Computerized reminders to monitor liver function to improve the use of etretinate

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Abstract

Objective: to determine whether computerized reminders during the process of prescribing can improve the use of drugs requiring prior laboratory testing according to the indications listed in the Drug Package Insert. Measures: Change in proportion of appropriate prescribing and frequency of severe hepatotoxicity between pre- and post-intervention. Methods: etretinate, a medication indicated for psoriasis, was selected as a monitored drug because it was the most prescribed of all the identified drugs that require specific prior laboratory tests. Computerized reminders are designed to alert a physician who is about to prescribe etretinate either without the alanine aminotranceferase (ALT) test or the aspartate aminotransferase (AST) test within 3 months or despite abnormality in ALT or AST. Data on alerts were gathered by using electronic mail whenever alerts occurred. Results: prescriptions of etretinate with normal ALT or AST results within the previous three months increased suddenly from 25.9% (127/491) in the pre-intervention period to 66.2% (353/533) in the post-intervention period (P<0.0001). Moreover, three patients who used etretinate had markedly abnormal tests in the pre-intervention period, but none of the patients were classified in this way in the post-intervention period. Conclusions: the computerized reminders appear to improve physicians’ use of a drug requiring specific prior laboratory tests.

Introduction

Adverse drug events (ADEs) are serious and common problems. When two studies were conducted at Latter Day Saint Hospital, Salt Lake City, UT, in different periods, ADEs complicated almost 2% of all admissions [1], [2]. In the Medical Practice Study (MPS), 3.7% of patients hospitalized in New York State in 1984 suffered an ADE, which was defined as an injury due to medical treatment [3]. The leading cause of medical injury in the MPS was the use of drugs, which accounted for 19.4% of these injuries [4]. ADEs may account for up to 140 000 deaths annually in the USA [5]. In one study, a fifth of all deaths were due to adverse drug events [6]. ADEs are also an increasingly common reason for litigation [7]. Similar statistics are not available in Japan where necessary clinical databases have not been developed for research.

ADRs are not only detrimental but also very costly. The occurrence of an ADE in an inpatient setting has been associated with increased length of stay of 2 days and an increased cost of approximately US$3000 [2], [8]. Sadly, many ADEs are preventable since they are caused by medication errors [9], [10], [11], [12], [13], [14]. The most common factors associated with these medication errors are inadequate knowledge or application of knowledge regarding drug therapy and unavailability of patient information, such as the results of laboratory tests [11], [15].

There are limits to human capabilities as information processors that assure the occurrence of random errors in complex activities [18]. Moreover, excessive amounts of data may cause clinicians to overlook important alterations in clinical indexes [19]. Changing the systems by which drugs are ordered and administered holds substantial potential for reducing the number of drug-related injuries. Computerized ordering systems, in which orders are written on-line by a physician and the physician receives feedback on the suitability of the order during the process of making it, are likely to have an especially large impact on reducing medication errors [14].

Computer-based clinical information systems offer the prospect of both improving the quality of health care by reducing such errors [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38] and lowering costs [39], [40], [41], [42], [43]. Computerized reminders are among the most widely tested and promising information systems [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31]. Most studies of these approaches have been conducted in the USA; we have not seen similar reports in English from Asian settings.

One recent study showed that the computer-based electronic mail alerts about patients with rising creatinine levels reduced significantly the risk of subsequent serious renal impairment [31]. However, in that study, 28% of clinicians found the alerts annoying. Considering the fact that medication errors mainly occur in the process of prescribing, computerized alerts might prevent clinicians from prescribing drugs when an abnormality has been found in the monitored laboratory test. Furthermore, such laboratory tests are often not carried out strictly according to the intervals recommended in the Drug Package Insert. Thus, we sought to determine whether a computerized reminder during the process of prescribing could improve use of one drug according to the recommendation of its drug package insert. Data about both prescription and cancellation of the subject drug were automatically sent by electronic mail (e-mail) to us for monitoring and analysis whenever a clinician submits prescription or cancellation.

Section snippets

Setting

The study was conducted at a 1040 bed tertiary care and teaching hospital in Tokyo. The hospital cares for approximately 2500 outpatients per day. The computerized medical information system has been operational since 1973, the physician order entry system for laboratory tests since 1987, and the ordering systems for prescribing to inpatients since 1988 and outpatients since 1994. Test results and prescription details over an 8-year period can be searched in real time. Moreover, physicians can

Change in proportion of appropriate prescribing

During the pre-intervention period, 491 prescriptions of etretinate were prescribed by 37 physicians for 54 patients. Of these, 467 prescriptions (95.1%) were for outpatients and 24 (4.9%) were for inpatients. The average age of these patients was 59.4 (S.D. 13.0) years old. There were 12 females (56.6±16.0 years old) and 42 males (60.2±12.2 years). Overall prescribing for etretinate remained approximately the same in the post-intervention period; 533 prescriptions of etretinate were prescribed

Discussion

We developed a system of computerized reminders to improve the quality of care associated with use of etretinate. The frequency of prescribing etretinate was approximately equal in the pre-intervention and post-intervention periods and no major changes occurred during this time except for the implementation of the alert system. With this system, prescription of etretinate with a normal ALT or AST result within three months increased from 25.9% in the pre-intervention period to 66.2% in the

Acknowledgements

We would like to thank the pharmacists, physicians, and other personnel on the clinical units, especially Kunimoto Tamaki and Tatsuji Iga, for their support in carrying out the study. We acknowledge Stephen B. Soumerai, Yasuo Ohashi and Chikuma Hamada, for invaluable comments on the study.

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