OBJECTIVES: To evaluate the effectiveness of computer-assisted decision support in reducing potentially inappropriate prescribing to older adults. DESIGN: Randomized, controlled trial. SETTING: An academic emergency department (ED) in Indianapolis, Indiana, where computerized physican order entry was used to write all medication prescriptions. Participants: Sixty-three emergency physicians were randomized to the intervention (32 physicians) or control (31 physicians) group. Intervention: Decision support that advised against use of nine potentially inappropriate medications and recommended safer substitute therapies. Measurements: The primary outcome was the proportion of ED visits by seniors that resulted in one or more prescriptions for an inappropriate medication. The main secondary outcomes were the proportions of medications prescribed that were inappropriate and intervention physicians' reasons for rejecting the decision support. RESULTS: The average age of the patients was 74, two-thirds were female, and just over half were African American. Decision support was provided 114 times to intervention physicians, who accepted 49 (43%) of the recommendations. Intervention physicians prescribed one or more inappropriate medications during 2.6% of ED visits by seniors, compared with 3.9% of visits managed by control physicians (<i>P</i> = .02; odds ratio = 0.55, 95% confidence interval = 0.34-0.89). The proportion of all prescribed medications that were inappropriate significantly decreased from 5.4% to 3.4%. The most common reason for rejecting decision support was that the patient had no prior problems with the medication. CONCLUSION: Computerized physican order entry with decision support significantly reduced prescribing of potentially inappropriate medications for seniors. This approach might be used in other efforts to improve ED care. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
OBJECTIVE: The aim of this study was to compare a standard insulin protocol with a computer-guided glucose management system to determine which method achieves tighter glucose control.
DESIGN: A prospective, randomized trial.
SETTING: A cardiothoracic intensive care unit (ICU) in a large academic medical center.
PARTICIPANTS: Forty patients with diabetes mellitus who were scheduled for cardiac surgery.
INTERVENTIONS: After induction of anesthesia and for the first 9 hours in the ICU, each subject received a standardized infusion of a 10% glucose solution at a rate of 1.0 mL/kg/h (ideal body weight). The subjects were then randomized to have their glucose controlled by either a paper-based insulin protocol or by a computer-guided glucose management system (CG). The desired range for blood glucose was set between 90 and 150 mg/dL.
MEASUREMENTS AND MAIN RESULTS: There were no differences between groups in baseline characteristics. Patients in the CG group spent more time in the desired range during both the intraoperative phase (49% v 27%, p = 0.001) and the ICU phase (84% v 60%, p < 0.0001). There were no statistical differences between groups in the number of hypoglycemia episodes.
CONCLUSIONS: The computer-guided glucose management system achieved tighter blood glucose control than a standard paper-based protocol in diabetic patients undergoing cardiac surgery. However, the low proportion of blood glucose recordings within the desired range in both groups during the intraoperative period reflects the challenges associated with achieving normoglycemia during cardiac surgery.
OBJECTIVE: To compare effects on premature infants' weight gain of a computer-generated and a nurse-determined incubator humidity strategy. An optimal humidity protocol is thought to reduce time to regain birthweight.
DESIGN: Prospective randomized controlled design.
SETTING: Level IIIC neonatal intensive care unit in the Netherlands.
PARTICIPANTS: Infants of 24 to 30 weeks gestational age with a birthweight less than 1,500 g.
INTERVENTION: Two incubator humidity strategies were studied: computer-generated and nurse-determined humidity. Main outcome measure: Time needed to regain birthweight.
RESULTS: One hundred thirty six infants were enrolled: 65 were exposed to the computer-generated strategy and 71 to the nurse-determined strategy. Demographic characteristics were well balanced between groups, with birthweight 981 +/- 245 versus 991 +/- 213 g, mean gestational age 27.7 +/- 1.7 versus 27.7 +/- 1.6 weeks. Main outcome did not significantly differ between strategies: survival analysis showed an equal number of days needed to regain birthweight (median 9 days, with 95% CIs 8-10 and 7-11 for infants exposed to the computer-generated and nurse-determined humidity strategy, respectively).
CONCLUSION: Computer-generated strategy does not reduce the time needed to regain birthweight.
Guided dosing within a computerized provider order entry (CPOE) system is an effective method of individualizing therapy for patients. Physicians' responses to guided dosing decision support have not been extensively studied. As part of a randomized trial evaluating efficacy of dosing advice on reducing falls in the elderly, CPOE prompts to physicians for 88 drugs included tailored messages and guided dose lists with recommended initial doses and frequencies. The study captured all prescribing activity electronically. The primary outcome was the ratio between prescribed dose and recommended dose. Over 9 months, 778 providers entered 9111 study-related medication orders on 2981 patients. Physicians using guided orders chose recommended doses more often than controls(28.6% vs. 24.1%, p<0.001). Selected doses were significantly lower in the intervention group (median ratio of actual to recommended 2.5, interquartile range [1.0,4.0]) than the control group (median 3.0 interquartile range [1.5,5.0], p<0.001). While physicians selected the recommended dose less than a third of the time, guided geriatric dosing modestly improved compliance with guidelines.
BACKGROUND: Overuse of blood products is common, but prior efforts to improve transfusion decisions have met with limited success. STUDY DESIGN AND METHODS: This study examines transfusion practices before and after a conventional educational intervention followed by a randomized controlled trial of a decision support (DS) intervention with computerized physician order entry (CPOE) for red blood cell, platelet, and fresh-frozen plasma orders. The study was conducted in an academic medical center between April 2003 and June 2004. Orders originating from units not using CPOE with DS (e.g., the emergency department) were excluded. Junior housestaff were randomly assigned into a control group and an intervention group who received DS for transfusion orders. Transfusion orders were initially classified according to guideline rules as DS-agree or DS-disagree. Chart reviews assessed inappropriateness for all DS-disagree orders and a sample of DS-agree orders. The total of inappropriate transfusion orders included chart review confirmed DS-disagree orders and DS-agree orders reclassified as inappropriate. RESULTS: The percentages of inappropriate nonemergent transfusion orders during the baseline phase for the entire staff and randomly assigned junior housestaff were 72.6 percent (2154/2967) and 71.9 percent (1259/1752) and improved after conventional education to 63.8 percent (1699/2663; p < 0.0001) and 63.3 percent (1263/1996; p < 0.0001), respectively. The percentage of inappropriate orders in the DS intervention group continued to improve (59.6%, 804/1350; p < 0.0001). Physicians accepted 14 percent (133/939) of new DS-recommended orders, especially recommendations to increase transfusion doses (73%). CONCLUSIONS: Education and computerized DS both decreased the percentage of inappropriate transfusions, although the residual amount of inappropriate transfusions remained high.
Objectives: Having shown previously that an electronic prescription writer and decision support system improved pediatric prescribing behavior for otitis media in an academic clinic setting, we assessed whether point-of-care delivery of evidence could demonstrate similar effects for a wide range of other common pediatric conditions. Design: Cluster randomized controlled trial. Setting: A teaching clinic/clinical practice site and a primary care pediatric clinic serving a rural and semi-urban patient mix. Participants: A total of 36 providers at the teaching clinic/practice site and eight providers at the private primary pediatric clinic. Intervention: An evidence-based message system that presented real-time evidence to providers based on prescribing practices for acute otitis media, allergic rhinitis, sinusitis, constipation, pharyngitis, croup, urticaria, and bronchiolitis. Outcome measures: The proportion of prescriptions dispensed in accordance with evidence. Results: The proportion of prescriptions dispensed in accordance with evidence improved four percentage points, from 38% at baseline to 42% following the intervention. The control group improved by one percentage point, from 39% at baseline to 40% at trial's conclusion. The adjusted difference between the intervention and control groups was 8% (95% confidence interval 1%, 15%). Intervention effectiveness did not decrease with time. Conclusion: For common pediatric outpatient conditions, a point-of-care evidence-based prescription writer and decision support system was associated with significant improvements in prescribing practices.
OBJECTIVE: We developed AsthmaCritic, a non-inquisitive critiquing system integrated with the general practitioners' electronic medical records. The system is based on the guidelines for asthma and chronic obstructive pulmonary disease (COPD) as issued by the Dutch College of General Practitioners. This paper assesses the effect of AsthmaCritic on monitoring and treatment of asthma and COPD by Dutch general practitioners in daily practice. METHODS: A randomized clinical trial in 32 practices (40 Dutch general practitioners) using electronic patient records. An intervention group was given the use of AsthmaCritic, a control group continued working in the usual manner. Both groups had the disposal of the asthma and COPD guidelines routinely distributed by the Dutch College of General Practitioners. We measured the average number of contacts, FEV 1 (forced expiratory volume), and peak-flow measurements per asthma/COPD patient per practice; and, the average number of antihistamine, cromoglycate, deptropine, and oral bronchodilator prescriptions per asthma/COPD patient per practice. RESULTS: The number of contacts increased in the age group of 12-39 years. The number of FEV1 , peak-flow measurements, and the ratio of coded measurements increased, whereas the number of cromoglycate prescriptions decreased in the age group of 12-39 years. CONCLUSIONS: Our study shows that the guideline-based critiquing system AsthmaCritic changed the manner in which the physicians monitored their patients and, to a lesser extent, their treatment behavior. In addition, the physicians changed their data-recording habits.
OBJECTIVE: To assess the effect of a computerized decision support system (CDSS) on the accuracy of patient temperature recording at the bed side.
DESIGN: This is a randomized, controlled trial comparing nurses assigned to an intervention group that received CDSS whenever they attempted to store a low temperature (</= 96.4 degrees F) or a control group that received no CDSS.
MEASUREMENTS: The computer recorded temperatures that would trigger reminders equally in both control and intervention groups. It also logged the reactions of nurses who received reminders and whether they retook the patient's temperature or chose to store the original low value.
RESULTS: We analyzed the temperature data over a 10-month period tracking a total of 44339 temperatures taken by the control group and 45823 temperatures taken by the intervention group. We showed a 51% relative reduction in the number of erroneous low temperatures stored by the intervention versus the control group.
CONCLUSION: CDSS are effective with nursing personnel in improving the accuracy of temperature capture at the bedside.
To evaluate the effectiveness of computer-assisted decision support in reducing potentially inappropriate prescribing to older adults.
DESIGN:
Randomized, controlled trial.
SETTING:
An academic emergency department (ED) in Indianapolis, Indiana, where computerized physican order entry was used to write all medication prescriptions. Participants: Sixty-three emergency physicians were randomized to the intervention (32 physicians) or control (31 physicians) group. Intervention: Decision support that advised against use of nine potentially inappropriate medications and recommended safer substitute therapies. Measurements: The primary outcome was the proportion of ED visits by seniors that resulted in one or more prescriptions for an inappropriate medication. The main secondary outcomes were the proportions of medications prescribed that were inappropriate and intervention physicians' reasons for rejecting the decision support.
RESULTS:
The average age of the patients was 74, two-thirds were female, and just over half were African American. Decision support was provided 114 times to intervention physicians, who accepted 49 (43%) of the recommendations. Intervention physicians prescribed one or more inappropriate medications during 2.6% of ED visits by seniors, compared with 3.9% of visits managed by control physicians (P = .02; odds ratio = 0.55, 95% confidence interval = 0.34-0.89). The proportion of all prescribed medications that were inappropriate significantly decreased from 5.4% to 3.4%. The most common reason for rejecting decision support was that the patient had no prior problems with the medication.
CONCLUSION:
Computerized physican order entry with decision support significantly reduced prescribing of potentially inappropriate medications for seniors. This approach might be used in other efforts to improve ED care. (PsycInfo Database Record (c) 2021 APA, all rights reserved)