Institute of Pharmacology, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Pharmacy, Shuang Ho Hospital, Taipei Medical University, New Taipei, Taiwan.
Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan.
Clin Ther. 2022 May;44(5):710-722. doi: 10.1016/j.clinthera.2022.03.003. Epub 2022 Apr 3.
Inappropriate dosing of glucose-lowering drugs in patients with renal insufficiency can cause severe harm. This study evaluated the short- and long-term effects of clinical decision support systems (CDSS) on inappropriate prescriptions of glucose-lowering agents for patients with renal insufficiency in an ambulatory care setting.
This retrospective longitudinal observational study was conducted by using an electronic medical record database and the CDSS log data at Taipei Veterans General Hospital between January 1, 2015, and December 31, 2018. Outpatients who received 7 target glucose-lowering medications and had an estimated glomerular filtration rate <50 mL/min/1.73 m were included. Inappropriate prescriptions were defined as a dose, frequency, or daily dose of target drugs that exceeded the dosing recommendations based on renal function. Inappropriate monthly rates were calculated, and the interrupted time series analysis method was used to explore the 1- and 3-year post-implementation effects of CDSS. The major outcome measurements were the level changes and the inappropriate prescription rate trend changes after renal CDSS implementation. The acceptance rates of alerts were also analyzed.
A total of 141,037 drug prescriptions were obtained during the study period. In the short-term analysis, the baseline inappropriate rate for overall medications was estimated to range from 30.54% in the first month to 27.06% in month 12. The predicted inappropriate rate 12 months after implementation was 19.35%, corresponding to an estimated 28.49% [(27.06 - 19.35)/27.06] decrease in inappropriate rate. However, after long-term analysis, the predicted inappropriate rate at the end of the study (36 months after implementation) was 18.02%. A total of 27,189 alerts were generated and 628 were accepted during the study period. Thus, after short- and long-term analysis, the overall acceptance rate was 3.06% and 2.31%, respectively.
Implementing a CDSS for renal dosing adjustment could significantly decrease the inappropriate prescription rate of glucose-lowing agents among patients with renal insufficiency in an ambulatory setting in the short term, while the long-term effect of a CDSS is limited.
在肾功能不全的患者中，降糖药物的剂量不当可能会造成严重危害。本研究评估了临床决策支持系统（CDSS）在门诊环境下对肾功能不全患者使用降糖药物的不当处方的短期和长期影响。
本回顾性纵向观察性研究使用电子病历数据库和台北荣民总医院 2015 年 1 月 1 日至 2018 年 12 月 31 日的 CDSS 日志数据进行。纳入接受 7 种目标降糖药物且估算肾小球滤过率<50mL/min/1.73m²的门诊患者。不适当的处方定义为根据肾功能超过目标药物剂量、频率或日剂量推荐的剂量。计算不适当的月发生率，并采用中断时间序列分析方法探讨 CDSS 实施后 1 年和 3 年的影响。主要观察指标是实施肾 CDSS 后水平变化和不适当处方率趋势变化。还分析了警报的接受率。
研究期间共获得 141037 张药物处方。在短期分析中，整体药物的基线不适当率估计范围从第 1 个月的 30.54%到第 12 个月的 27.06%。实施后 12 个月的预测不适当率为 19.35%，对应不适当率估计降低 28.49%[（27.06-19.35）/27.06]。然而，经过长期分析，研究结束时（实施后 36 个月）的预测不适当率为 18.02%。研究期间共生成 27189 条警报，其中 628 条被接受。因此，经过短期和长期分析，总体接受率分别为 3.06%和 2.31%。
在门诊环境下，实施 CDSS 进行肾剂量调整可显著降低肾功能不全患者使用降糖药物的不适当处方率，短期效果显著，而 CDSS 的长期效果有限。
