Purpose To evaluate the impact of a newly implemented clinical decision support (CDS) tool targeting QT interval–prolonging medications on order verification and provider interventions. Methods A multicenter, retrospective quasi-experimental study was conducted to evaluate provider response to CDS alerts triggered during ordering of QT-prolonging medications for adult patients. The primary outcome was the proportion of orders triggering QTc alerts that were continued without intervention during a specified preimplementation phase (n = 49) and during a postimplementation phase (n = 100). Patient risk factors for QTc prolongation, provider alert response, and interventions to reduce the risk of QTc-associated adverse events were evaluated. Results The rate of order continuation without intervention was 82% in the preimplementation phase and 37% in the postimplementation phase, representing an 55% reduction in continued verified orders following implementation of the QT-focused CDS tool. Most alerts were initially responded to by the prescriber, with pharmacist intervention needed in only 33% of cases. There were no significant differences in patient QTc-related risk factors between the 2 study groups (P = 0.11); the postimplementation group had a higher proportion of patients using at least 2 QTc-prolonging medications (48%, compared to 26% in the preimplementation group; P = 0.02). Conclusion Implementation of the CDS tool was associated with a reduction in the proportion of orders continued without intervention in patients at high risk for QTc-related adverse events.

IN BRIEF Several studies have compared the safety and efficacy of insulin detemir and insulin glargine; however, most have been conducted in the ambulatory care setting. This retrospective cohort study compared hypoglycemia rates between the two basal insulin analogs in hospitalized patients with diabetes. No difference was found between the two insulin cohorts in the proportion of patients who experienced hypoglycemic events.

Background: Prior research has demonstrated increased mortality with increasing glycemic variability (GV) in hospitalized patients with diabetes. Objective: We aimed to compare glycemic variability (GV) of insulin glargine to detemir in the inpatient setting. Methods: This single-center, retrospective, cohort study evaluated noncritically ill patients with diabetes on long-acting insulin at a large academic medical institution between 2010 and 2017. This study was reviewed and approved by the Institutional Review Board. The formulary transitioned from insulin glargine to detemir in December 2013; therefore, patients were compared before and after transition. The primary endpoint was to compare coefficient of variation (CV), a measure of GV, between detemir and glargine. Secondary endpoints included GV measured by standard deviation (SD), CV within 72 hours of long-acting insulin initiation, length-of-stay (LOS), in-hospital mortality, and comparison between subgroups. Results: 2334 patients were included in the study, and there were 1167 in each group. CV was significantly less variable with detemir compared to glargine (33.7% versus 34.8%, difference = 1.09, p = 0.02) and remained significant after controlling for confounders. Similarly, SD was significantly less with detemir (p = 0.048). CV within 72 hours, LOS, and in-hospital mortality were not statistically different. Lastly, GV was higher in medical patients compared to surgical. Conclusion: Insulin detemir exhibited less GV than insulin glargine, although the small difference is unlikely to be clinically significant. Application of this data will aid in formulary decisions and support the use of either agent within the hospital setting.

Background There is a lack of data comparing azithromycin to alternative antibiotic choices in managing COPD exacerbations, making appropriate antibiotic selection controversial. Objective To compare treatment failure in hospitalized patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) receiving azithromycin or beta-lactams. Design Retrospective, multicenter cohort study using logistic regression for multivariable analysis. Patients were included if they were at least 18 years old, admitted with AECOPD, and received at least two consecutive days of either a beta-lactam or azithromycin. Patients were excluded if they received concomitant azithromycin and beta-lactam antibiotics during the first 2 days, had a history of other severe underlying pulmonary diseases, pregnancy, COVID-19, alpha-1 antitrypsin deficiency, or received a corticosteroid for a diagnosis other than COPD. Participants Five hundred ninety-five patients were included, of which 428 (72%) received azithromycin and 167 patients (28%) received a beta-lactam. Main Measures The primary endpoint was treatment failure rate in patients receiving azithromycin versus beta-lactams, which was a composite endpoint defined as in-hospital mortality, admission to intensive care, initiation of invasive mechanical ventilation, initiation of a new antibiotic, steroid therapy escalation, or readmission due to AECOPD within 30 days. Key Results The composite primary outcome occurred in 84 patients (19.6%) in the azithromycin group and 54 (32.3%) in the beta-lactam group ( p <0.01). The difference in the composite outcome was a result of higher rates of new antibiotics during admission (12.6% vs 4.2%; p <0.01) and higher readmission within 30 days (19.3% vs 12.4%; p =0.032). After controlling for potential confounders, beta-lactams continued to demonstrate a higher risk for treatment failure (OR, 2.30; 95% CI, 1.46–3.63). There was no difference in adverse effects between the groups. Conclusion Azithromycin was associated with less treatment failure in AECOPD which was driven by lower readmission rates and prescription of new antimicrobials.

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