Appl Clin Inform - A trial of inpatient indication based prescribing during computerized order entry with medications commonly used off-label.

Tópicos

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Resumo

CKGROUND: Requiring indications for inpatient medication orders may improve the quality of prescribing and allow for easier placement of diagnoses on the problem list. Indications for inpatient medication orders are also required by some regulators.OBJECTIVE: This study assessed a clinical decision support (CDS) system designed to obtain indications and document problems during inpatient computerized physician order entry (CPOE) of medications frequently used off-label.METHODS: A convenience sample of three medications frequently used off-label were selected: the PPI lansoprazole; intravenous immune globulin, and recombinant Factor VIIa. Alerts triggered when a medication was ordered without an FDA approved indication in the problem list. The alerts prompted clinicians to enter either a labeled or off-label indication for the order. Chart review was used as the gold standard to assess the accuracy of clinician entered information.RESULTS: The PPI intervention generated 873 alerts during 60 days of operation; IVIG 55 alerts during alerts during 93 days; Factor VIIa 25 alerts during 175 days. Agreement between indications entered and chart review was 63% for PPI, 49% for IVIG, and 29% for Factor VIIa. The alerts for PPI, IVIG and Factor VIIa alerts produced accurate diagnoses for the problem list 9%, 16% and 24% respectively. Rates of off-label use measured by chart review were 87% for PPI, and 100% for IVIG and factor VIIa, which were higher than if measured using the ordering clinicians' indications.CONCLUSION: This trial of indication-based prescribing using CDS and CPOE produced less than optimal accuracy of the indication data as well as a low yield of accurate problems placed on the problem list. These results demonstrate the challenge inherent in obtaining accurate indication information during prescribing and should raise concerns over potential mandates for indication based prescribing and motivate further study of appropriate mechanisms to obtain indications during CPOE.

Resumo Limpo

ckground requir indic inpati medic order may improv qualiti prescrib allow easier placement diagnos problem list indic inpati medic order also requir regulatorsobject studi assess clinic decis support cds system design obtain indic document problem inpati computer physician order entri cpoe medic frequent use offlabelmethod conveni sampl three medic frequent use offlabel select ppi lansoprazol intraven immun globulin recombin factor viia alert trigger medic order without fda approv indic problem list alert prompt clinician enter either label offlabel indic order chart review use gold standard assess accuraci clinician enter informationresult ppi intervent generat alert day oper ivig alert alert day factor viia alert day agreement indic enter chart review ppi ivig factor viia alert ppi ivig factor viia alert produc accur diagnos problem list respect rate offlabel use measur chart review ppi ivig factor viia higher measur use order clinician indicationsconclus trial indicationbas prescrib use cds cpoe produc less optim accuraci indic data well low yield accur problem place problem list result demonstr challeng inher obtain accur indic inform prescrib rais concern potenti mandat indic base prescrib motiv studi appropri mechan obtain indic cpoe

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