Context Usual drug-prescribing practices may not consider the effects of renal
insufficiency on the disposition of certain drugs. Decision aids may help
optimize prescribing behavior and reduce medical error.
Objective To determine if a system application for adjusting drug dose and frequency
in patients with renal insufficiency, when merged with a computerized 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 September 1997–April 1998 with
outcomes assessed among a consecutive sample of 17 828 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, the adjusted
dose list, default dose amount, and default frequency were displayed to the
order-entry user and a notation was provided that adjustments had been made
based on renal insufficiency. During control periods, these recommended adjustments
were not revealed to the order-entry user, and the unadjusted parameters were
Main Outcome Measures Rates of appropriate prescription by dose and frequency, length of stay,
hospital and pharmacy costs, and changes in renal function, 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 insufficiency.
In this group, 97 151 orders were written on renally cleared or nephrotoxic
medications, of which 14 440 (15%) had at least 1 dosing parameter modified
by the computer based on renal function. The fraction of prescriptions 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). Mean (SD) length of stay was 4.3 (4.5) days
vs 4.5 (4.8) days in the intervention vs control periods, respectively (P = .009). There were no significant differences 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 insufficiency appears
to result in improved dose and frequency choices. This intervention demonstrates
a way in which computer-based decision support systems can improve care.