Multicentre randomised study of computerised anticoagulant dosage. European Concerted Action on Anticoagulation. Clinical studies with computer-assisted initial lidocaine therapy. Individualised aminoglycoside dosage based on pharmacokinetic analysis is superior to dosage based on physician intuition at achieving target plasma drug concentrations. Computer-assisted optimization of aminophylline therapy in the emergency department. Initiation of warfarin therapy: comparison of physician dosing with computer-assisted dosing. Effect of computer-aided management on the quality of treatment in anticoagulated patients: a prospective, randomized, multicenter trial of APROAT (Automated PRogram for Oral Anticoagulant Treatment). Comparison of oral anticoagulant control by a nurse-practitioner using a computer decision-support system with that by clinicians. A randomized comparison of a computer-based dosing program with a manual system to monitor oral anticoagulant therapy. A randomized controlled clinical trial of pharmacokinetic theophylline dosing. Evaluation of three dosage-prediction methods for initial in-hospital stabilization of warfarin therapy. Midazolam and fentanyl continuous infusion anesthesia for cardiac surgery: a comparison of computer-assisted versus manual infusion systems. A new sodium-nitroprusside-infusion controller for the regulation of arterial blood pressure. Impact of a clinical pharmacokinetic service on patients treated with aminoglycosides: a cost-benefit analysis. Guided medication dosing for inpatients with renal insufficiency. A prospective randomized comparison of the accuracy of computer-assisted versus GUSTO nomogram--directed heparin therapy. A computerized decision support system for ovarian stimulation by gonadotropins. A prospective randomised trial comparing individualised pharmacokinetic dosage prediction for aminoglycosides with prediction based on estimated creatinine clearance in critically ill patients. Outpatient management of warfarin therapy: comparison of computer-predicted dosage adjustment to skilled professional care. Computer assisted design of a theophylline dosing regimen in acute bronchospasm: serum concentrations and clinical outcome. Evaluation of a decision support system for initiation and control of oral anticoagulation in a randomised trial. A randomized controlled trial of computerized pharmacokinetic theophylline dosing versus empiric physician dosing. A controlled trial of the cost benefit of computerized bayesian aminoglycoside administration. Oral anticoagulation management in primary care with the use of computerized decision support and near-patient testing: a randomized, controlled trial.
The demand for anticoagulant treatment is increasing. We compared the benefits of computer-generated anticoagulant dosing with traditional dosing decided by experienced medical staff in achieving target international normalised ratios (INRs).
                In five European centres we randomly assigned 285 patients in the stabilisation period and stabilised patients to the computer-generated-dose group (n=137) or traditional-dose group (n=148). Centres had a specialist interest in oral anticoagulation but no previous experience with computer-generated dosing. The computer program calculated doses and times to next visit. Our main endpoint was time spent in target INR range (Rosendaal method).
                For all patients combined, computer-generated dosing was significantly beneficial overall in achieving target INR (p=0.004). The mean time within target INR range for all patients and all ranges was 63.3% (SD 28.0) of days in the computer-generated-dose group compared with 53.2% (27.7) in the traditional-dose group. For the stabilisation patients alone, computer-generated doses led to a non-significant benefit in all INR ranges (p=0.06), whereas in the stable patients the benefit was significant (p=0.02).
                The computer program gave better INR control than the experienced medical staff and at least similar standards to the specialised centres should be generally available. Clinical outcome and cost effectiveness remain to be assessed. A randomized prospective study compared achievement and maintenance of therapeutic plasma concentrations in patients receiving computer-assisted (CA) initial lidocaine hydrochloride therapy, designed pharmacokinetically to achieve and maintain a chosen plasma concentration, v conventional lidocaine therapy (CT). A separate audit of outcome was also conducted. The CA regimens provided more effective concentrations in the first hour than did CT, 2.65 v 1.5 micrograms/mL average. In the audit, ventricular fibrillation occurred in two of 78 CA v eight of 78 CT patients. Dosage adjustments were required in two CA patients v 33 CT patients. The CA therapy improved therapeutic precision, reduced dosage adjustments, and may have improved safety during initial lidocaine therapy before fitting to plasma concentration data for subsequent feedback. An improved clinical computer program now also fits to plasma concentration data. It is accessed and used routinely by hospitals over an international time-sharing network. 1. A prospective randomised trial was conducted to compare aminoglycoside dose prediction based on individually measured pharmacokinetic data, with dosage based on physician intuition. 2. After 2 days of therapy more patients in the pharmacokinetic group had achieved both peak (6-10 mg 1(-1] and trough (1-2 mg 1(-1] target plasma concentrations (P = 0.007), peaks alone (P = 0.01) and troughs alone (P = 0.01). Their mean (s.e. mean) peak concentration was 6.49 +/- 0.39 mg 1(-1) compared with 4.27 +/- 0.52 mg 1(-1) in the control group (P = 0.001), with trough concentrations of 1.44 +/- 0.22 mg 1(-1) and 0.94 +/- 0.21 mg 1(-1) respectively (P = 0.054). 3. After 5 days of therapy, peak and trough concentrations were still significantly higher in the pharmacokinetic group despite empirical dose adjustment (P = 0.01 and P = 0.013 respectively). 4. The mean (s.e. mean) daily dose of aminoglycoside was higher in the computer group (312 +/- 17 mg vs 203 +/- 13 mg, P = 0.001). 5. These findings suggest that dose estimation based on measured pharmacokinetic parameters is superior at achieving target plasma drug concentrations. The emergency department (ED) is a unique setting for pharmacokinetic-guided drug administration because of the need to rapidly optimize therapy. We compared outcomes in patients receiving intravenous aminophylline according to population-based ED guidelines (group 1) or Bayesian-derived pharmacokinetic estimates (group 2), we determined predictors for admission or discharge in our study group, and we assessed the ability of a Bayesian pharmacokinetic model to estimate theophylline requirements in the ED. The study population was composed of 82 patients (42 males, 40 females) with a mean age of 43 +/- 15.5 years. Fifteen patients were excluded because of protocol violations. Of the 67 cases studied, 30 were assigned to group 1, and 37 were assigned to group 2. Patient demographics, baseline theophylline concentration, and theophylline loading dose did not differ significantly between treatment groups. The aminophylline maintenance infusion was significantly (P less than .001) lower in group 1 (0.4 +/- 0.2 mg/kg/h) than in group 2 (0.6 +/- 0.2 mg/kg/h). Serum theophylline concentrations at one hour post-loading-dose did not differ significantly between treatment groups; however, significant differences were observed at two hours post-load (P less than .002) and four hours post-load (P less than .001). Baseline peak flow rate (PFR) was significantly (P less than .03) higher in group 1 (170 +/- 85 L/min) than in group 2 (132 +/- 62 L/min), but did not differ significantly at any other times throughout the study. The PFR one hour post-load (PFR-1) was the strongest (P less than .003) predictor of outcome.(ABSTRACT TRUNCATED AT 250 WORDS) In a prospective, randomized study at two university hospitals, the authors examined how effectively housestaff physicians (n = 36) managed the initiation of warfarin therapy compared with a computer-assisted dosing regimen (n = 39) using the software program Warfcalc, which was managed by one of the authors. Target prothrombin time ratios were selected by the physicians. Study endpoints included: the time to reach a therapeutic prothrombin ratio, the time to reach a stable therapeutic dose, the number of patients transiently overanticoagulated, the number of bleeding complications, and the accuracy of the predicted maintenance dose, which was assessed at steady-state 10-14 days later. Computer-assisted dosing consistently out-performed the physicians: a stable therapeutic dose was achieved 3.7 days earlier (p = 0.002), fewer patients were overanticoagulated (10% versus 41%), and the predicted maintenance dose was in the therapeutic range in 85% of the computer-dosed patients versus 42% of the physician group (p less than 0.002). For physicians who did not routinely manage warfarin therapy, computer-assisted dosing improved the accuracy of dosing and shortened the time required to achieve a stable therapeutic dose. We carried out a prospective, randomized trial to test whether a computer-based decision support system to initiate and maintain oral anticoagulant (OA) treatment can improve the laboratory quality of therapy.
                Two separate sets of patients on oral anticoagulants, in five Italian anticoagulant clinics, were studied: 335 patients in the first three months of treatment (stabilization phase), 916 patients (775 patient-years) beyond the third month of treatment (maintenance phase). Patients were randomized to a computerized system, which included algorithms able to suggest OA dosing and to schedule appointments (computer-aided dosing) or to an arm in which OA were prescribed by the same teams of expert physicians without such algorithms (control group). Primary outcomes were: A) the percentage of patients reaching a stable state of anticoagulation during each of the first three months of treatment; B) the percentage of time individuals spent within the aimed therapeutic range (maintenance phase).
                Patients in the computer-aided dosing group achieved a stable state significantly faster (p<0.01) and they spent more time within the therapeutic range during maintenance (p<0.001) than controls. The favorable effect of computer-aided dosing was mainly due to a reduction of the time spent below the therapeutic range and was associated with an increase of mean INR value, of anticoagulant drug dosage, and with a reduction of the number of appointments per patient (all changes significant: p<0.001).
                The computer decision-aided support improves the laboratory quality of anticoagulant treatment, both during long-term maintenance and in the early, highly unstable phase of treatment, and it also significantly reduces the number of scheduled laboratory controls. With increasing work-loads in anticoagulant clinics different methods of service delivery need evaluation. The quality of anticoagulant control achieved by a nurse-practitioner using a computer decision-support system (CDSS) was compared with that achieved by trainee doctors without CDSS. Eighty-one out-patients (group A, therapeutic range 2-3) and 96 out-patients (group B, therapeutic range 3-4.5) were randomized to management by a nurse-practitioner or by trainee doctors (clinicians). Thirty-seven patients in group A and 50 patients in group B were randomized to be managed by the nurse-practitioner. In group A, patients in the nurse-practitioner group spent a longer time in the therapeutic range than those in the clinician group (60.7% compared with 51.6%). Dose suggestion acceptance in the nurse-practitioner group (88%) was higher compared with agreement between the CDSS and the clinicians (60%). In group B, patients in the clinician group spent a slightly longer time in the therapeutic range (70% compared with 67.6%). Acceptance of dose suggestion was lower in the nurse-practitioner group (67%) compared with agreement between the CDSS and the clinicians (73%). In conclusion, the CDSS can improve the quality of control of warfarin therapy by a nurse-practitioner over that by trainee doctors for the therapeutic range 2-3. Similar quality of control is achieved for the therapeutic range 3-4.5. The CDSS may be used by nurse-practitioners to achieve safe and effective anticoagulation in hospital-based or out-reach anticoagulant clinics. nan Ninety-one patients admitted to hospital with acute air-flow obstruction and requiring theophylline therapy were randomly assigned to either a monitored or a control group. Intravenously administered and subsequent orally administered theophylline dosages for patients in the monitored group were adjusted daily on the basis of each patients's estimated theophylline clearance; dosages for control patients were determined by attending physicians, using knowledge of theophylline serum concentrations. During intravenous therapy, fewer monitored than control patients had serum theophylline concentrations in the toxic range (18.9 versus 37.8%, p = 0.04), and during subsequent oral therapy more monitored than control patients had serum theophylline concentrations in the therapeutic range (71.1 versus 44.4%, p = 0.018). There was a trend for peak expiratory flow rates to normalize more quickly in monitored patients, and their mean duration of hospital stay was shorter (6.3 versus 8.7 days, p = 0.029). Two patients in the control group died; both had theophylline concentrations above 25 micrograms/ml and clinical toxicity. No serious side effects were observed in the monitored group. With pharmacokinetic individualization of theophylline dosage, more patients achieved serum concentrations in the therapeutic range, and there was a tendency for more rapid clinical improvement. Three dosage-prediction methods for initial in-hospital stabilization of warfarin therapy were evaluated. Adult inpatients who had received warfarin sodium 10 mg daily for less than three days were eligible for the study. After receiving their third warfarin dose, patients were randomly assigned to have their warfarin dosages adjusted using one of three dosage-prediction methods: by analog computer (n = 31), linear regression (n = 22), or empiric dosing by the physician (n = 34). A prothrombin time (PT) ratio (patient PT divided by control PT) between 1.3 and 2.5 was considered to be in the therapeutic range. For patients who achieved a stable PT ratio (defined as a PT ratio between 1.3 and 2.5 that varied by less than 0.05 on two consecutive days or by less than 0.1 on three consecutive days without a dosage change) before discharge, the number of days (time to stabilization) from administration of the first warfarin dose to achievement of the warfarin dosage that produced a stable PT ratio (stabilization dosage) was compared. A total of 54 patients met the study criteria for a stable PT ratio before hospital discharge (analog computer, n = 20; linear regression, n = 15; empiric dosing, n = 19). The mean times to stabilization were 6.8 days in the analog-computer group, 7.3 days in the linear-regression group, and 8.4 days in the empiric-dosing group; these times were not significantly different. All 20 stabilized patients in the analog-computer group achieved a stable PT ratio by the fourth dosage prediction.(ABSTRACT TRUNCATED AT 250 WORDS) Continuous infusion of intravenous anesthetics can be achieved either by a manually controlled infusion (MCI) pump, or by a computer-assisted continuous infusion (CACI) pharmacokinetic model-driven infusion system. Randomized double-blind comparisons of the two infusion systems for general anesthesia were performed in 24 patients undergoing coronary artery bypass grafting. Patients were allocated to receive continuous infusions of midazolam and fentanyl by either a MCI device or CACI. Midazolam and fentanyl infusions were independently titrated to maintain hemodynamic stability, defined as mean arterial pressure (MAP) and heart rate (HR) within 20% of baseline values. As directed by the study design, comparable hemodynamic control was achieved in both groups. Mean plasma fentanyl concentrations measured at specific timepoints were similar between groups. The plasma midazolam level for induction was 196 +/- 139 ng/mL in the CACI group and 300 +/- 128 ng/mL in the MCI group, and the fentanyl level was similar in both groups, 6.7 +/- 1.9 ng/mL in CACI and 6.3 +/- 4.6 ng/mL in the MCI group. The drug levels were lower (P < or = .05) for midazolam during maintenance of anesthesia and similar for fentanyl during the maintenance of anesthesia. In the MCI group, the average duration of anesthesia was 246.5 +/- 35.0 minutes, with a mean total fentanyl dose of 30.27 +/- 11.14 micrograms/kg. In the CACI group, the average duration of anesthesia was 230.8 +/- 44.1 minutes, with a mean total fentanyl dose of 34.61 +/- 5.40 micrograms/kg (P > 0.05 for comparisons between groups for duration of anesthesia and total fentanyl dose).(ABSTRACT TRUNCATED AT 250 WORDS) Automatic optimization of the infusion rate of sodium nitroprusside (SNP) is achieved by an integrated hardware-software closed-loop controller implemented as a small bedside device. A microprocessor-based blood pressure monitor controls an infusion pump. The shape of the arterial pressure wave is digitally sampled; its analysis incorporates artifact-detection and -rejection routines. The implemented algorithm applies a rule-based closed-loop control that incorporates fuzzy logic. The system models the decision-making ability of the expert, instead of trying to model the patient's physiologic dynamics. Several internal fuzzy-state variables are defined to achieve a clear understanding of mean arterial pressure (MAP) evolution with time. The system performance is very robust, employing, under all possible situations, a sort of "common sense." A clinical trial of the controller was conducted in 60 patients requiring vasodilation therapy for systemic arterial hypertension following cardiac surgery, 20 who had conventional manual control by an experienced nursing staff and 40 who had automated closed-loop control. The first 240 minutes of the postoperative period were closely watched, taking into account 1) the percentage of time during which MAP was within the 10-mmHg wide frame above the target pressure (target gap); 2) the mean difference of pressure values that crossed the boundary of the target gap; 3) the mean SNP-infusion rate. With automatic control, the time mean arterial pressure values were located in the target gap during the first hour amounted to 72.8 +/- 6.7%, vs 51.2 +/- 10.3% in the manual-control group. In the second hour, it was 79.3 +/- 2.5% vs 67.4 +/- 11.7% (p < 0.005).(ABSTRACT TRUNCATED AT 250 WORDS) In a prospective, randomized study, 75 adults receiving aminoglycosides were followed by a clinical pharmacokinetic service and 70 followed as controls. The two groups were similar in age, gender, height, and APACHE II score. A cost-to-charge ratio was used to derive direct costs of hospitalization and calculate cost-benefit. Excluded from this comparison were patients with incomplete acceptance of pharmacokinetic service recommendations and patients followed by other clinical pharmacists. Pharmacokinetic service patients had shorter hospitalizations (322.67 +/- 270.28 h; controls 442.89 +/- 536.81, p = 0.087) and febrile periods (50.05 +/- 79.38 h; controls 92.23 +/- 122.50, p less than 0.05). More pharmacokinetic service patients had adequate peak levels. Pharmacokinetic service direct costs were lower ($7,102.56 +/- 9,898.19; controls $13,758.64 +/- 22,874.31, p less than 0.05). Calculated direct cost of the service was $85.00/patient. Annual savings for 500 patients is $2,220,540.00. Usual drug-prescribing practices may not consider the effects of renal insufficiency on the disposition of certain drugs. Decision aids may help optimize prescribing behavior and reduce medical error.
                To determine if a system application for adjusting drug dose and frequency in patients with renal insufficiency, when merged with a computerized order entry system, improves drug prescribing and patient outcomes.
                Four consecutive 2-month intervals consisting of control (usual computerized order entry) alternating with intervention (computerized order entry plus decision support system), conducted in September 1997-April 1998 with outcomes assessed among a consecutive sample of 17 828 adults admitted to an urban tertiary care teaching hospital.
                Real-time computerized decision support system for prescribing drugs in patients with renal insufficiency. During intervention periods, the adjusted dose list, default dose amount, and default frequency were displayed to the order-entry user and a notation was provided that adjustments had been made based on renal insufficiency. During control periods, these recommended adjustments were not revealed to the order-entry user, and the unadjusted parameters were displayed.
                Rates of appropriate prescription by dose and frequency, length of stay, hospital and pharmacy costs, and changes in renal function, compared among patients with renal insufficiency who were hospitalized during the intervention vs control periods.
                A total of 7490 patients were found to have some degree of renal insufficiency. In this group, 97 151 orders were written on renally cleared or nephrotoxic medications, of which 14 440 (15%) had at least 1 dosing parameter modified by the computer based on renal function. The fraction of prescriptions deemed appropriate during the intervention vs control periods by dose was 67% vs 54% (P<.001) and by frequency was 59% vs 35% (P<.001). Mean (SD) length of stay was 4.3 (4.5) days vs 4.5 (4.8) days in the intervention vs control periods, respectively (P =.009). There were no significant differences in estimated hospital and pharmacy costs or in the proportion of patients who experienced a decline in renal function during hospitalization.
                Guided medication dosing for inpatients with renal insufficiency appears to result in improved dose and frequency choices. This intervention demonstrates a way in which computer-based decision support systems can improve care. Failure to adequately anticoagulate the blood of patients receiving recombinant tissue plasminogen activator (TPA) leads to greater rates of rethrombosis. In a multicentered, randomized trial in 51 patients we compared the ability to achieve and maintain therapeutic anticoagulation by use of computer-assisted heparin therapy or the GUSTO (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) heparin nomogram guidelines in patients with myocardial infarction treated with recombinant TPA. Heparin therapy was initiated with either computer-generated starting doses or GUSTO guideline starting doses. Activated partial thromboplastin times were measured every 6 to 8 hours for the first 24 hours. The therapeutic range used in this trial was 1.5 to 2.5 times the patient's baseline activated partial thromboplastin time (APTT). Ninety-four percent of the APTT ratios in the computer group were equal to or greater than 1.5 in the first 24 hours compared with 78% in the GUSTO group (p < 0.009). No significant difference in bleeding was found (7.7% for GUSTO; 4.2% for computer). Incremental time-dependent changes in heparin dose were found (day 1, 1110 +/- 243 units/hr, APTT ratio = 2.5 +/- 1.4; day 3, 1380 +/- 374 units/hr, APTT ratio, 1.9 +/- 0.4). Computer-assisted heparin therapy TPA results in superior anticoagulation accuracy compared with the GUSTO guidelines. In addition, the pharmacodynamic response to heparin changes in the 2 to 3 days after administration of TPA, leading to greater heparin requirements. To evaluate the effectiveness of a computerized decision support system for ovarian stimulation with gonadotropins.
                Retrospective and prospective randomized studies.
                Private and university teaching hospital.
                Women undergoing ovarian stimulation to treat infertility.
                Pregnancy rate.
                In the retrospective study, computer-generated decisions were compared with clinicians' decisions in 118 stimulated cycles in 53 patients. In 90% of cases, the choice of FSH regimens and adjustments to dosages were identical. In the prospective study, the computer-generated decisions achieved a pregnancy rate per cycle of 18% (15 of 82 cycles), compared with 16% (13 of 82 cycles) achieved by clinicians.
                A computerized decision making system was as effective as skilled clinicians in achieving pregnancy by using ovarian stimulation with FSH. A prospective randomised trial was conducted in critically ill patients to evaluate a computer aided pharmacokinetic method of aminoglycoside dose prediction based on 3 measured plasma concentrations following the loading dose. The ability of this method to achieve therapeutic plasma aminoglycoside concentrations early in the course of treatment was compared with that of a nomogram approach based on creatinine clearance estimated using the formula of Cockroft and Gault. Ninety-two percent of patients in the computer group achieved peak plasma concentrations within the optimum range of 6-10 mg/l at 48-72 h compared with 21% of control group patients (p = 0.0009). The mean peak plasma concentration of 7.45 mg/l at 48-72 h in the computer group was closer to the target concentration of 8 mg/l than was the 5.14 mg/l in the control group (p = 0.0004). There was no significant difference between the groups in measured indices of renal function, both groups showing an improvement in mean estimated creatinine clearance from the beginning to the end of the course of treatment. Dosing based on individualised pharmacokinetic data is therefore a more reliable method of achieving therapeutic blood concentrations early in the course of treatment than is nomogram based dosing. Other studies suggest that this should be associated with a reduction in mortality in severe infections. In a prospective, randomized clinical trial, we compared the accuracy of warfarin dosage-adjustments predictions using a computer program to the skill of an experienced anticoagulation nurse-specialist. The computer program predicts the steady state warfarin dose by applying Bayesian forecasting techniques to a mathematical model of the dynamic pharmacologic response to warfarin. Fifty patients who were receiving chronic warfarin therapy and who required a dosage adjustment because their prothrombin time was greater than or equal to 2 s away from their target prothrombin time were enrolled. The baseline characteristics of each group were similar, including the mean of the absolute value of the differences between initial prothrombin times and corresponding target prothrombin times. After a new a new warfarin dose was predicted, the prothrombin time was measured at least 7 days after dosage adjustment. Overall, the results in each group were comparable. There was no significant difference between groups and the mean of the absolute value of the differences between final prothrombin times and target prothrombin times, nor was there a difference in the proportion of patients who had a final prothrombin time within 2 s of the target prothrombin time. We conclude that the accuracy of warfarin dosage adjustments made using computer modeling is comparable to the skill of an anticoagulation nurse-specialist. The effect of intravenous theophylline on the outcome of inhospital treatment of acute bronchospasm has been assessed, comparing the results achieved by computer-assisted dosing, designed to achieve and maintain a serum theophylline level of 16 micrograms.ml-1 (10 patients) with those of unaided physicians (15 control patients). The outcome measures compared were clinical improvement, peak expiratory flow rate and serum theophylline concentration. Loading doses of theophylline in the control and computer groups were: 167 and 437 mg, respectively. Initial serum theophylline concentrations, measured 20 min after the loading dose, were 13.6 and 17.0 micrograms.ml-1 in the control and computer groups, respectively. In patients who had not received theophylline prior to admission, loading doses and initial concentrations were: 200 mg and 9.4 micrograms.ml-1 in the control group (n = 5) versus 613 mg and 15.7 micrograms.ml-1 in the computer group (n = 4), respectively. During maintenance therapy, serum theophylline concentrations were kept in the therapeutic range (10-20 micrograms.ml-1) throughout 51% and 77% of the hospitalisation period, in the control and computer groups, respectively. There were no differences between the two groups in the rate or extent of clinical improvement or in change in peak expiratory flow rate. The computer assisted theophylline dosing regimen outperformed that of the unaided physicians in achieving and maintaining therapeutic serum theophylline concentrations in acute bronchospasm. There was no correlation between clinical outcome and serum theophylline concentration, but this may have been due to the small sample size and modest difference in serum theophylline between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS) 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.
                Randomised controlled trial.
                District general hospital in North London.
                148 inpatients requiring start of warfarin treatment.
                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).
                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.
                72 patients were randomised to the intervention group and 76 to control group. Median time to reach international normalised ratio of > or = 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%).
                The computerised decision support system was safe and effective and improved the quality of initiation and control of warfarin treatment by trainee doctors. This study was undertaken to determine if a computerized pharmacokinetic program for adjusting theophylline infusion rates could attain a goal serum theophylline level more accurately than physician-derived adjustments and what clinical impact this would have. Thirty-five patients with diagnoses of asthma or chronic obstructive pulmonary disease were randomized to a control group (empiric) or experimental group (kinetic) after initial theophylline levels were drawn from each group. After second levels were drawn, patients in the kinetic group had their infusion rates adjusted by the computerized pharmacokinetic program to achieve a level of 15 mg/L, whereas patients in the empiric group had their infusions adjusted empirically by the primary care physicians to achieve a serum theophylline level of 15 mg/L. A final theophylline level was obtained just before the infusion was discontinued. The kinetic group was closer to the goal level of 15 mg/L than the empiric group, but this was not statistically significant (14.8 +/- 4.4 versus 12.6 +/- 4.1; p > 0.05). The total number of days that patients were receiving intravenous theophylline was slightly longer for the kinetic group (4.1 +/- 3.3 versus 3.2 +/- 1.5; p > 0.05) as was the total number of hospital days, but neither of these were statistically significant (11.4 +/- 21.6 versus 8.8 +/- 15.4 days; p > 0.05). There were no differences between the two groups in the number of subtherapeutic or toxic levels, and there were no significant differences in arterial blood gas measurements.(ABSTRACT TRUNCATED AT 250 WORDS) We studied the effect of a bayesian pharmacokinetic dosing program on the outcome of aminoglycoside therapy in patients with clinical infections. Patients were randomized to a control (dosing based on physician choice; n = 75) or experimental group (dosing based on the bayesian program; n = 72). Both groups used serum aminoglycoside concentration data when making dosing decisions. Improved response rates were seen in the experimental (60%; 42/68) compared with the control group (48%; 36/68). A higher, but not statistically significant, incidence of toxicity was found in the control (7/75; 9.7%) versus the experimental group (4/72; 5.1%). Mean length of total hospital stay was significantly longer for patients in the control group (20.3 days) compared with the experimental group (16.0 days) (p = 0.028). The variables from multivariate analysis with a significant impact on length of stay were patient group and length of aminoglycoside therapy. On the basis of a reduced length of stay, a potential cost savings of $1311 per patient can be achieved. There is increased pressure on primary care physicians to monitor oral anticoagulation.
                To test the null hypothesis that oral anticoagulation care can be provided at least as well in primary care through a nurse-led clinic, involving near-patient testing and computerized decision support software, compared with routine hospital management based on a variety of clinical outcome measures.
                A randomized, controlled trial in 12 primary care practices in Birmingham, England (9 intervention and 3 control). Two control populations were used: patients individually randomly allocated as controls in the intervention practices (intrapractice controls) and all patients in control practices (interpractice controls). Intervention practices' patients were randomized to the intervention (practice-based anticoagulation clinic) or control (hospital clinic) group. The main outcome measure was therapeutic control of the international normalized ratio.
                Three hundred sixty-seven patients were recruited (122 intervention patients, 102 intrapractice control patients, and 143 interpractice control patients). Standard measures of control of the international normalized ratio (point prevalence) showed no significant difference between the intervention and control groups. Data on proportion of time spent in the international normalized ratio range showed significant improvement for patients in the intervention group (paired t test, P =.008).
                Nurse-led anticoagulation clinics can be implemented in novice primary care settings by means of computerized decision support software and near-patient testing. Care given by this model is at least as good as routine hospital follow-up. The model is generalizable to primary health care centers operating in developed health care systems.
This review suggests that computerized advice for drug dosage has some benefits: it increased the initial dose of drug, increased serum drug concentrations and led to a more rapid therapeutic control. It also reduced the risk of toxic drug levels and the length of time spent in the hospital. However, it had no effect on adverse reactions. In addition, there was no evidence to suggest that some decision support technical features (such as its integration into a computer physician order entry system) or aspects of organization of care (such as the setting) could optimise the effect of computerised advice.