Impact of pharmacist-evaluated clinical decision support system alerts on potentially missing or inappropriately prescribed proton pump inhibitors at hospital discharge: a retrospective cross-sectional study

Abstract

Background: Proton pump inhibitors (PPIs) are among the most prescribed drugs. A clinical decision support system (CDSS) could improve their rational use.

Aim: The impact of an electronic algorithm (e-algorithm) implemented in a CDSS on potentially missing or inappropriately prescribed PPIs at hospital discharge, its specificity and sensitivity, and the outcome of the alerts issued were analysed.

Method: An e-algorithm continuously monitored patients of a tertiary care hospital for missing or inappropriate PPIs. Following relevance assessment by a pharmacist, the alerts raised were either displayed in the patients' electronic record or dismissed. After a three-month period, all adult patients' records were retrospectively reviewed for missing or inappropriate PPIs at discharge. The results were compared with a corresponding period before CDSS introduction. Sensitivity, specificity and outcome of alerts were quantified.

Results: In a 3-month period with 5018 patients, the CDSS created 158 alerts for missing PPIs and 464 alerts for inappropriate PPIs. PPI prescribing was proposed 81 times and PPI termination 122 times, with acceptance rates of 73% and 34%, respectively. A specificity of 99.4% and sensitivity of 92.0% for missing PPIs and a specificity of 97.1% and a sensitivity of 69.7% for inappropriate PPIs were calculated. The algorithm reduced incidents of missing PPIs by 63.4% (p < 0.001) and of inappropriate PPIs by 16.2% (p = 0.022).

Conclusion: The algorithm identified patients without necessary gastroprotection or inappropriate PPIs with high specificity and acceptable sensitivity. It positively impacted the rational use of PPIs by reducing incidents of missing and inappropriate PPIs.

Keywords: Clinical decision support systems; Electronic health records; Hospital; Medication safety; Patient safety; Proton pump inhibitors.

Fig. 1

Number of triggered alerts per type (alert no) and assessment. a a message was sent to the physician with a recommendation. b Alerts automatically terminated by the CDSS were labelled as problem resolved. c Alerts labelled as not relevant were terminated by the clinical pharmacist. AT = antiplatelet drug, AC = anticoagulation in therapeutic dose, CS = corticosteroid ≥ 10 mg prednisone equivalent, dRF = drug associated with gastrointestinal bleeding, Tc = thrombocytes < 30 G/L, DAPT = dual antiplatelet therapy, AS = low dose aspirin, Rf = risk factor for gastrointestinal bleeding (drugs, age ≥ 65 years or Tc)

Fig. 2

Acceptance rate of interventions messages. The acceptance is shown in percentages as accepted, not accepted or unknown (no follow up or not assessable) for missing PPIs (alerts 1–11) and inappropriate PPI (alert 12)

Fig. 3

Sensitivity and specificity decision pathway and evaluation of cases