Guided medication dosing for inpatients with renal insufficiency

Context Usual drug-prescribing practices may not consider the effects of re nal insufficiency on the disposition of certain drugs. Decision aids may he lp optimize prescribing behavior and reduce medical error. Objective To determine if a system application for adjusting drug close and frequency in patients with renal insufficiency, when merged with a compute rized order entry system, improves drug prescribing and patient outcomes. Design, Setting, and Patients Four consecutive 2-month intervals consisting of control (usual computerized order entry) alternating with intervention (computerized order entry plus decision support system), conducted in Septe mber 1997-April 1998 with outcomes assessed among a consecutive sample of 1 7 828 adults admitted to an urban tertiary care teaching hospital. Intervention Real-time computerized decision support system for prescribing drugs in patients with renal insufficiency. During intervention periods, t he adjusted dose list, default dose amount, and default frequency were disp layed to the order-entry user and a notation was provided that adjustments had been made based on renal insufficiency. During control periods, these r ecommended adjustments were not revealed to the order-entry user, and the u nadjusted parameters were displayed. Main Outcome Measures Rates of appropriate prescription by dose and frequen cy, length of stay, hospital and pharmacy costs, and changes in renal funct ion, compared among patients with renal insufficiency who were hospitalized during the intervention vs control periods. Results A total of 7490 patients were found to have some degree of renal in sufficiency. In this group, 97 151 orders were written on renally cleared o r nephrotoxic medications, of which 14440 (15%) had at least 1 dosing param eter modified Ely the computer based on renal function. The fraction of pre scriptions deemed appropriate during the intervention vs control periods by dose was 67% vs 54% (P<.001) and by frequency was 59% vs 35% (P<.001). Mea n (SD) length of stay was 4.3 (4.5) days vs 4.5 (4.8) days in the intervent ion vs control periods, respectively (P=.009). There were no significant di fferences in estimated hospital and pharmacy costs or in the proportion of patients who experienced a decline in renal function during hospitalization . Conclusions Guided medication dosing for inpatients with renal insufficienc y appears to result in improved dose and frequency choices. This interventi on demonstrates a way in which computer-based decision support systems can improve care.