The impact of real-time alerting on appropriate prescribing in kidney disease: a cluster randomized controlled trial

Awdishu, Linda; Coates, Carrie; Lyddane, Adam; Tran, Kim; Daniels, Charles E.; Lee, Joshua; El‐Kareh, Robert

doi:10.1093/jamia/ocv159

Cited by 53 publications

(54 citation statements)

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“…While almost half of the studies were cross‐sectional, 21 studies implemented interventions to reduce IP . Of these interventions, almost half were manual decision aids (n = 10), others were computerised decision support aids to physicians and pharmacists (n=9) and in the remaining studies (n=2), physicians were prompted with calculated eGFR values (Figure ).…”

Section: Resultsmentioning

confidence: 99%

“…The studies were conducted in 23 different countries; predominantly in the USA (n=11) and Australia (n=5) …”

Section: Resultsmentioning

confidence: 99%

“…Forty‐three of the included studies were rated as moderate or high quality (can be accessed on supporting information). All studies defined their inclusion criteria and evaluated IP objectively with comparators described clearly, where applicable .…”

Section: Resultsmentioning

confidence: 99%

“…Most studies have used the CG to estimate renal function for drug dosing (n=26), whereas 16 studies used MDRD . Six other studies employed either Jelliffe's equation or a combination of formulas to determine renal function status (Table ).…”

Section: Resultsmentioning

confidence: 99%

“…Of the interventional studies (n=21), almost half of them (n=10) were manual supports to physicians in the form of interactive training, education, and feedback by pharmacists or clinical experts . Immediate concurrent feedback given to physicians had brought the highest reduction in IP, ie, from 77% to 19% ( P< .001) (Shown in Figure ).…”

Section: Resultsmentioning

confidence: 99%

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Inappropriate prescribing in chronic kidney disease: A systematic review of prevalence, associated clinical outcomes and impact of interventions

et al. 2017

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Section: Resultsmentioning

confidence: 99%

“…The studies were conducted in 23 different countries; predominantly in the USA (n=11) and Australia (n=5) …”

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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Inappropriate prescribing in chronic kidney disease: A systematic review of prevalence, associated clinical outcomes and impact of interventions

et al. 2017

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Automated Electronic Alert for the Care and Outcomes of Adults With Acute Kidney Injury

Li,

Wu,

et al. 2024

JAMA Netw Open

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ImportanceDespite the expansion of published electronic alerts for acute kidney injury (AKI), there are still concerns regarding their effect on the clinical outcomes of patients.ObjectiveTo evaluate the effect of the AKI alert combined with a care bundle on the care and clinical outcomes of patients with hospital-acquired AKI.Design, Setting, and ParticipantsThis single-center, double-blind, parallel-group randomized clinical trial was conducted in a tertiary teaching hospital in Nanjing, China, from August 1, 2019, to December 31, 2021. The inclusion criteria were inpatient adults aged 18 years or older with AKI, which was defined using the Kidney Disease: Improving Global Outcomes creatinine criteria. Participants were randomized 1:1 to either the alert group or the usual care group, which were stratified by medical vs surgical ward and by intensive care unit (ICU) vs non-ICU setting. Analyses were conducted on the modified intention-to-treat population.InterventionsA programmatic AKI alert system generated randomization automatically and sent messages to the mobile telephones of clinicians (alert group) or did not send messages (usual care group). A care bundle accompanied the AKI alert and consisted of general, nonindividualized, and nonmandatory AKI management measures.Main Outcomes and MeasuresThe primary outcome was maximum change in estimated glomerular filtration rate (eGFR) within 7 days after randomization. Secondary patient-centered outcomes included death, dialysis, AKI progression, and AKI recovery. Care-centered outcomes included diagnostic and therapeutic interventions for AKI.ResultsA total of 2208 patients (median [IQR] age, 65 [54-72] years; 1560 males [70.7%]) were randomized to the alert group (n = 1123) or the usual care group (n = 1085) and analyzed. Within 7 days of randomization, median (IQR) maximum absolute changes in eGFR were 3.7 (−6.4 to 19.3) mL/min/1.73 m2 in the alert group and 2.9 (−9.2 to 16.9) mL/min/1.73 m2 in the usual care group (P = .24). This result was robust in all subgroups in an exploratory analysis. For care-centered outcomes, patients in the alert group had more intravenous fluids (927 [82.6%] vs 670 [61.8%]; P &lt; .001), less exposure to nonsteroidal anti-inflammatory drugs (56 [5.0%] vs 119 [11.0%]; P &lt; .001), and more AKI documentation at discharge (560 [49.9%] vs 296 [27.3%]; P &lt; .001) than patients in the usual care group. No differences were observed in patient-centered secondary outcomes between the 2 groups.Conclusions and RelevanceResults of this randomized clinical trial showed that the electronic AKI alert did not improve kidney function or other patient-centered outcomes but changed patient care behaviors. The findings warrant the use of a combination of high-quality interventions and AKI alert in future clinical practice.Trial RegistrationClinicalTrials.gov Identifier: NCT03736304

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Prescription and Dispensation of QT-Prolonging Medications in Individuals Receiving Hemodialysis

Wang,

Assimon

et al. 2024

JAMA Netw Open

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ImportanceIndividuals with dialysis-dependent kidney failure have numerous risk factors for medication-related adverse events, including receipt of care by multiple clinicians and initiation of some QT-prolonging medications with known risk of torsades de pointes (TdP), which is associated with higher risk of sudden cardiac death. Little is known about the prescription and dispensation patterns of QT-prolonging medications among people receiving dialysis, hindering efforts to reduce drug-related harm from these and other medications in this high-risk population.ObjectiveTo examine prescription and dispensation patterns of QT-prolonging medications with known TdP risk and selected interacting medications prescribed to individuals receiving hemodialysis.Design, Setting, and ParticipantsThis cross-sectional study included patients 60 years or older who were enrolled in Medicare Parts A, B, and D receiving in-center hemodialysis from January 1 to December 31, 2019. Analyses were conducted from October 20, 2022, to June 16, 2023.ExposuresNew-user prescriptions for the 7 most frequently filled QT-prolonging medications characterized by the timing of the new prescription relative to acute care encounters, the type of prescribing clinician and pharmacy that dispensed the medication, and concomitant use of selected medications known to interact with the 7 most frequently filled QT-prolonging medications with known TdP risk.Main Outcomes and MeasuresThe main outcomes were the frequencies of the most commonly filled and new-use episodes of QT-prolonging medications; the timing of medication fills relative to acute care events; prescribers and dispensing pharmacy characteristics for new use of medications; and the frequency and types of new-use episodes with concurrent use of potentially interacting medications.ResultsOf 20 761 individuals receiving hemodialysis in 2019 (mean [SD] age, 74 [7] years; 51.1% male), 10 992 (52.9%) filled a study drug prescription. Approximately 80% (from 78.6% for odansetron to 93.9% for escitalopram) of study drug new-use prescriptions occurred outside of an acute care event. Between 36.8% and 61.0% of individual prescriptions originated from general medicine clinicians. Between 16.4% and 26.2% of these prescriptions occurred with the use of another QT-prolonging medication. Most potentially interacting drugs were prescribed by different clinicians (46.3%-65.5%).Conclusions and RelevanceIn this cross-sectional study, QT-prolonging medications for individuals with dialysis-dependent kidney failure were commonly prescribed by nonnephrology clinicians and from nonacute settings. Prescriptions for potentially interacting medications often originated from different prescribers. Strategies aimed at minimizing high-risk medication-prescribing practices in the population undergoing dialysis are needed.

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The impact of real-time alerting on appropriate prescribing in kidney disease: a cluster randomized controlled trial

Abstract: The rate of appropriate drug prescribing in kidney impairment is low and remains a patient safety concern. Our results suggest that CDS improves drug prescribing, particularly when providing guidance on new prescriptions.

Cited by 53 publications

References 21 publications

Inappropriate prescribing in chronic kidney disease: A systematic review of prevalence, associated clinical outcomes and impact of interventions

Inappropriate prescribing in chronic kidney disease: A systematic review of prevalence, associated clinical outcomes and impact of interventions

Automated Electronic Alert for the Care and Outcomes of Adults With Acute Kidney Injury

Prescription and Dispensation of QT-Prolonging Medications in Individuals Receiving Hemodialysis

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