A trial of inpatient indication based prescribing during computerized order entry with medications commonly used off-label

BACKGROUND

Requiring indications for inpatient medication orders may improve the quality of prescribing and allow for easier placement of diagnoses on the problem list. Indications for inpatient medication orders are also required by some regulators.

OBJECTIVE

This study assessed a clinical decision support (CDS) system designed to obtain indications and document problems during inpatient computerized physician order entry (CPOE) of medications frequently used off-label.

METHODS

A convenience sample of three medications frequently used off-label were selected: the PPI lansoprazole; intravenous immune globulin, and recombinant Factor VIIa. Alerts triggered when a medication was ordered without an FDA approved indication in the problem list. The alerts prompted clinicians to enter either a labeled or off-label indication for the order. Chart review was used as the gold standard to assess the accuracy of clinician entered information.

RESULTS

The PPI intervention generated 873 alerts during 60 days of operation; IVIG 55 alerts during alerts during 93 days; Factor VIIa 25 alerts during 175 days. Agreement between indications entered and chart review was 63% for PPI, 49% for IVIG, and 29% for Factor VIIa. The alerts for PPI, IVIG and Factor VIIa alerts produced accurate diagnoses for the problem list 9%, 16% and 24% respectively. Rates of off-label use measured by chart review were 87% for PPI, and 100% for IVIG and factor VIIa, which were higher than if measured using the ordering clinicians' indications.

CONCLUSION

This trial of indication-based prescribing using CDS and CPOE produced less than optimal accuracy of the indication data as well as a low yield of accurate problems placed on the problem list. These results demonstrate the challenge inherent in obtaining accurate indication information during prescribing and should raise concerns over potential mandates for indication based prescribing and motivate further study of appropriate mechanisms to obtain indications during CPOE.

Anaesthetists' and surgeons' attitudes towards informed consent in the UK: an observational study

BACKGROUND

The attitudes of patients' to consent have changed over the years, but there has been little systematic study of the attitudes of anaesthetists and surgeons in this process. We aimed to describe observations made on the attitudes of medical professionals working in the UK to issues surrounding informed consent.

METHOD

A questionnaire made up of 35 statements addressing the process of consent for anaesthesia and surgery was distributed to randomly selected anaesthetists and surgeons in Queen's Medical Centre (Nottingham), Royal Sussex County Hospital (Brighton) and Eastbourne District General Hospital (Eastbourne) during 2007. Participants were asked to what extent they agreed with statements regarding consent.

RESULTS

Of 234 questionnaires distributed, 63% were returned. Of the respondents 79% agreed that the main purpose of the consent process is to respect patient autonomy. While 55% of the examined cohort agreed that the consent process maybe inappropriate as patients do not usually remember all the information given to them. Furthermore, 84% of the participants agreed that what the procedure aims to achieve should be explained to the patient during the consent process. While of the participants, over 70% agreed that major risks of incidence greater than 1/100 should be disclosed to the patient as part of the consent process.

CONCLUSIONS

The majority of respondents appear to hold attitudes in standing with current guidelines on informed consent however there was still a significant minority who held more paternalistic views to the consent process bringing into question the need for further training in the area.

Analysis of the use of digoxin immune fab for the treatment of non-life-threatening digoxin toxicity

BACKGROUND

Studies indicate that digoxin toxicity often results in lengthy hospitalizations and considerable costs, both of which may be decreased through the routine use of digoxin immune Fab (FAB).

METHODS

A computer-based decision analysis model was developed to compare the treatment of non-life-threatening digoxin toxicity with either FAB or standard therapy from the hospital perspective. A cost-minimization analysis was then performed to compare overall total costs (primary endpoint) for each treatment branch. A secondary endpoint of length of hospital stay (LOS) was also compared between the 2 groups. Clinical variables (serum digoxin concentration [SDC], creatinine clearance [Clcr], and body weight), event probabilities, and other model-specific variables were varied in univariate and multivariate sensitivity analyses.

RESULTS

FAB was associated with an incremental cost of $54 compared with standard therapy ($2,784 vs. $2,730, respectively) but reduced LOS by 1.5 days (1.5 days vs. 3.0 days, respectively). Sensitivity analyses show that FAB is less costly at SDC > 3.5 ng/mL and Clcr < 22 mL/min. FAB reduced LOS at SDC > 2.3 ng/mL. Monte Carlo simulation revealed that FAB was less costly in 37% of the cases and reduced LOS 72% of the time compared with standard therapy.

CONCLUSIONS

The abbreviated LOS associated with the use of FAB in patients with non-life-threatening digoxin toxicity may translate into lower treatment costs in many clinical scenarios, making it a cost-saving alternative to standard therapy in patients with high SDC and renal dysfunction.

Advances in use of the 5-HT3 receptor antagonists

Nausea and vomiting continue to rank as important side effects for cancer patients receiving chemotherapy. The class of drugs known as the 5-HT3 receptor antagonists have become widely used for chemotherapy-induced nausea and vomiting, and are considered a standard part of care for moderately- and highly-emetogenic chemotherapy in combination with corticosteroids. Ondansetron (Zofran, Glaxo Wellcome), granisetron (Kytril, SmithKline Beecham) and dolasetron (Anzemet, Hoechst Marion Roussel) are commercially available in the US. Intravenous forms of all three drugs have demonstrated efficacy in preventing acute (< or = 24 h following chemotherapy) nausea and emesis due to moderately- and highly-emetogenic chemotherapy. Oral forms of the drugs have been shown to be effective in prevention of nausea and emesis due to moderately-emetogenic chemotherapy. More recently, oral 5-HT3 receptor antagonists have demonstrated efficacy in the prevention of nausea and vomiting due to highly-emetogenic chemotherapy as well. Comparative trials between the three agents have shown no clinically important differences in outcome and they should be considered clinically equivalent. Optimal oral anti-emetic regimens for high-dose chemotherapy with bone marrow or stem cell transplantation remain to be determined and future oral studies should target this population. In general, the decision of which 5-HT3 receptor antagonist to select for formulary inclusion should be based on the dose of anti-emetic used and the acquisition cost of the agents being compared. The oral route should be used whenever possible.

Therapeutic use of colony stimulating factors for established neutropenic fever

The hematopoietic growth factors granulocyte colony-stimulating factor (G-CSF) and granulocyte-macrophage colony-stimulating factor (GM-CSF) are approved only for prophylaxis of infectious complications secondary to the use of chemotherapy, yet both are often used off-label therapeutically in conjunction with antibiotics following the onset of neutropenic fever. Several recent trials have evaluated the use of CSFs as adjuncts to antibiotic therapy for the management of patients presenting with neutropenic fever following chemotherapy administration. Statistically significant reductions in days of neutropenia by one or two days were observed in some trials but the clinical significance of these results is uncertain. Most trials demonstrated no reductions in duration of hospitalization, number of days of fever, or mortality. Given the current lack of data supporting the use of CSFs as adjuncts to antibiotic therapy in patients presenting with neutropenic fever, and given the high cost of these drugs, their use for this indication is not recommended at this time.

The antenatal diagnosis of fetal abnormalities: a 10 year audit of influencing factors

During the 10 years 1984-1993, a total of 438 fetuses and children with a congenital abnormality, identified antenatally or in the first year of life, were registered from the North Tees Health District with the Northern Region Congenital Abnormality Survey (NorCAS). This represented an abnormality rate of 2% of all births. In total, 252 structural abnormalities (57.5%) were detected by antenatal ultrasound examination. In spite of a targeted education programme, identification of cardiac lesions remained poor. The detection of structural abnormality by antenatal scan rose from 52% in 1984 to 85% in 1993, due mainly to improvements in image quality and resolution of ultrasound equipment. Also important was audit, based both on review of images and feedback from a comprehensive central register (NorCAS).

Outcome of pregnancies referred to a general practitioner maternity unit in a district hospital

OBJECTIVE

To audit the outcome of pregnancies booked for confinement in a general practitioner maternity unit in a district general hospital.

DESIGN

Retrospective review of case records.

SETTING

General practitioner maternity unit in a district general hospital.

PATIENTS

685 Women referred to a general practitioner unit in 1987.

RESULTS

315 Nulliparous women and 330 multiparous women were booked for confinement; 202 women transferred to consultant care before delivery and a further 104 during labour or after delivery. Recognised risk factors, other than nulliparity, rarely predicted the need for transfer. Confinement in the general practitioner unit was associated with low intervention and good fetal outcomes.

CONCLUSIONS

The general practitioner maternity unit provides a safe alternative for confinement in low risk pregnancies. High rates of transfer deny this facility to many women who desire confinement in a low technology environment.

Ethnic considerations in ultrasonic scanning of fetal biparietal diameters

Biparietal diameters (BPD) were determined by ultrasonography on 86 Caucasians and 107 Polynesians at different gestations. Analysis of variance showed a highly significant (p less than 0.01) difference between groups. At any gestational age, Polynesian fetuses had BPDs 1.89 mm greater than Caucasian fetuses and this fact must be taken into consideration when a single measured value of BPD is being used in the estimation of gestational age. In areas where the obstetrical population comprises different ethnic groups, there is a need for establishing local reference tables by race.

Haemangioma of the uterine cervix--case report

A cervical haemangioma of a size not previously reported was found in a 45-year-old parous patient. Treatment was by lateral retrograde hysterectomy.

A survey of tubal ectopic pregnancy, with particular reference to cases following sterilization

In a series of 47 ectopic pregnancies occurring over a 2-year period, 5 followed tubal sterilization. Foreknowledge of the previous sterilization resulted in delay of surgical management. Sterilization techniques should be revised to prevent the incidence of ectopic pregnancy.