 03/19/2014] [Indexed: 01/18/2023]
Abstract
BACKGROUND Inadequate lab monitoring of drugs is a potential cause of ADEs (adverse drug events) which is remediable. OBJECTIVES To determine the effectiveness of computerized drug-lab alerts to improve medication-related outcomes. DATA SOURCES Citations from the Computerized Clinical Decision Support System Systematic Review (CCDSSR) and MMIT (Medications Management through Health Information Technology) databases, which had searched MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, International Pharmaceutical Abstracts from 1974 to March 27, 2013. STUDY SELECTION Randomized controlled trials (RCTs) of clinician-targeted computerized drug lab alerts conducted in any healthcare setting. Two reviewers performed full text review to determine study eligibility. DATA ABSTRACTION A single reviewer abstracted data and evaluated validity of included studies using Cochrane handbook domains. DATA SYNTHESIS Thirty-six studies met the inclusion criteria (25 single drug studies with 22,504 participants, 14 targeting anticoagulation; 11 multi-drug studies with 56,769 participants). ADEs were reported as an outcome in only four trials, all targeting anticoagulants. Computerized drug-lab alerts did not reduce ADEs (OR 0.89, 95% CI 0.79-1.00, p=0.05), length of hospital stay (SMD 0.00, 95%CI -0.93 to 0.93, p=0.055, 1 study), likelihood of hypoglycemia (OR 1.29, 95% CI 0.31-5.37) or likelihood of bleeding, but were associated with increased likelihood of prescribing changes (OR 1.73, 95% CI 1.21-2.47) or lab monitoring (OR 1.47, 95% confidence interval 1.12-1.94) in accordance with the alert. CONCLUSIONS There is no evidence that computerized drug-lab alerts are associated with important clinical benefits, but there is evidence of improvement in selected clinical surrogate outcomes (time in therapeutic range for vitamin K antagonists), and changes in process outcomes (lab monitoring and prescribing decisions).
Collapse
Affiliation(s)
- Imaan Bayoumi
- Department of Family Medicine, McMaster University, Canada; Kingston Community Health Centres, Canada; Department of Family Medicine, Queen's University, Canada.
| | - Mosab Al Balas
- Department of Pharmacy, St. Joseph's Health Care Hamilton, Hamilton, Canada
| | - Steven M Handler
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System (VAPHS), Pittsburgh, PA, United States; Center for Health Equity Research and Promotion (CHERP), VAPHS, Pittsburgh, PA, United States
| | - Lisa Dolovich
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Canada; Department of Family Medicine, McMaster University, Canada; Centre for Evaluation of Medicines, St. Joseph's Healthcare Hamilton, Canada
| | - Brian Hutchison
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Canada; Department of Family Medicine, McMaster University, Canada
| | - Anne Holbrook
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Canada; Division of Clinical Pharmacology & Therapeutics, Department of Medicine, McMaster University, Canada; Centre for Evaluation of Medicines, St. Joseph's Healthcare Hamilton, Canada
| |
Collapse
|
7
|
Gillaizeau F, Chan E, Trinquart L, Colombet I, Walton RT, Rège-Walther M, Burnand B, Durieux P. Computerized advice on drug dosage to improve prescribing practice. Cochrane Database Syst Rev 2013; 2013:CD002894. [PMID: 24218045 PMCID: PMC11393523 DOI: 10.1002/14651858.cd002894.pub3] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Maintaining therapeutic concentrations of drugs with a narrow therapeutic window is a complex task. Several computer systems have been designed to help doctors determine optimum drug dosage. Significant improvements in health care could be achieved if computer advice improved health outcomes and could be implemented in routine practice in a cost-effective fashion. This is an updated version of an earlier Cochrane systematic review, first published in 2001 and updated in 2008. OBJECTIVES To assess whether computerized advice on drug dosage has beneficial effects on patient outcomes compared with routine care (empiric dosing without computer assistance). SEARCH METHODS The following databases were searched from 1996 to January 2012: EPOC Group Specialized Register, Reference Manager; Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Ovid; EMBASE, Ovid; and CINAHL, EbscoHost. A "top up" search was conducted for the period January 2012 to January 2013; these results were screened by the authors and potentially relevant studies are listed in Studies Awaiting Classification. The review authors also searched reference lists of relevant studies and related reviews. SELECTION CRITERIA We included randomized controlled trials, non-randomized controlled trials, controlled before-and-after studies and interrupted time series analyses of computerized advice on drug dosage. The participants were healthcare professionals responsible for patient care. The outcomes were any objectively measured change in the health of patients resulting from computerized advice (such as therapeutic drug control, clinical improvement, adverse reactions). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality. We grouped the results from the included studies by drug used and the effect aimed at for aminoglycoside antibiotics, amitriptyline, anaesthetics, insulin, anticoagulants, ovarian stimulation, anti-rejection drugs and theophylline. We combined the effect sizes to give an overall effect for each subgroup of studies, using a random-effects model. We further grouped studies by type of outcome when appropriate (i.e. no evidence of heterogeneity). MAIN RESULTS Forty-six comparisons (from 42 trials) were included (as compared with 26 comparisons in the last update) including a wide range of drugs in inpatient and outpatient settings. All were randomized controlled trials except two studies. Interventions usually targeted doctors, although some studies attempted to influence prescriptions by pharmacists and nurses. Drugs evaluated were anticoagulants, insulin, aminoglycoside antibiotics, theophylline, anti-rejection drugs, anaesthetic agents, antidepressants and gonadotropins. Although all studies used reliable outcome measures, their quality was generally low.This update found similar results to the previous update and managed to identify specific therapeutic areas where the computerized advice on drug dosage was beneficial compared with routine care:1. it increased target peak serum concentrations (standardized mean difference (SMD) 0.79, 95% CI 0.46 to 1.13) and the proportion of people with plasma drug concentrations within the therapeutic range after two days (pooled risk ratio (RR) 4.44, 95% CI 1.94 to 10.13) for aminoglycoside antibiotics;2. it led to a physiological parameter more often within the desired range for oral anticoagulants (SMD for percentage of time spent in target international normalized ratio +0.19, 95% CI 0.06 to 0.33) and insulin (SMD for percentage of time in target glucose range: +1.27, 95% CI 0.56 to 1.98);3. it decreased the time to achieve stabilization for oral anticoagulants (SMD -0.56, 95% CI -1.07 to -0.04);4. it decreased the thromboembolism events (rate ratio 0.68, 95% CI 0.49 to 0.94) and tended to decrease bleeding events for anticoagulants although the difference was not significant (rate ratio 0.81, 95% CI 0.60 to 1.08). It tended to decrease unwanted effects for aminoglycoside antibiotics (nephrotoxicity: RR 0.67, 95% CI 0.42 to 1.06) and anti-rejection drugs (cytomegalovirus infections: RR 0.90, 95% CI 0.58 to 1.40);5. it tended to reduce the length of time spent in the hospital although the difference was not significant (SMD -0.15, 95% CI -0.33 to 0.02) and to achieve comparable or better cost-effectiveness ratios than usual care;6. there was no evidence of differences in mortality or other clinical adverse events for insulin (hypoglycaemia), anaesthetic agents, anti-rejection drugs and antidepressants.For all outcomes, statistical heterogeneity quantified by I(2) statistics was moderate to high. AUTHORS' CONCLUSIONS This review update suggests that computerized advice for drug dosage has some benefits: it increases the serum concentrations for aminoglycoside antibiotics and improves the proportion of people for which the plasma drug is within the therapeutic range for aminoglycoside antibiotics.It leads to a physiological parameter more often within the desired range for oral anticoagulants and insulin. It decreases the time to achieve stabilization for oral anticoagulants. It tends to decrease unwanted effects for aminoglycoside antibiotics and anti-rejection drugs, and it significantly decreases thromboembolism events for anticoagulants. It tends to reduce the length of hospital stay compared with routine care while comparable or better cost-effectiveness ratios were achieved.However, there was no evidence that decision support had an effect on mortality or other clinical adverse events for insulin (hypoglycaemia), anaesthetic agents, anti-rejection drugs and antidepressants. In addition, there was no evidence to suggest that some decision support technical features (such as its integration into a computer physician order entry system) or aspects of organization of care (such as the setting) could optimize the effect of computerized advice.Taking into account the high risk of bias of, and high heterogeneity between, studies, these results must be interpreted with caution.
Collapse
Affiliation(s)
- Florence Gillaizeau
- French Cochrane Center, Hôpital Hôtel-Dieu, 1 place du Parvis Notre-Dame, Paris, France, 75004
| | | | | | | | | | | | | | | |
Collapse
|
8
|
Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ, Svensson PJ, Veenstra DL, Crowther M, Guyatt GH. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e152S-e184S. [PMID: 22315259 DOI: 10.1378/chest.11-2295] [Citation(s) in RCA: 889] [Impact Index Per Article: 74.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND High-quality anticoagulation management is required to keep these narrow therapeutic index medications as effective and safe as possible. This article focuses on the common important management questions for which, at a minimum, low-quality published evidence is available to guide best practices. METHODS The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. RESULTS Most practical clinical questions regarding the management of anticoagulation, both oral and parenteral, have not been adequately addressed by randomized trials. We found sufficient evidence for summaries of recommendations for 23 questions, of which only two are strong rather than weak recommendations. Strong recommendations include targeting an international normalized ratio of 2.0 to 3.0 for patients on vitamin K antagonist therapy (Grade 1B) and not routinely using pharmacogenetic testing for guiding doses of vitamin K antagonist (Grade 1B). Weak recommendations deal with such issues as loading doses, initiation overlap, monitoring frequency, vitamin K supplementation, patient self-management, weight and renal function adjustment of doses, dosing decision support, drug interactions to avoid, and prevention and management of bleeding complications. We also address anticoagulation management services and intensive patient education. CONCLUSIONS We offer guidance for many common anticoagulation-related management problems. Most anticoagulation management questions have not been adequately studied.
Collapse
Affiliation(s)
- Anne Holbrook
- Division of Clinical Pharmacology and Therapeutics, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Daniel M Witt
- Department of Pharmacy, Kaiser Permanente Colorado, Denver, CO
| | - Per Olav Vandvik
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | - Jason Fish
- Department of Internal Medicine, University of California Los Angeles, Los Angeles, CA
| | - Michael J Kovacs
- Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Peter J Svensson
- Department for Coagulation Disorders, University of Lund, University Hospital, Malmö, Sweden
| | | | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gordon H Guyatt
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
9
|
Nieuwlaat R, Connolly SJ, Mackay JA, Weise-Kelly L, Navarro T, Wilczynski NL, Haynes RB. Computerized clinical decision support systems for therapeutic drug monitoring and dosing: a decision-maker-researcher partnership systematic review. Implement Sci 2011; 6:90. [PMID: 21824384 PMCID: PMC3170236 DOI: 10.1186/1748-5908-6-90] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 08/03/2011] [Indexed: 11/26/2022] Open
Abstract
Background Some drugs have a narrow therapeutic range and require monitoring and dose adjustments to optimize their efficacy and safety. Computerized clinical decision support systems (CCDSSs) may improve the net benefit of these drugs. The objective of this review was to determine if CCDSSs improve processes of care or patient outcomes for therapeutic drug monitoring and dosing. Methods We conducted a decision-maker-researcher partnership systematic review. Studies from our previous review were included, and new studies were sought until January 2010 in MEDLINE, EMBASE, Evidence-Based Medicine Reviews, and Inspec databases. Randomized controlled trials assessing the effect of a CCDSS on process of care or patient outcomes were selected by pairs of independent reviewers. A study was considered to have a positive effect (i.e., CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive. Results Thirty-three randomized controlled trials were identified, assessing the effect of a CCDSS on management of vitamin K antagonists (14), insulin (6), theophylline/aminophylline (4), aminoglycosides (3), digoxin (2), lidocaine (1), or as part of a multifaceted approach (3). Cluster randomization was rarely used (18%) and CCDSSs were usually stand-alone systems (76%) primarily used by physicians (85%). Overall, 18 of 30 studies (60%) showed an improvement in the process of care and 4 of 19 (21%) an improvement in patient outcomes. All evaluable studies assessing insulin dosing for glycaemic control showed an improvement. In meta-analysis, CCDSSs for vitamin K antagonist dosing significantly improved time in therapeutic range. Conclusions CCDSSs have potential for improving process of care for therapeutic drug monitoring and dosing, specifically insulin and vitamin K antagonist dosing. However, studies were small and generally of modest quality, and effects on patient outcomes were uncertain, with no convincing benefit in the largest studies. At present, no firm recommendation for specific systems can be given. More potent CCDSSs need to be developed and should be evaluated by independent researchers using cluster randomization and primarily assess patient outcomes related to drug efficacy and safety.
Collapse
Affiliation(s)
- Robby Nieuwlaat
- Population Health Research Institute, McMaster University, Hamilton General Hospital Campus, 237 Barton Street East, Hamilton, ON, Canada
| | | | | | | | | | | | | | | |
Collapse
|
10
|
|
11
|
Ahmadian L, van Engen-Verheul M, Bakhshi-Raiez F, Peek N, Cornet R, de Keizer NF. The role of standardized data and terminological systems in computerized clinical decision support systems: literature review and survey. Int J Med Inform 2010; 80:81-93. [PMID: 21168360 DOI: 10.1016/j.ijmedinf.2010.11.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 11/13/2010] [Accepted: 11/13/2010] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Clinical decision support systems (CDSSs) should be seamlessly integrated with existing clinical information systems to enable automatic provision of advice at the time and place where decisions are made. It has been suggested that a lack of agreed data standards frequently hampers this integration. We performed a literature review to investigate whether CDSSs used standardized (i.e. coded or numerical) data and which terminological systems have been used to code data. We also investigated whether a lack of standardized data was considered an impediment for CDSS implementation. METHODS Articles reporting an evaluation of a CDSS that provided a computerized advice based on patient-specific data items were identified based on a former literature review on CDSS and on CDSS studies identified in AMIA's 'Year in Review'. Authors of these articles were contacted to check and complete the extracted data. A questionnaire among the authors of included studies was used to determine the obstacles in CDSS implementation. RESULTS We identified 77 articles published between 1995 and 2008. Twenty-two percent of the evaluated CDSSs used only numerical data. Fifty one percent of the CDSSs that used coded data applied an international terminology. The most frequently used international terminology were the ICD (International Classification of Diseases), used in 68% of the cases and LOINC (Logical Observation Identifiers Names and Codes) in 12% of the cases. More than half of the authors experienced barriers in CDSS implementation. In most cases these barriers were related to the lack of electronically available standardized data required to invoke or activate the CDSS. CONCLUSION Many CDSSs applied different terminological systems to code data. This diversity hampers the possibility of sharing and reasoning with data within different systems. The results of the survey confirm the hypothesis that data standardization is a critical success factor for CDSS development.
Collapse
Affiliation(s)
- Leila Ahmadian
- Dept. of Medical Informatics, Academic Medical Center, University of Amsterdam, The Netherlands.
| | | | | | | | | | | |
Collapse
|
12
|
Abstract
Although warfarin has been the mainstay of oral anticoagulation therapy for decades, evidence-based methods for improving the quality of warfarin therapy remain underused. The arrival of new anticoagulants that do not require routine laboratory monitoring and lack the significant dietary and drug interaction potential that are seen with warfarin is an important evolutionary step in the management of thromboembolic disease. However, it will be years before the efficacy and long-term safety of these new agents are defined. Newer oral anticoagulants will be more expensive than generic warfarin. This article examines various approaches to optimize the clinical use of warfarin. For patients able to achieve stable anticoagulation control, warfarin remains an important therapeutic option, delivering similar clinical outcomes at a fraction of the cost to the health care system.
Collapse
|
13
|
Louis KM, Martineau J, Rodrigues I, Fournier M, Berbiche D, Blais N, Ginsberg J, Blais L, Montigny M, Perreault S, Vanier MC, Lalonde L. Primary care practices and determinants of optimal anticoagulation management in a collaborative care model. Am Heart J 2010; 159:183-9. [PMID: 20152215 DOI: 10.1016/j.ahj.2009.11.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Accepted: 11/18/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND In a collaborative care model (CCM) for managing oral anticoagulant therapy, patients are followed at a pharmacist-managed anticoagulation service and, once stabilized, are transferred to their primary care physician. The objective of this study was to describe physicians' clinical practices and the practice characteristics associated with better international normalized ratio (INR) control in a CCM. METHODS A telephone questionnaire about their practices was administered to 121 physicians exposed to a CCM. The physicians followed 121 patients for a mean of 14.5 weeks. The percentage of time within the exact INR target range was computed and dichotomized (> or = or < median time within target range). Determinants of better INR control were identified using logistic regression models. RESULTS The survey revealed that, after discharge from the pharmacist-managed anticoagulation service, patients are followed mainly by physicians and their secretaries. Physicians do not often consult other health professionals. Few report using technological resources to obtain INR results (39.7%), document medical follow-up (6.6%), or detect drug (32.2%) and food (9.9%) interactions. The median percentage of time within the exact INR target range was 84%. Determinants of better INR control include using computerized support to monitor patients (odds ratio [OR] 9.16, 95% CI 1.77-47.4) and detect drug interactions (OR 3.49, 95% CI 1.71-7.10) and consulting specialists (OR 5.92, 95% CI 1.49-32.48). CONCLUSIONS Primary care physicians are poorly supported by technological and human resources to monitor patients on oral anticoagulant. Even in a CCM, interprofessional collaboration and better technological support may be associated with optimal INR control.
Collapse
Affiliation(s)
- Kerby Maud Louis
- Biomedical Science Department, Faculty of Medicine, University of Montreal, Montreal, Canada
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Changes in surrogate outcomes can be translated into clinical outcomes using a Monte Carlo model. J Clin Epidemiol 2009; 62:1306-15. [DOI: 10.1016/j.jclinepi.2009.01.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Revised: 01/19/2009] [Accepted: 01/28/2009] [Indexed: 11/19/2022]
|
15
|
Pearson SA, Moxey A, Robertson J, Hains I, Williamson M, Reeve J, Newby D. Do computerised clinical decision support systems for prescribing change practice? A systematic review of the literature (1990-2007). BMC Health Serv Res 2009; 9:154. [PMID: 19715591 PMCID: PMC2744674 DOI: 10.1186/1472-6963-9-154] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2008] [Accepted: 08/28/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Computerised clinical decision support systems (CDSSs) are used widely to improve quality of care and patient outcomes. This systematic review evaluated the impact of CDSSs in targeting specific aspects of prescribing, namely initiating, monitoring and stopping therapy. We also examined the influence of clinical setting (institutional vs ambulatory care), system- or user-initiation of CDSS, multi-faceted vs stand alone CDSS interventions and clinical target on practice changes in line with the intent of the CDSS. METHODS We searched Medline, Embase and PsychINFO for publications from 1990-2007 detailing CDSS prescribing interventions. Pairs of independent reviewers extracted the key features and prescribing outcomes of methodologically adequate studies (experiments and strong quasi-experiments). RESULTS 56 studies met our inclusion criteria, 38 addressing initiating, 23 monitoring and three stopping therapy. At the time of initiating therapy, CDSSs appear to be somewhat more effective after, rather than before, drug selection has occurred (7/12 versus 12/26 studies reporting statistically significant improvements in favour of CDSSs on = 50% of prescribing outcomes reported). CDSSs also appeared to be effective for monitoring therapy, particularly using laboratory test reminders (4/7 studies reporting significant improvements in favour of CDSSs on the majority of prescribing outcomes). None of the studies addressing stopping therapy demonstrated impacts in favour of CDSSs over comparators. The most consistently effective approaches used system-initiated advice to fine-tune existing therapy by making recommendations to improve patient safety, adjust the dose, duration or form of prescribed drugs or increase the laboratory testing rates for patients on long-term therapy. CDSSs appeared to perform better in institutional compared to ambulatory settings and when decision support was initiated automatically by the system as opposed to user initiation. CDSSs implemented with other strategies such as education were no more successful in improving prescribing than stand alone interventions. Cardiovascular disease was the most studied clinical target but few studies demonstrated significant improvements on the majority of prescribing outcomes. CONCLUSION Our understanding of CDSS impacts on specific aspects of the prescribing process remains relatively limited. Future implementation should build on effective approaches including the use of system-initiated advice to address safety issues and improve the monitoring of therapy.
Collapse
Affiliation(s)
- Sallie-Anne Pearson
- UNSW Cancer Research Centre, University of New South Wales and Prince of Wales Clinical School, Sydney, Australia.
| | | | | | | | | | | | | |
Collapse
|
16
|
Cios DA, Baker WL, Sander SD, Phung OJ, Coleman CI. Evaluating the impact of study-level factors on warfarin control in U.S.-based primary studies: a meta-analysis. Am J Health Syst Pharm 2009; 66:916-25. [PMID: 19420310 DOI: 10.2146/ajhp080507] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The effect of study-level factors on the proportion of time spent with International Normalized Ratio (INR) values inside the therapeutic range in patients treated with warfarin in the United States was evaluated. METHODS Studies evaluated in a previous meta-analysis were screened for potential inclusion, in addition to a systematic literature search of databases from January 2005 through February 2008. Studies were included if they (1) contained at least one warfarin dosing group that enrolled >25 patients for whom INR control was monitored for at least three weeks, (2) included only patients treated in the United States, (3) used a patient-time approach to report outcomes, and (4) reported proportion of time spent in the therapeutic INR range. Analyses included determining how study-level factors, such as study setting, year of study publication, INR interpolation method, study design, and presence of self-management, affected outcomes. RESULTS Twenty-four studies, including a total of 43 unique warfarin groups, were included in the analysis. Overall, patients spent 57% of their time in the therapeutic range (95% confidence interval [CI], 55-59%). Compared with anticoagulation clinics, community management resulted in less time (-13%; 95% CI, -18% to -7.9%) and prospective studies resulted in more time (7.3%; 95% CI, 1.5-13.1%) spent in the therapeutic range than retrospective studies. When studies from both the United States and Canada were included, similar results to those in the base-case analysis were seen; however, study year and interpolation method were also found to be significant modifiers of INR control. CONCLUSION Patients included in the meta-analysis maintained INR values within the therapeutic range 57% of the time, although the use of anticoagulation clinic services appeared to be superior to standard community care in this regard. However, patients treated in anticoagulation clinics had INR values within the therapeutic range less than two thirds of the time.
Collapse
Affiliation(s)
- Deborah A Cios
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | | |
Collapse
|
17
|
Su EY, Naganathan V, Fallah H, Bajorek BV, McLachlan AJ. Anticoagulation Control in Hospitalised Patients on Warfarin. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2008. [DOI: 10.1002/j.2055-2335.2008.tb00392.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Elaine Y Su
- Faculty of Pharmacy; The University of Sydney
| | - Vasi Naganathan
- Centre for Education and Research on Ageing, Concord Repatriation General Hospital, and Faculty of Medicine; The University of Sydney
| | | | - Beata V Bajorek
- Northern Sydney Central Coast Health, and Faculty of Pharmacy; The University of Sydney
| | - Andrew J McLachlan
- Centre for Education and Research on Ageing, Concord Repatriation General Hospital, and Faculty of Pharmacy; The University of Sydney; Sydney New South Wales
| |
Collapse
|
18
|
ONUNDARSON PT, EINARSDOTTIR KA, GUDMUNDSDOTTIR BR. Warfarin anticoagulation intensity in specialist-based and in computer-assisted dosing practice. Int J Lab Hematol 2008; 30:382-9. [DOI: 10.1111/j.1751-553x.2007.00976.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
19
|
van Walraven C, Jennings A, Oake N, Fergusson D, Forster AJ. Effect of Study Setting on Anticoagulation Control. Chest 2006; 129:1155-66. [PMID: 16685005 DOI: 10.1378/chest.129.5.1155] [Citation(s) in RCA: 358] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND For patients receiving therapy with oral anticoagulants (OACs), the proportion of time spent in the therapeutic range (ie, anticoagulation control) is strongly associated with bleeding and thromboembolic risk. The effect of study-level factors, especially study setting, on anticoagulation control is unknown. OBJECTIVES Describe anticoagulation control achieved in the published literature. We also used metaregressive techniques to determine which study-level factors significantly influenced anticoagulation control. STUDIES All published randomized or cohort studies that measured international normalized ratios (INRs) serially in anticoagulated patients and reported the proportion of time between INRs ranging from 1.8 to 2.0 and 3.0 to 3.5. RESULTS We identified 67 studies with 123 patient groups having 50,208 patients followed for a total of 57,154.7 patient-years. A total of 68.3% of groups were from anticoagulation clinics, 7.3% were from clinical trials, and 24.4% were from community practices. Overall, patients were therapeutic 63.6% of time (95% confidence interval [CI], 61.6 to 65.6). In the metaregression model, study setting had the greatest effect on anticoagulation control with studies in community practices having significantly lower control than either anticoagulation clinics or clinical trials (-12.2%; 95% CI, -19.5 to -4.8; p < 0.0001). Self-management was associated with a significant improvement of time spent in the therapeutic range (+7.0%; 95% CI, 0.7 to 13.3; p = 0.03). CONCLUSIONS Patients who have received anticoagulation therapy spend a significant proportion of their time with an INR out of the therapeutic range. Patients from community practices showed significantly worse anticoagulation control than those from anticoagulation clinics or clinical trials. This should be considered when interpreting the results of, and generalizing from, studies involving OACs.
Collapse
Affiliation(s)
- Carl van Walraven
- Clinical Epidemiology Program, Ottawa Health Research Institute, C405, Ottawa Hospital, Civic Campus, 1053 Carling Ave, Ottawa, ON, K1Y 4E9 Canada.
| | | | | | | | | |
Collapse
|