Abstract
BackgroundAlthough most outpatients are relatively healthy, many have chronic renal insufficiency, and high override rates for suggestions on renal dosing have been observed. To better understand the override of renal dosing alerts in an outpatient setting, we conducted a study to evaluate which patients were more frequently prescribed contraindicated medications, to assess providers’ responses to suggestions, and to examine the drugs involved and the reasons for overrides.MethodsWe obtained data on renal alert overrides and the coded reasons for overrides cited by providers at the time of prescription from outpatient clinics and ambulatory hospital-based practices at a large academic health care center over a period of 3 years, from January 2009 to December 2011. For detailed chart review, a group of 6 trained clinicians developed the appropriateness criteria with excellent inter-rater reliability (κ = 0.93). We stratified providers by override frequency and then drew samples from the high- and low-frequency groups. We measured the rate of total overrides, rate of appropriate overrides, medications overridden, and the reason(s) for override.ResultsA total of 4120 renal alerts were triggered by 584 prescribers in the study period, among which 78.2% (3,221) were overridden. Almost half of the alerts were triggered by 40 providers and one-third was triggered by high-frequency overriders. The appropriateness rates were fairly similar, at 28.4% and 31.6% for high- and low-frequency overriders, respectively. Metformin, glyburide, hydrochlorothiazide, and nitrofurantoin were the most common drugs overridden. Physicians’ appropriateness rates were higher than the rates for nurse practitioners (32.9% vs. 22.1%). Physicians with low frequency override rates had higher levels of appropriateness for metformin than the high frequency overriders (P = 0.005).ConclusionA small number of providers accounted for a large fraction of overrides, as was the case with a small number of drugs. These data suggest that a focused intervention targeting primarily these providers and medications has the potential to improve medication safety.
Highlights
Most outpatients are relatively healthy, many have chronic renal insufficiency, and high override rates for suggestions on renal dosing have been observed
According to the kidney disease statistics in the United States, the prevalence of chronic kidney disease (CKD) in people aged ≥ 60 years increased from 18.8% to 24.5%, as reported in the 1988–1994 National Health and Nutrition Examination Survey (NHANES) study and the 2003–2006 NHANES study [6]
Previous studies have shown that providers override 50–80% of alerts generated by renal decision support systems. [7,8,9] These high override rates imply that either too many alerts are being delivered or providers may be overriding clinically important suggestions
Summary
Most outpatients are relatively healthy, many have chronic renal insufficiency, and high override rates for suggestions on renal dosing have been observed. To better understand the override of renal dosing alerts in an outpatient setting, we conducted a study to evaluate which patients were more frequently prescribed contraindicated medications, to assess providers’ responses to suggestions, and to examine the drugs involved and the reasons for overrides. A previous study showed that completeness of patients’ problem list in terms of renal insufficiency in one network was only 4.7%, which is lower than that for hypertension, diabetes, and breast cancer [7]. This finding suggests that their providers may not be aware of the CKD in these patients, even though the glomerular filtration rate (GFR) can be readily estimated from data routinely available in the electronic health records. Some providers may be especially likely to override alerts, and there is scope for improvement
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