Evaluation of a decision support system for initiation and control of oral anticoagulation in a randomised trial

Abstract

Objectives: To determine whether a computerised decision support system for initiation and control of oral anticoagulant treatment improves quality of anticoagulant control achieved by trainee doctors. Design: Randomised controlled trial. Setting: District general hospital in North London. Subjects: 148 inpatients requiring start of warfarin treatment. Interventions: Management by trainee doctors (to achieve therapeutic range of international normalised ratio of 2 to 3) with indirect assistance from computerised decision support system (intervention group) or without such assistance (control group). Main outcome measures: Median time to therapeutic range, stable dose, and first pseudoevent (excessive international normalised ratio after therapeutic range has been reached) and person time spent in the therapeutic range. Results: 72 patients were randomised to the intervention group and 76 to control group. Median time to reach international normalised ratio of >2 was not significantly different in the two groups (3 days). Median time to achieve a stable dose was significantly lower in intervention group than in controls (7 days v 9 days, P = 0.01) without excessive overtreatment or undertreatment with anticoagulant. Patients in intervention group spent greater proportion of time in therapeutic range, both as inpatients (59% v 52%) and outpatients (64% v 51%). Conclusion:The computerised decision support system was safe and effective and improved the quality of initiation and control of warfarin treatment by trainee doctors.

Evidence-Based Management of Anticoagulant Therapy

“…46,[78][79][80][81][82][83][84][85][86][87][88][89][90][91][92][93][94][95][96][97] These dosing adjuncts have been studied at the initiation of therapy (no prior VKA doses) and during the maintenance phase of therapy and were compared with dose deci sions made without the use of decision support (manual dosing). Both nomogram/computer-assisted and manual dosing were performed by experienced anticoagulation providers in some studies 78,86,87,90,91 and by providers without specialized training (eg, trainee physicians, house staff, regular physician, nurses) in others.…”

“…Both nomogram/computer-assisted and manual dosing were performed by experienced anticoagulation providers in some studies 78,86,87,90,91 and by providers without specialized training (eg, trainee physicians, house staff, regular physician, nurses) in others. 46,[79][80][81][82][83][84][85]88,89,[92][93][94][95] Decision support-guided dosing (paper nomograms or computer programs) performed no better than manual dosing during initiation of VKA therapy in pooled analyses of available RCTs ( Table 7 , Table S7). Pooled analyses of RCTs evaluating decision supportguided dosing during maintenance therapy (all were computer-assisted dosing programs) revealed a mean TTR improvement of 4.5% (95% CI, 2.4%-6.7%) compared with no decision support.…”

Effectiveness of a measurement feedback system on outcome in rheumatoid arthritis: a controlled clinical trial

“…A systematic review of computerised drug dosing systems included five RCTs dealing with outpatient maintenance anticoagulation treatment, 32 of which one trial provided evidence that quality of initiation and control of warfarin treatment was improved by CDSS in comparison with usual care. 33 From this it can be concluded that until now there is no strong evidence of the effectiveness of measurement feedback systems, computerised drug dosing systems, or computerised guideline implementation systems in several chronic conditions in primary care. However, there is still a strong argument for the adoption of a measurement feedback system, or some other form of CDSS, in RA.…”

Analysis of Clinical Record Data for Anticoagulation Management within an EHR System

“…He developed an algorithm for warfarin dosing which was evaluated in a randomised controlled trial at the Whittington Hospital [18,19]. It was found that using the decision support tool the median time to achieve a stable dose was significantly lower, and both inpatients and outpatients spent longer within the therapeutic range than did patients dosed by unassisted trainee doctors.…”