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Understanding physicians' behavior toward alerts about nephrotoxic medications in outpatients: a cross-sectional analysis.

Cho I, Slight SP, Nanji KC, Seger DL, Maniam N, Dykes PC, Bates DW - BMC Nephrol (2014)

Bottom Line: Physicians with low frequency override rates had higher levels of appropriateness for metformin than the high frequency overriders (P=0.005).A small number of providers accounted for a large fraction of overrides, as was the case with a small number of drugs.These data suggest that a focused intervention targeting primarily these providers and medications has the potential to improve medication safety.

View Article: PubMed Central - PubMed

Affiliation: The Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA. insook.cho@inha.ac.kr.

ABSTRACT

Background: Although most outpatients are relatively healthy, many have chronic renal insufficiency, and high override rates for suggestions on renal dosing have been observed. To better understand the override of renal dosing alerts in an outpatient setting, we conducted a study to evaluate which patients were more frequently prescribed contraindicated medications, to assess providers' responses to suggestions, and to examine the drugs involved and the reasons for overrides.

Methods: We obtained data on renal alert overrides and the coded reasons for overrides cited by providers at the time of prescription from outpatient clinics and ambulatory hospital-based practices at a large academic health care center over a period of 3 years, from January 2009 to December 2011. For detailed chart review, a group of 6 trained clinicians developed the appropriateness criteria with excellent inter-rater reliability (κ=0.93). We stratified providers by override frequency and then drew samples from the high- and low-frequency groups. We measured the rate of total overrides, rate of appropriate overrides, medications overridden, and the reason(s) for override.

Results: A total of 4120 renal alerts were triggered by 584 prescribers in the study period, among which 78.2% (3,221) were overridden. Almost half of the alerts were triggered by 40 providers and one-third was triggered by high-frequency overriders. The appropriateness rates were fairly similar, at 28.4% and 31.6% for high- and low-frequency overriders, respectively. Metformin, glyburide, hydrochlorothiazide, and nitrofurantoin were the most common drugs overridden. Physicians' appropriateness rates were higher than the rates for nurse practitioners (32.9% vs. 22.1%). Physicians with low frequency override rates had higher levels of appropriateness for metformin than the high frequency overriders (P=0.005).

Conclusion: A small number of providers accounted for a large fraction of overrides, as was the case with a small number of drugs. These data suggest that a focused intervention targeting primarily these providers and medications has the potential to improve medication safety.

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Related in: MedlinePlus

Criteria of judgment of appropriateness for renal alert override. CrCL: creatinine clearance.
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Fig2: Criteria of judgment of appropriateness for renal alert override. CrCL: creatinine clearance.

Mentions: To set up the criteria for judgment of overriding appropriateness, a group of 6 trained clinicians consisting of physicians, pharmacists, and nurses worked together. We adopted a stepwise approach recommended by the Kidney Disease: Improving Global Outcomes guidelines of 2010 to improve drug dosing [11, 12]. The stepwise approach facilitates inclusion of multiple considerations to achieve the desired goal in a timely manner for each drug. Similarly, we considered multiple data in a stepwise manner. First, we examined the values and trend of eGFR or estimated CrCL for the last 6 months to determine if there was a steadily moderate or severe decrease in renal function. Second, we reviewed electronic medical records of demographics, history of disease, physician notes, and laboratory results to obtain evidence to support the override reason(s) entered by a provider, i.e., to determine whether a patient has tolerated the drug in the past, whether new evidence supports the type of therapy, or whether a consultant was approached. Third, we reviewed the medication history, monitored drug responses, and revised the regimen after assessing whether substitute drugs were used before (Figure 2). The initial criteria were modified iteratively until a consensus was reached, with over 90% agreement for examination of a sample of 50 randomly selected overrides.Figure 2


Understanding physicians' behavior toward alerts about nephrotoxic medications in outpatients: a cross-sectional analysis.

Cho I, Slight SP, Nanji KC, Seger DL, Maniam N, Dykes PC, Bates DW - BMC Nephrol (2014)

Criteria of judgment of appropriateness for renal alert override. CrCL: creatinine clearance.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4279964&req=5

Fig2: Criteria of judgment of appropriateness for renal alert override. CrCL: creatinine clearance.
Mentions: To set up the criteria for judgment of overriding appropriateness, a group of 6 trained clinicians consisting of physicians, pharmacists, and nurses worked together. We adopted a stepwise approach recommended by the Kidney Disease: Improving Global Outcomes guidelines of 2010 to improve drug dosing [11, 12]. The stepwise approach facilitates inclusion of multiple considerations to achieve the desired goal in a timely manner for each drug. Similarly, we considered multiple data in a stepwise manner. First, we examined the values and trend of eGFR or estimated CrCL for the last 6 months to determine if there was a steadily moderate or severe decrease in renal function. Second, we reviewed electronic medical records of demographics, history of disease, physician notes, and laboratory results to obtain evidence to support the override reason(s) entered by a provider, i.e., to determine whether a patient has tolerated the drug in the past, whether new evidence supports the type of therapy, or whether a consultant was approached. Third, we reviewed the medication history, monitored drug responses, and revised the regimen after assessing whether substitute drugs were used before (Figure 2). The initial criteria were modified iteratively until a consensus was reached, with over 90% agreement for examination of a sample of 50 randomly selected overrides.Figure 2

Bottom Line: Physicians with low frequency override rates had higher levels of appropriateness for metformin than the high frequency overriders (P=0.005).A small number of providers accounted for a large fraction of overrides, as was the case with a small number of drugs.These data suggest that a focused intervention targeting primarily these providers and medications has the potential to improve medication safety.

View Article: PubMed Central - PubMed

Affiliation: The Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA. insook.cho@inha.ac.kr.

ABSTRACT

Background: Although most outpatients are relatively healthy, many have chronic renal insufficiency, and high override rates for suggestions on renal dosing have been observed. To better understand the override of renal dosing alerts in an outpatient setting, we conducted a study to evaluate which patients were more frequently prescribed contraindicated medications, to assess providers' responses to suggestions, and to examine the drugs involved and the reasons for overrides.

Methods: We obtained data on renal alert overrides and the coded reasons for overrides cited by providers at the time of prescription from outpatient clinics and ambulatory hospital-based practices at a large academic health care center over a period of 3 years, from January 2009 to December 2011. For detailed chart review, a group of 6 trained clinicians developed the appropriateness criteria with excellent inter-rater reliability (κ=0.93). We stratified providers by override frequency and then drew samples from the high- and low-frequency groups. We measured the rate of total overrides, rate of appropriate overrides, medications overridden, and the reason(s) for override.

Results: A total of 4120 renal alerts were triggered by 584 prescribers in the study period, among which 78.2% (3,221) were overridden. Almost half of the alerts were triggered by 40 providers and one-third was triggered by high-frequency overriders. The appropriateness rates were fairly similar, at 28.4% and 31.6% for high- and low-frequency overriders, respectively. Metformin, glyburide, hydrochlorothiazide, and nitrofurantoin were the most common drugs overridden. Physicians' appropriateness rates were higher than the rates for nurse practitioners (32.9% vs. 22.1%). Physicians with low frequency override rates had higher levels of appropriateness for metformin than the high frequency overriders (P=0.005).

Conclusion: A small number of providers accounted for a large fraction of overrides, as was the case with a small number of drugs. These data suggest that a focused intervention targeting primarily these providers and medications has the potential to improve medication safety.

Show MeSH
Related in: MedlinePlus