Subscribe to RSS
DOI: 10.4338/ACI-2010-11-RA-0072
A trial of inpatient indication based prescribing during computerized order entry with medications commonly used off-label
Publication History
received:
22 November 2010
accepted:
08 February 2011
Publication Date:
16 December 2017 (online)
Summary
Background: Requiring indications for inpatient medication orders may improve the quality of prescribing and allow for easier placement of diagnoses on the problem list. Indications for inpatient medication orders are also required by some regulators.
Objective: This study assessed a clinical decision support (CDS) system designed to obtain indications and document problems during inpatient computerized physician order entry (CPOE) of medications frequently used off-label.
Methods: A convenience sample of three medications frequently used off-label were selected: the PPI lansoprazole; intravenous immune globulin, and recombinant Factor VIIa. Alerts triggered when a medication was ordered without an FDA approved indication in the problem list. The alerts prompted clinicians to enter either a labeled or off-label indication for the order. Chart review was used as the gold standard to assess the accuracy of clinician entered information.
Results: The PPI intervention generated 873 alerts during 60 days of operation; IVIG 55 alerts during alerts during 93 days; Factor VIIa 25 alerts during 175 days. Agreement between indications entered and chart review was 63% for PPI, 49% for IVIG, and 29% for Factor VIIa. The alerts for PPI, IVIG and Factor VIIa alerts produced accurate diagnoses for the problem list 9%, 16% and 24% respectively. Rates of off-label use measured by chart review were 87% for PPI, and 100% for IVIG and factor VIIa, which were higher than if measured using the ordering clinicians’ indications.
Conclusion: This trial of indication-based prescribing using CDS and CPOE produced less than optimal accuracy of the indication data as well as a low yield of accurate problems placed on the problem list. These results demonstrate the challenge inherent in obtaining accurate indication information during prescribing and should raise concerns over potential mandates for indication based prescribing and motivate further study of appropriate mechanisms to obtain indications during CPOE.
-
References
- 1 The Joint Commission. edition of the 2010 Comprehensive Accreditation Manual; MM.02.01.01 and MM 05.01.01 [cited 2011 Jan 5]. Available from: http://e-dition.jcrinc.com.
- 2 Blumenthal D, Tavenner M. The “Meaningful Use” regulation for electronic health records. N Engl J Med 2010; 363 (06) 501-504.
- 3 Meystre SM, Haug PJ. Randomized controlled trial of an automated problem list with improved sensitivity. Int J Med Inform 2008; 77 (09) 602-612.
- 4 Radley DC, Finkelstein SN, Stafford RS. Off-label prescribing among office-based physicians. Arch Intern Med 2006; 166: 1021-1026.
- 5 Leveque D. Off-label use of anticancer drugs. Lancet Oncol 2008; 9: 1102-1107.
- 6 Galanter WL, Hier DB, Jao C, Sarne D. Computerized physician order entry of medications and clinical decision support can improve problem list documentation compliance. Int J Med Inform 2010; 79: 332-338.
- 7 Schedlbauer A, Prasad V, Mulvaney C, Phansalkar S, Stanton W, Bates DW, Avery AJ. What evidence supports the use of computerized alerts and prompts to improve clinicians’ prescribing behavior?. J Am Med Inform Assoc 2009; 16: 531-538.
- 8 Pham PA. Drug-drug interaction programs in clinical practice. Clin Pharmacol Ther 2008; 83: 396-398.
- 9 Chertow GM, Lee J, Kuperman GJ, Burdick E, Horsky J, Seger DL. et al. Guided medication dosing for inpatients with renal insufficiency. JAMA 2001; 286: 2839-2844.
- 10 Teich JM, Petronzio AM, Gerner JR, Seger DL, Shek C, Fanikos J. An information system to promote intravenous-to-oral medication conversion. Proc AMIA Symp 1999: 415-419.
- 11 Galanter WL, Didomenico RJ, Polikaitis A. A trial of automated decision support alerts for contraindicated medications using computerized physician order entry. J Am Med Inform Assoc 2005; 12 (03) 269-274.
- 12 Suzuki H, Hibi T. Novel effects other than antisecretory action and off-label use of proton pump inhibitors. Expert Opin Pharmacother 2005; 6: 59-67.
- 13 Stanford-UCSF evidence-based practice center, comparative effectiveness of in-hospital use of recombinant factor VIIa for off-label indications vs. usual care, comparative effectiveness review No. 21, prepared under Contract No. 290-02-0017 for the Agency for Healthcare Research and Quality. May 2010 [cited 2011 Jan 5]. Available from: http://www.effectivehealthcare.ahrq.gov/ehc/products/20/450/Final%20Report_CER21_Factor7.pdf.
- 14 DRUGDEX System [Internet database]. Greenwood Village, Colo: Thomson Micromedex; Updated periodically.
- 15 2009 ICD-9-CM.. [cited 2011 Jan 5]. Available from: http://icd9cm.chrisendres.com.
- 16 International Health Terminology Standards Development Organization, SNOMED Clinical Terms User Guide January 2010 International Release (US English), 2002-2010 International Health Terminology Standards Development Organization, CVR #30363434; 2010. [cited 2011 Jan 5]. Available from:http://www.ihtsdo.org/fileadmin/user_upload/Docs_01/Publications/doc_UserGuide_Current-enUS_INT_20100131.pdf.
- 17 WHO.. ICD. [cited 2011 Jan 5]. Available from: http://apps.who.int/classifications/apps/icd/icd10online.
- 18 Gupta R, Garg P, Kottoor R, Munoz JC, Jamal MM, Lambiase LR. et al. Overuse of acid suppression therapy in hospitalized patients. South Med J 2010; 103: 207-211.