title: Clinical decision support implemented with academic detailing improves prescribing of key renally cleared drugs in the hospital setting.
abstract: OBJECTIVE
  Lack of dose adjustment for renally cleared drugs in the presence of poor renal function is a common problem in the hospital setting. The absence of a clinical decision support system (CDSS) from direct clinician workflows such as computerized provider order entry (CPOE) hinders the uptake of CDSS. This study implemented CDSS in an environment independent of CPOE, introduced to prescribers via academic detailing, to address the dosing of renally cleared drugs.
  
  
  METHODS
  GFR+ was designed to automatically calculate and update renal function, doses of key drugs adjusted for renal function, and highlight clinically significant decreases in renal function. Prescribers were made aware of GFR+, its navigation, and surrounding clinical issues, using academic detailing.
  
  
  METHODS
  The rate of dosing conformity and management for key renally cleared drugs in hospitalized patients, before and after GFR+ implementation.
  
  
  RESULTS
  Improvements were seen in dosing conformity for enoxaparin (from 68% to 86%, p=0.03), gentamicin (63-87%, p=0.01), and vancomycin (47-77%, p=0.07), as well as the appropriate use of gentamicin therapeutic drug monitoring (70-90%, p=0.02). During episodes of acute renal impairment, renally cleared drugs were held on 38% of instances in the pre-intervention period compared with 62% post-intervention (p=0.01).
  
  
  CONCLUSIONS
  Clinical decision support implemented with academic detailing improved dosing conformity and management of key renally cleared drugs in a hospitalized population. Academic detailing should be strongly considered to facilitate the introduction of CDSS systems that cannot be placed directly into the clinician workflow.
authors.affiliation: Pharmacy Department, Repatriation General Hospital, Daw Park, South Australia, Australia. greg.roberts2@health.sa.gov.au
authors.forename: Gregory W
authors.initials: GW
authors.lastname: Roberts
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Farmer
authors.forename: Philip C
authors.initials: PC
authors.lastname: Cheney
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Govis
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Belcher
authors.forename: Scott A
authors.initials: SA
authors.lastname: Walsh
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Adams
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000493:pharmacokinetics; D000925:Anticoagulants / Q000008:administration & dosage / Q000493:pharmacokinetics; D001315:Australia; D020000:Decision Support Systems, Clinical; D016903:Drug Monitoring / Q000379:methods*; D017984:Enoxaparin / Q000008:administration & dosage / Q000493:pharmacokinetics; D005839:Gentamicins / Q000008:administration & dosage / Q000493:pharmacokinetics; D019983:Guideline Adherence; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control; D008510:Medication Systems, Hospital; D008657:Metabolic Clearance Rate; D010818:Practice Patterns, Physicians'; D051437:Renal Insufficiency; D014640:Vancomycin / Q000008:administration & dosage / Q000493:pharmacokinetics
chemical_list: D000900:Anti-Bacterial Agents; D000925:Anticoagulants; D017984:Enoxaparin; D005839:Gentamicins; D014640:Vancomycin