Clinical decision support system supported interventions in hospitalized older patients: a matter of natural course and adequate timing

BACKGROUND

Drug-related problems (DRPs) and potentially inappropriate prescribing (PIP) are associated with adverse patient and health care outcomes. In the setting of hospitalized older patients, Clinical Decision Support Systems (CDSSs) could reduce PIP and therefore improve clinical outcomes. However, prior research showed a low proportion of adherence to CDSS recommendations by clinicians with possible explanatory factors such as little clinical relevance and alert fatigue.

OBJECTIVE

To investigate the use of a CDSS in a real-life setting of hospitalized older patients. We aim to (I) report the natural course and interventions based on the top 20 rule alerts (the 20 most frequently generated alerts per clinical rule) of generated red CDSS alerts (those requiring action) over time from day 1 to 7 of hospitalization; and (II) to explore whether an optimal timing can be defined (in terms of day per rule).

METHODS

All hospitalized patients aged ≥ 60 years, admitted to Zuyderland Medical Centre (the Netherlands) were included. The evaluation of the CDSS was investigated using a database used for standard care. Our CDSS was run daily and was evaluated on day 1 to 7 of hospitalization. We collected demographic and clinical data, and moreover the total number of CDSS alerts; the total number of top 20 rule alerts; those that resulted in an action by the pharmacist and the course of outcome of the alerts on days 1 to 7 of hospitalization.

RESULTS

In total 3574 unique hospitalized patients, mean age 76.7 (SD 8.3) years and 53% female, were included. From these patients, in total 8073 alerts were generated; with the top 20 of rule alerts we covered roughly 90% of the total. For most rules in the top 20 the highest percentage of resolved alerts lies somewhere between day 4 and 5 of hospitalization, after which there is equalization or a decrease. Although for some rules, there is a gradual increase in resolved alerts until day 7. The level of resolved rule alerts varied between the different clinical rules; varying from > 50-70% (potassium levels, anticoagulation, renal function) to less than 25%.

CONCLUSION

This study reports the course of the 20 most frequently generated alerts of a CDSS in a setting of hospitalized older patients. We have shown that for most rules, irrespective of an intervention by the pharmacist, the highest percentage of resolved rules is between day 4 and 5 of hospitalization. The difference in level of resolved alerts between the different rules, could point to more or less clinical relevance and advocates further research to explore ways of optimizing CDSSs by adjustment in timing and number of alerts to prevent alert fatigue.

Electrocardiographic characteristics of patients with coronavirus disease 2019 (COVID-2019) related pneumonia at first presentation

Funding Acknowledgements

Type of funding sources: None.

Purpose

To evaluate electrocardiographic (ECG) characteristics at first presentation in patients with possible coronavirus disease (COVID-19) pneumonia.

Methods and results

356 patients presenting at the emergency room with possible COVID-19 pneumonia based on clinical presentation and computed tomography findings were included and subdivided into a COVID-19 positive group ([COVID-19-positive], n = 231, 65%) and a COVID-19 negative group ([COVID-19-negative], n = 125, 35%) based on polymerase chain reaction tests.

The study population was predominantly middle aged-elderly (67 ± 14 year; n = 235, 66% male). Mortality rate was 24% after 1-month follow-up. There were no significant (NS) differences in sex, age, and mortality between the COVID-19-positive and COVID-19-negative group. 

Atrial fibrillation (AF) was common (9%), though its prevalence was NS (regression analyses adjusted for age and sex) different in the COVID-19-positive vs. the COVID-19-negative group. ECG characteristics reflecting atrial enlargement and repolarization abnormalities were frequently present (<38% and 14% respectively). No significant differences were found between the COVID-19-positive vs. the COVID-19-negative group for the majority of morphological ECG characteristics (Figure 1 for more detailed data). 

Conclusion

AF and ECG characteristics reflecting atrial enlargement and repolarization abnormalities are commonly present in COVID-19 patients. The prevalence of these ECG characteristics however do NS differ from their COVID-19-negative counterparts.

Risk of infections in patients with gout: a population-based cohort study

To investigate the risk of various types of infections (pneumonia and urinary tract infection (UTI)), and infection-related mortality in patients with gout compared with population-based controls. A retrospective cohort study was conducted using data from the UK Clinical Practice Research Datalink (CPRD). All patients with a first diagnosis of gout and aged >40 years between January 1987-July 2014, were included and matched with up to two controls. Time-varying Cox proportional hazards models were used to estimate the risk of infections and mortality. 131,565 patients and 252,763 controls (mean age: 64 years, 74% males, mean follow-up of 6.7 years) were included in the full cohort. After full statistical adjustment, the risk of pneumonia was increased (adj. HR 1.27, 95% CI 1.18 to 1.36), while the risk of UTI (adj. HR 0.99, 95% CI 0.97 to 1.01) was similar in patients compared to controls. No differences between patients and controls were observed for infection-related mortality due to pneumonia (adj. HR 1.03, 95% CI 0.93 to 1.14) or UTI (adj. HR 1.16, 95% CI 0.98 to 1.37). In conclusion, patients with gout did not have decreased risks of pneumonia, UTI or infection-related mortality compared to population-based controls.

Health and Utilities in Patients With Gout Under the Care of a Rheumatologist

OBJECTIVE

To compare limitations in health between Dutch patients with gout and the general population and to determine factors influencing societal and patient values for health as assessed with different utility approaches.

METHODS

A cross-sectional study was done among 110 patients with gout under the care of a rheumatologist, with patients completing the EuroQol 5-domain instrument (EQ-5D), the EQ-5D visual analog scale (EQ-5D VAS), and the Short Form 6-dimensions health survey (SF-6D). Scores on EQ-5D domains were compared with age- and sex-matched general population data. Agreement between utility measures was assessed using the intraclass correlation coefficient (ICC). Mixture modeling was used to assess factors associated with the different approaches to assess utility.

RESULTS

Compared to the general population, gout patients reported more limitations in mobility (66% versus 12%), self-care (24% versus 8%), daily activities (49% versus 24%), and pain (76% versus 45%), but equal anxiety/depressive symptoms (18% versus 19%). For patients with gout, utilities were reduced: the mean, median, and interquartile range, respectively, were 0.74, 0.81, and 0.69-0.84 for EQ-5D, 0.69, 0.67, and 0.59-0.81 for SF-6D, and 66, 70, and 57-77 for EQ-5D VAS. ICC agreement between each pair of utilities was only moderate (0.52-0.59). Only minor differences were seen in the type of variables associated with each utility approach, with worse Health Assessment Questionnaire scores, cardiovascular disease (CVD), gout concern, and gout pain consistently associated with lower utility. The strength of contribution of these variables, however, differed among the 3 approaches.

CONCLUSION

Patients with gout experience substantially impaired health compared to the general population. Although absolute values of utility varied between instruments and perspectives, functional disability, CVD, and higher gout impact contributed to utility independently of which instrument was used.