title: Computerized clinical decision support systems for therapeutic drug monitoring and dosing: a decision-maker-researcher partnership systematic review.
abstract: BACKGROUND
  Some drugs have a narrow therapeutic range and require monitoring and dose adjustments to optimize their efficacy and safety. Computerized clinical decision support systems (CCDSSs) may improve the net benefit of these drugs. The objective of this review was to determine if CCDSSs improve processes of care or patient outcomes for therapeutic drug monitoring and dosing.
  
  
  METHODS
  We conducted a decision-maker-researcher partnership systematic review. Studies from our previous review were included, and new studies were sought until January 2010 in MEDLINE, EMBASE, Evidence-Based Medicine Reviews, and Inspec databases. Randomized controlled trials assessing the effect of a CCDSS on process of care or patient outcomes were selected by pairs of independent reviewers. A study was considered to have a positive effect (i.e., CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive.
  
  
  RESULTS
  Thirty-three randomized controlled trials were identified, assessing the effect of a CCDSS on management of vitamin K antagonists (14), insulin (6), theophylline/aminophylline (4), aminoglycosides (3), digoxin (2), lidocaine (1), or as part of a multifaceted approach (3). Cluster randomization was rarely used (18%) and CCDSSs were usually stand-alone systems (76%) primarily used by physicians (85%). Overall, 18 of 30 studies (60%) showed an improvement in the process of care and 4 of 19 (21%) an improvement in patient outcomes. All evaluable studies assessing insulin dosing for glycaemic control showed an improvement. In meta-analysis, CCDSSs for vitamin K antagonist dosing significantly improved time in therapeutic range.
  
  
  CONCLUSIONS
  CCDSSs have potential for improving process of care for therapeutic drug monitoring and dosing, specifically insulin and vitamin K antagonist dosing. However, studies were small and generally of modest quality, and effects on patient outcomes were uncertain, with no convincing benefit in the largest studies. At present, no firm recommendation for specific systems can be given. More potent CCDSSs need to be developed and should be evaluated by independent researchers using cluster randomization and primarily assess patient outcomes related to drug efficacy and safety.
authors.affiliation: Population Health Research Institute, McMaster University, Hamilton General Hospital Campus, 237 Barton Street East, Hamilton, ON, Canada.
authors.forename: Robby
authors.initials: R
authors.lastname: Nieuwlaat
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Connolly
authors.forename: Jean A
authors.initials: JA
authors.lastname: Mackay
authors.forename: Lorraine
authors.initials: L
authors.lastname: Weise-Kelly
authors.forename: Tamara
authors.initials: T
authors.lastname: Navarro
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Wilczynski
authors.forename: R Brian
authors.initials: RB
authors.lastname: Haynes
mesh_terms: D035843:Biomedical Research / Q000458:organization & administration*; D002170:Canada; D003299:Cooperative Behavior; D003657:Decision Making; D020000:Decision Support Systems, Clinical / Q000295:instrumentation*; D016903:Drug Monitoring / Q000295:instrumentation* / Q000379:methods; D014943:Global Health; D006801:Humans; D007328:Insulin / Q000008:administration & dosage; D010818:Practice Patterns, Physicians'; D016896:Treatment Outcome; D014812:Vitamin K / Q000037:antagonists & inhibitors
chemical_list: D007328:Insulin; D014812:Vitamin K