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Negligible impact of highly patient-specific decision support for potassium-increasing drug-drug interactions – a cluster-randomised controlled trial


Beeler, Patrick E; Eschmann, Emmanuel; Schneemann, Markus; Blaser, Jrg (2019). Negligible impact of highly patient-specific decision support for potassium-increasing drug-drug interactions – a cluster-randomised controlled trial. Swiss Medical Weekly, 149:w20035.

Abstract

BACKGROUND AND OBJECTIVE: Clinical decision support (CDS) might improve management of potassium-increasing drug-drug interactions (DDI). We studied CDS with five features intended to increase effectiveness: (i) focus on serious DDIs, (ii) fewer notifications, (iii) presentation of current laboratory results, (iv) timing (when adverse event becomes likelier), (v) removal of notification when appropriate. METHODS: We conducted a 1-year, hospital-wide, cluster- randomised controlled trial in the inpatient setting at a large tertiary-care academic medical centre. Three CDS types were implemented: monitoring reminders (unknown potassium, no monitoring ordered), elevated potassium warnings (≥4.9 mEq/l), and hyperkalaemia alerts (≥5.5 mEq/l). The primary endpoint was the frequency of potassium- monitoring intervals >72 h. RESULTS: We analysed 15,272 and 18,981 stays with 2804 and 2057 potassium-increasing DDIs in the intervention and control groups, respectively. Patient-specific notifications: displayed were 869 reminders (1 per 3.2 potassium- increasing DDIs), 356 warnings (1:7.9), and 62 alerts (1:45.2). Nevertheless, insufficiently monitored DDIs were not reduced (intervention 451 of 9686 intervals >72 h [4.66%]; control 249 of 6140 [4.06%]). The only secondary outcome improved was the length of potassium monitoring intervals (intervention group mean 22.9 h, control 23.7 h; p <0.001). However, in the intervention group, during 50 of 2804 observed potassium-increasing DDI periods (1.78%) one or more serum potassium values ≥ 5.5mEq/ l were measured, in the control group, during 27 of 2057 (1.31%; p = 0.20). CONCLUSIONS: A highly patient-specific CDS feature combination had a negligible impact on the management of potentially serious potassium-increasing DDIs and was unable to improve safety among hospitalised patients. Trial registration number: The study was registered at ClinicalTrials.gov (NCT02020317). Keywords: drug interactions, hyperkalaemia, potassium, medical order entry systems, electronic health records, clinical decision support systems, computer-assissted drug therapy, patient safety, drug monitoring

Abstract

BACKGROUND AND OBJECTIVE: Clinical decision support (CDS) might improve management of potassium-increasing drug-drug interactions (DDI). We studied CDS with five features intended to increase effectiveness: (i) focus on serious DDIs, (ii) fewer notifications, (iii) presentation of current laboratory results, (iv) timing (when adverse event becomes likelier), (v) removal of notification when appropriate. METHODS: We conducted a 1-year, hospital-wide, cluster- randomised controlled trial in the inpatient setting at a large tertiary-care academic medical centre. Three CDS types were implemented: monitoring reminders (unknown potassium, no monitoring ordered), elevated potassium warnings (≥4.9 mEq/l), and hyperkalaemia alerts (≥5.5 mEq/l). The primary endpoint was the frequency of potassium- monitoring intervals >72 h. RESULTS: We analysed 15,272 and 18,981 stays with 2804 and 2057 potassium-increasing DDIs in the intervention and control groups, respectively. Patient-specific notifications: displayed were 869 reminders (1 per 3.2 potassium- increasing DDIs), 356 warnings (1:7.9), and 62 alerts (1:45.2). Nevertheless, insufficiently monitored DDIs were not reduced (intervention 451 of 9686 intervals >72 h [4.66%]; control 249 of 6140 [4.06%]). The only secondary outcome improved was the length of potassium monitoring intervals (intervention group mean 22.9 h, control 23.7 h; p <0.001). However, in the intervention group, during 50 of 2804 observed potassium-increasing DDI periods (1.78%) one or more serum potassium values ≥ 5.5mEq/ l were measured, in the control group, during 27 of 2057 (1.31%; p = 0.20). CONCLUSIONS: A highly patient-specific CDS feature combination had a negligible impact on the management of potentially serious potassium-increasing DDIs and was unable to improve safety among hospitalised patients. Trial registration number: The study was registered at ClinicalTrials.gov (NCT02020317). Keywords: drug interactions, hyperkalaemia, potassium, medical order entry systems, electronic health records, clinical decision support systems, computer-assissted drug therapy, patient safety, drug monitoring

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Item Type:Journal Article, refereed, original work
Communities & Collections:04 Faculty of Medicine > University Hospital Zurich > Clinic and Policlinic for Internal Medicine
Dewey Decimal Classification:610 Medicine & health
Uncontrolled Keywords:General Medicine
Language:English
Date:8 April 2019
Deposited On:23 Apr 2019 12:50
Last Modified:25 Sep 2019 00:33
Publisher:EMH Swiss Medical Publishers
ISSN:0036-7672
OA Status:Gold
Free access at:Publisher DOI. An embargo period may apply.
Publisher DOI:https://doi.org/10.4414/smw.2019.20035

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