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Using handheld computers with specific prescribing software at the point of care can reduce unsafe NSAID prescribing

Although nonselective, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen increase the risk of gastrointestinal (GI) bleeding, they are often prescribed for patients at risk for GI bleeding. These medications are also often prescribed without a prescription for a gastroprotective agent such as a proton pump inhibitor or misoprostol, which limit acid secretion in the stomach. A handheld computer (personal digital assistant, PDA) includes a software program that assesses GI risk factors prior to prescribing NSAIDs and can reduce unsafe practices in prescribing NSAIDs, concludes a study supported in part by the Agency for Healthcare Research and Quality (HS11820).

At baseline, the mean proportion of cases per resident physician with unsafe NSAID prescriptions for PDA intervention and control physicians was similar (0.27 vs. 0.29). However, intervention physicians, whose PDA software advised them to assess patient GI risk factors before prescribing NSAIDs, wrote half as many unsafe prescriptions for NSAIDs as control physicians, whose PDA software did not include the GI risk assessment rule (0.23 vs. 0.45). The GI rule prompted physicians to assess six established risk factors for GI complications from NSAIDs (age, self-assessed health status, diagnosis of rheumatoid arthritis, steroid use, a history of GI hemorrhage or hospitalization for an ulcer, and symptoms with NSAIDs).

The program also provided real-time treatment recommendations based on a patient's risk, explains Eta S. Berner, Ed.D., of the University of Alabama at Birmingham. Dr. Berner and colleagues randomized 68 internal medicine resident physicians at a university-based clinic to either the PDA intervention or control group. They assessed residents' prescribing practices by examining the treatment provided for "standardized patients." In this case, the standardized patients were lay individuals trained to portray patients with musculoskeletal symptoms typically treated with NSAIDs, as well as one of four cases that posed a risk for GI hemorrhage if nonselective NSAIDs were prescribed for an extended period of time without gastroprotection.

See "Improving ambulatory prescribing safety with a handheld decision support system: A randomized controlled trial," by Dr. Berner, Thomas K. Houston, M.D., M.P.H., Midge N. Ray, R.N., M.S.N., and others in the March 2006 Journal of the American Medical Informatics Association 13(2), pp. 171-179.

Editor's note: In a related study, also supported in part by AHRQ, researchers developed and evaluated a rating scale, the Attitudes toward Handheld Decision Support Software Scale (H-DSS), to assess physician attitudes about handheld decision support systems. The psychometric properties of the H-DSS were tested among 82 residents, with 75 residents completing the assessment once prior to receiving a PDA and again 6 months after receiving the PDA. Their evaluation showed that the H-DSS scale was reliable, valid, and responsive and can be used to guide future handheld DSS development and implementation. See Ray, M.N, Houston, T.K., Yu, F.B., and others (2006, September/October). "Development and testing of a scale to assess physician attitudes about handheld computers with decision support." (AHRQ grant HS11820). Journal of the American Medical Informatics Association 13(5), pp. 567-572.

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