Clinical decision support implemented with academic detailing improves prescribing of key renally cleared drugs in the hospital setting

Abstract

Objective: Lack of dose adjustment for renally cleared drugs in the presence of poor renal function is a common problem in the hospital setting. The absence of a clinical decision support system (CDSS) from direct clinician workflows such as computerized provider order entry (CPOE) hinders the uptake of CDSS. This study implemented CDSS in an environment independent of CPOE, introduced to prescribers via academic detailing, to address the dosing of renally cleared drugs.

Design: GFR+ was designed to automatically calculate and update renal function, doses of key drugs adjusted for renal function, and highlight clinically significant decreases in renal function. Prescribers were made aware of GFR+, its navigation, and surrounding clinical issues, using academic detailing.

Measurement: The rate of dosing conformity and management for key renally cleared drugs in hospitalized patients, before and after GFR+ implementation.

Results: Improvements were seen in dosing conformity for enoxaparin (from 68% to 86%, p=0.03), gentamicin (63-87%, p=0.01), and vancomycin (47-77%, p=0.07), as well as the appropriate use of gentamicin therapeutic drug monitoring (70-90%, p=0.02). During episodes of acute renal impairment, renally cleared drugs were held on 38% of instances in the pre-intervention period compared with 62% post-intervention (p=0.01).

Conclusion: Clinical decision support implemented with academic detailing improved dosing conformity and management of key renally cleared drugs in a hospitalized population. Academic detailing should be strongly considered to facilitate the introduction of CDSS systems that cannot be placed directly into the clinician workflow.

Figure 1

Prescribing of key drugs and therapeutic drug monitoring. *p<0.05 for difference.

Figure 2

Monthly number of hits per patient on GFR+. 2005—study period (GFR+ with academic detailing performed as part of the study); 2006—GFR+ available, no academic detailing performed, regular use by clinical pharmacists only; 2008—GFR+ available, academic detailing performed as routine clinical practice. p<0.01 for the number of monthly hits per patient in 2005 versus 2006, and 2005 versus 2008. p=0.8 for 2005 versus 2008. Note, data for 2007 were incomplete.