Durieux P et al. 2008 "Computerized advice on drug dosage to improve prescribing practice."
Reference
Durieux P, Trinquart L, Colombet I, et al. Computerized advice on drug dosage to improve prescribing practice. Cochrane Database Syst Rev 2008;3.
Abstract
"Background: Maintaining therapeutic concentrations of drugs with a narrow therapeutic window is a complex task. Several computer systems have been designed to help doctors determine optimum drug dosage. Significant improvements in health care could be achieved if computer advice improved health outcomes and could be implemented in routine practice in a cost effective fashion. This is an updated version of an earlier Cochrane systematic review, by Walton et al, published in 2001.
Objectives: To assess whether computerised advice on drug dosage has beneficial effects on the process or outcome of health care.
Search strategy: We searched the Cochrane Effective Practice and Organisation of Care Group specialized register (June 1996 to December 2006), MEDLINE (1966 to December 2006), EMBASE (1980 to December 2006), hand searched the journal Therapeutic Drug Monitoring (1979 to March 2007) and the Journal of the American Medical Informatics Association (1996 to March 2007) as well as reference lists from primary articles.
Selection criteria: Randomized controlled trials, controlled trials, controlled before and after studies and interrupted time series analyses of computerized advice on drug dosage were included. The participants were health professionals responsible for patient care. The outcomes were: any objectively measured change in the behaviour of the health care provider (such as changes in the dose of drug used); any change in the health of patients resulting from computerized advice (such as adverse reactions to drugs).
Data collection and analysis: Two reviewers independently extracted data and assessed study quality.
Main results: Twenty-six comparisons (23 articles) were included (as compared to fifteen comparisons in the original review) including a wide range of drugs in inpatient and outpatient settings. Interventions usually targeted doctors although some studies attempted to influence prescriptions by pharmacists and nurses. Although all studies used reliable outcome measures, their quality was generally low. Computerized advice for drug dosage gave significant benefits by: 1.increasing the initial dose (standardised mean difference 1.12, 95% CI 0.33 to 1.92)
2.increasing serum concentrations (standradised mean difference 1.12, 95% CI 0.43 to 1.82)
3.reducing the time to therapeutic stabilisation (standardised mean difference -0.55, 95%CI -1.03 to -0.08)
4.reducing the risk of toxic drug level (rate ratio 0.45, 95% CI 0.30 to 0.70)
5.reducing the length of hospital stay (standardised mean difference -0.35, 95% CI -0.52 to -0.17).
Authors' conclusions: This review suggests that computerized advice for drug dosage has some benefits: it increased the initial dose of drug, increased serum drug concentrations and led to a more rapid therapeutic control. It also reduced the risk of toxic drug levels and the length of time spent in the hospital. However, it had no effect on adverse reactions. In addition, there was no evidence to suggest that some decision support technical features (such as its integration into a computer physician order entry system) or aspects of organization of care (such as the setting) could optimise the effect of computerised advice."
Objectives: To assess whether computerised advice on drug dosage has beneficial effects on the process or outcome of health care.
Search strategy: We searched the Cochrane Effective Practice and Organisation of Care Group specialized register (June 1996 to December 2006), MEDLINE (1966 to December 2006), EMBASE (1980 to December 2006), hand searched the journal Therapeutic Drug Monitoring (1979 to March 2007) and the Journal of the American Medical Informatics Association (1996 to March 2007) as well as reference lists from primary articles.
Selection criteria: Randomized controlled trials, controlled trials, controlled before and after studies and interrupted time series analyses of computerized advice on drug dosage were included. The participants were health professionals responsible for patient care. The outcomes were: any objectively measured change in the behaviour of the health care provider (such as changes in the dose of drug used); any change in the health of patients resulting from computerized advice (such as adverse reactions to drugs).
Data collection and analysis: Two reviewers independently extracted data and assessed study quality.
Main results: Twenty-six comparisons (23 articles) were included (as compared to fifteen comparisons in the original review) including a wide range of drugs in inpatient and outpatient settings. Interventions usually targeted doctors although some studies attempted to influence prescriptions by pharmacists and nurses. Although all studies used reliable outcome measures, their quality was generally low. Computerized advice for drug dosage gave significant benefits by: 1.increasing the initial dose (standardised mean difference 1.12, 95% CI 0.33 to 1.92)
2.increasing serum concentrations (standradised mean difference 1.12, 95% CI 0.43 to 1.82)
3.reducing the time to therapeutic stabilisation (standardised mean difference -0.55, 95%CI -1.03 to -0.08)
4.reducing the risk of toxic drug level (rate ratio 0.45, 95% CI 0.30 to 0.70)
5.reducing the length of hospital stay (standardised mean difference -0.35, 95% CI -0.52 to -0.17).
Authors' conclusions: This review suggests that computerized advice for drug dosage has some benefits: it increased the initial dose of drug, increased serum drug concentrations and led to a more rapid therapeutic control. It also reduced the risk of toxic drug levels and the length of time spent in the hospital. However, it had no effect on adverse reactions. In addition, there was no evidence to suggest that some decision support technical features (such as its integration into a computer physician order entry system) or aspects of organization of care (such as the setting) could optimise the effect of computerised advice."
Objective
There were two objectives to this study. The first was to determine "whether there is evidence that computerized advice on drug dosage is beneficial". The second objective was to find out "whether any technical features of computerized systems or organizational aspects concerning their implementation are critical to obtain this benefit."
Size
not applicable
Type of Health IT
Decision support system
Type of Health IT Functions
The functions of the systems included in this study were decision support as it relates to drug dosing. Systems included in the review could, for example calculate the dose of a drug, or provide information to the clinician about the optimum dose for the patient. "Most of the studies provided advice about appropriate drug dosages to health care professionals who then decided whether to follow this or not."
Workflow-Related Findings
"In the comparisons that we identified, unaided health professionals tended to be cautious in estimating the amount of drug to use. This caution presumably results from an unwillingness to expose the patient to adverse effects of drug therapy. Unaided clinicians tended to use lower loading, maintenance and total doses, than when computer support was available. Lower doses lead to lower blood levels and often to sub-optimal therapeutic effects. Although doses with computer support tended to be higher than those used by unaided doctors, toxic drug levels were significantly reduced."
Advice on drug dosing "was given in real time to the health professional in all studies except four."
"The computerized advice was user-initiated in ten studies, system-initiated in seven studies and it was unclear in nine studies."
"Initial doses tended to be higher with computerized advice". Furthermore, computerized advice on drug dosing "seems to lead to a change in the initial dose of drug but to have no effect on the maintenance dose and the total amount of drugs used. In addition, computerized advice doesn't reduce the number of dosage adjustments."
Study Design
Systematic literature review
Study Participants
The following types of studies were included: randomized controlled trials, controlled clinical trials, controlled pre and post intervention studies, and interrupted time series analyses. The goal was to identify "all comparative studies of computer advice on drug dosage." The following databases were searched: Cochrane Effective Practice and Organisation of Care Group (EPOC) specialized register (June 1996 - December 2006); MEDLINE (1966 - June 1996); and EMBASE (1980 - June 1996). The Therapeutic Drug Monitoring journal was hand searched (1979 - June 1996). Twenty-six comparisons were found in 23 articles.