Clinical Decision Support and Optional Point of Care Testing of Renal Function for Safe Use of Antibiotics in Elderly Patients: A Retrospective Study in Community Pharmacy Practice

Abstract

ObjectiveThe aim was to investigate the management of drug therapy alerts on safe use of antibiotics in elderly patients with (potential) renal impairment and the contribution of optional creatinine point of care testing (PoCT) in community pharmacy practice.MethodsCommunity pharmacists used a clinical decision support system (CDSS) for seven antibiotics. Alerts were generated during prescription processing in the case of previously registered renal impairment and when no information on renal function was available for patients aged 70 and over. Pharmacists could perform PoCT when renal function could not be retrieved from other health care professionals. Actions were registered in the CDSS. A retrospective descriptive analysis of alert management, performed PoCT and medication dispensing histories was performed.ResultsA total of 351 pharmacists registered the management of 88,391 alerts for 64,763 patients. For 68,721 alerts (77.7%), the pharmacist retrieved a renal function above the threshold for intervention. 1.7% of the alerts (n = 1532) led to a prescription modification because of renal impairment; in 3.0% of the alerts (n = 2631), the patient had renal impairment, but the pharmacist judged that no intervention was needed. Pharmacists performed 1988 PoCTs (2.2% of the alerts), which led to 15 prescription modifications (0.8% of the PoCT).ConclusionCommunity pharmacists performed CDSS-based interventions to prevent potentially inappropriate (dosing of) antibiotics in elderly patients with renal impairment. Pharmacists were well able to retrieve information on renal function, using PoCT in a limited number of cases. The intervention rate could be greatly increased by better registration of information on renal function. Performing PoCT seems especially worthwhile in the highest age groups.

A scoping review exploring the impact of digital systems on processes and outcomes in the care management of acute kidney injury and progress towards establishing learning healthcare systems

“…[14,18,20–28] Most studies were conducted in hospitals with one in primary care,[29] and one involving community pharmacy services. [22] There were eight randomised controlled trials. [12,20,29–34] The other studies used a range of observational designs, with the majority being uncontrolled before and after studies.…”

“…Thirty-two studies featured an intervention at the micro (individual patient) level. In 15 the main purpose of the intervention was harm prevention,[13,17,19,21,22,26,28,32,35–39] in 12 it was earlier diagnosis,[14,20,24,25,30,31,40–45] and in two, risk prediction. [12,46] Harm prevention interventions involved alerts to clinicians of the need to change nephrotoxic drugs (non-prescription, dose altering or drug suspension) based on a patient’s renal function.…”

Merits, features, and desiderata to be considered when developing electronic health records with embedded clinical decision support systems in Palestinian hospitals: a consensus study

“…Consensus was also achieved on items related to alerts provided by the system after checking prescriptions. Previous studies have shown usefulness of EHRs with embedded CDSSs in assessing appropriateness and safety of doses in relation to renal function [32], drug allergies, contraindications, adverse drug reactions, drug-drug, and drug-food interactions [19, 33, 50]. It is noteworthy mentioning that in order to improve diagnostic accuracy and patient care, systems should provide the healthcare provider with up-to-date information and evidence [21].…”

Budget Impact Analysis of a Renal Point-of-Care Test in Dutch Community Pharmacies to Prevent Antibiotic-Related Hospitalizations

“…The patient dataset reflecting the included study population was the main source for estimating transition probabilities in the decision model (Appendix 2, Table 7 ). Patient characteristics are displayed in Table 2 [ 9 ]. When patients had more than one prescription of interest in the studied year (and therefore were in the dataset more than once), we only used their information if there was a > 13-month interval between visits.…”

“…In 2015 a PoCT for renal function measurement was introduced in the Netherlands in 336 community pharmacies. The importance and relevance of better medication monitoring in community pharmacies in patients with renal impairment is described in a previously published study by Heringa et al [ 4 , 9 ].…”