Physicians less likely to respond with antimicrobial agents
Researchers from Harvard Medical School’s teaching hospital in Boston decided to test if they could encourage physicians to switch appropriate patients from intravenous (IV) to oral (PO) medications.
They found that the physicians responded to a computer prompt almost 36% of time, either making the switch to PO administration or canceling the order altogether. The physicians, however, were less likely to change the order when it involved an antimicrobial agent. The results of the study were published in the Nov. 24 issue of the Archives of Internal Medicine.
It was clear from observation that patients were receiving expensive IV medications upon admission — when they were sickest, needed the highest concentrations of drugs, and might have trouble taking PO medications, says Jonathan M. Teich, MD, PhD, one of the researchers and a physician in the department of emergency medicine at Brigham and Women’s Hospital in Boston. Teich also is an assistant professor of medicine at Harvard University and a senior vice president and chief medical officer of HEALTHvision, in Irving, TX. Then, even when the patients improved and were in better condition, the IV medications were continued rather than being switched to oral administration.
"Our pharmacists and our informatics leaders talk frequently about key problems and possible improvements," Teich says. "Through these discussions, the pharmacists expressed their concern about unnecessary costs from this practice, and we in the informatics division suggested that an algorithm could be developed and put into play." The hospital performs formal studies on many of its interventions, particularly if they are new or unique.
Five medications chosen
The researchers targeted five medications with equal oral and intravenous bioavailability: fluconazole, levofloxacin, metronidazole, ranitidine, and amiodarone. The researchers programmed an algorithm in the hospital’s computerized order entry system (CPOE) to prompt physicians to convert appropriate IV medications to PO.
The first algorithm was fairly simple, Teich says. It looked for orders for the target IV drugs for patients who also were taking oral medications or nutrition — indicating that they could handle taking medications by mouth.
In the first phase of the study, the prompts for the IV-to-PO conversion were given to the pharmacists, who then could decide which ones needed follow-up, Teich says. Although the pharmacists were enthusiastic about the study, they were short-staffed at the time of the original study and had a hard time getting even a few minutes to do the review. "When we moved the prompting over to physicians — who are used to getting all sorts of prompts from the computer — they responded well, but only after we had tightened up the algorithm to eliminate more conditions where the doctor was likely to reject the alert," he says. "Our physicians, and physicians everywhere, are generally happy to get prompts like these from the computer, if they are not excessive and if most of them are valid."
The researchers then measured the total use of the five medications via each route in the four months before and after the implementation of the intervention. They also measured the rate at which physicians responded to the intervention when prompted.
The researchers found that the average IV-defined daily dose declined by 11% during the intervention period, while the average oral-defined daily dose increased by 3.7%. These figures came at a time when the overall length of stay, case-mix index, and total drug use at the hospital increased.
Physicians responded to the prompts in 35.6% of the 1,045 orders, by either converting from IV to PO administration or canceling the order altogether. The responses, however, differed depending on the medication. More than 20% of the amiodarone orders were canceled, but none were directly converted to the oral route.
The researchers surmised that the automated IV-to-PO conversion prompt did not provide physicians with the dose recommendations they needed for this drug.
Among the other four medications, physicians were willing to replace or cancel ranitidine more often than the three antimicrobial agents, the researchers say. Orders for ranitidine were changed or canceled 42.5% of the time, followed by those for levofloxacin (30.3%), metronidazole (27.0%), and fluconazole (18.2%).
There are several conditions associated with physicians rejecting the suggested conversion, Teich says. Included among these are patients in the intensive care unit, patients in very recent postoperative status, patients taking drugs for a gastrointestinal problem, and others.
"We determined these factors from a review of the initial data. More refinement [to the algorithm] would lead to a consistent set of rules, usable or all target medications, that would further concentrate the alerts so that their specificity is very high," he adds.
Lessons from the study
Pharmacists can discern from this study that in many cases, doctors are happy to switch to PO medications when reminded to do so, Teich says. "The fact that they don’t do it without prompting may be more a matter of not changing what’s working,’ and concentrating on acute clinical problems, than a deep belief that the IV drug is still superior."
The study also shows that computer algorithms are great tools for screening patients, he adds. "Even if not all of the selected patients should have the IV-to-PO change made, it is much easier to review a small number of patients [after the computer has pre-screened them] than to try and look at the entire service by hand."
Finally, there are many examples of how CPOE benefits patient care, Teich says. "Usually, CPOE concentrates on immediate alerts: The doctor writes an order, and the system tells the doctor that the patient is allergic. This is a different kind of clinical decision support, and takes a little more thought to put into play, but it can be very powerful."