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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

Breakdown of alert and override frequency by prescribers.
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Fig3: Breakdown of alert and override frequency by prescribers.

Mentions: For the 3-year period, total alerts triggered were 197,288, by 1,718 prescribers along with all types of medication in the CDS system, which included renal alerts. Among the alerts, 4,120 were renal alerts and were triggered by 584 prescribers (34% of all prescribers), and 3,221 (78.2%) were overridden (Figure 3). Among the prescribers, 544 (93.2%) had triggered ≤20 alerts. This group had an average override rate of 70%. The remaining 40 providers (6.8%) had triggered >20 alerts and had triggered almost half of the renal alerts, with a 90.5% override rate. On classifying the providers into the top 25 overriders (high-frequency overriders) and the remaining overriders (low-frequency overriders), the override rates were 95.0% and 78.9%, respectively.Figure 3


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)

Breakdown of alert and override frequency by prescribers.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Fig3: Breakdown of alert and override frequency by prescribers.
Mentions: For the 3-year period, total alerts triggered were 197,288, by 1,718 prescribers along with all types of medication in the CDS system, which included renal alerts. Among the alerts, 4,120 were renal alerts and were triggered by 584 prescribers (34% of all prescribers), and 3,221 (78.2%) were overridden (Figure 3). Among the prescribers, 544 (93.2%) had triggered ≤20 alerts. This group had an average override rate of 70%. The remaining 40 providers (6.8%) had triggered >20 alerts and had triggered almost half of the renal alerts, with a 90.5% override rate. On classifying the providers into the top 25 overriders (high-frequency overriders) and the remaining overriders (low-frequency overriders), the override rates were 95.0% and 78.9%, respectively.Figure 3

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