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Glenn M. Chertow, MD,MPH; Joshua Lee, MD; Gilad J. Kuperman, MD; Elisabeth Burdick; Jan Horsky; Diane L. Seger; Rita Lee; Aparna Mekala; Jean Song; Anthony L. Komaroff, MD; David W. Bates, MD,MSc

JAMA. 2001;286:2839-2844.

Context  Usual drug-prescribing practices may not consider the effects of renal insufficiency on the disposition of certain drugs. Decision aids may help optimize prescribing behavior and reduce medical error.

Objective  To determine if a system application for adjusting drug dose and frequency in patients with renal insufficiency, when merged with a computerized order entry system, improves drug prescribing and patient outcomes.

Design, Setting, and Patients  Four consecutive 2-month intervals consisting of control (usual computerized order entry) alternating with intervention (computerized order entry plus decision support system), conducted in September 1997–April 1998 with outcomes assessed among a consecutive sample of 17 828 adults admitted to an urban tertiary care teaching hospital.

Intervention  Real-time computerized decision support system for prescribing drugs in patients with renal insufficiency. During intervention periods, the adjusted dose list, default dose amount, and default frequency were displayed to the order-entry user and a notation was provided that adjustments had been made based on renal insufficiency. During control periods, these recommended adjustments were not revealed to the order-entry user, and the unadjusted parameters were displayed.

Main Outcome Measures  Rates of appropriate prescription by dose and frequency, length of stay, hospital and pharmacy costs, and changes in renal function, compared among patients with renal insufficiency who were hospitalized during the intervention vs control periods.

Results  A total of 7490 patients were found to have some degree of renal insufficiency. In this group, 97 151 orders were written on renally cleared or nephrotoxic medications, of which 14 440 (15%) had at least 1 dosing parameter modified by the computer based on renal function. The fraction of prescriptions deemed appropriate during the intervention vs control periods by dose was 67% vs 54% (P<.001) and by frequency was 59% vs 35% (P<.001). Mean (SD) length of stay was 4.3 (4.5) days vs 4.5 (4.8) days in the intervention vs control periods, respectively (P = .009). There were no significant differences in estimated hospital and pharmacy costs or in the proportion of patients who experienced a decline in renal function during hospitalization.

Conclusions  Guided medication dosing for inpatients with renal insufficiency appears to result in improved dose and frequency choices. This intervention demonstrates a way in which computer-based decision support systems can improve care.

Author Affiliations: Division of General Internal Medicine (Drs J. Lee, Komaroff, and Bates and Mss Burdick, Horsky, and Seger), and Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School (Dr Chertow), Department of Information Systems, Partners HealthCare System (Dr Kuperman and Mss R. Lee, Mekala, and Song) Boston, Mass. Dr Chertow is now with the Division of Nephrology, Department of Medicine, University of California, San Francisco.

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