Abstract
Purpose :
To implement and assess the impact of an electronic clinical decision support tool (DST) on prescriber adherence to 2016 Academy of Ophthalmology (AAO) recommendations for a hydroxychloroquine maximum daily dose of 5 mg/kg actual body weight.
Methods :
A DST was developed to trigger a pop-up alert within the electronic medical record when a prescriber orders hydroxychloroquine exceeding 5 mg/kg actual body weight or >400mg daily. The prescriber may choose to amend the prescription or override the alert. The tool was implemented on April 21, 2020. A chart review was performed of all hydroxychloroquine prescriptions in the 6-month post-intervention period (May – November 2020). Inclusion criteria were patient age ≥18 years; availability of dose and frequency; availability of actual body weight; and outpatient prescription status. Only the most recent prescription was used in cases of an individual patient having multiple prescriptions. Prevalence of excess hydroxychloroquine dosing (>5mg/kg/day) and mean daily dose in the post-intervention period was compared to previously collected, pre-intervention data from 2018 (under review for publication), using the chi-squared test and 2-sample t-test, respectively. The odds ratios of excessive dosing was assessed using multivariable logistic regression that included sex, race, weight, and prescriber specialty.
Results :
There were 7915 patients with active hydroxychloroquine prescription, of which 7415 (94%) met inclusion criteria. There prevalence of excessive dosing decreased from 27.4% pre-DST to 21.1% post-DST (P<0.001). Mean daily dose decreased from 342±94 mg (4.3±1.4 mg/kg/day) pre-DST to 324±93mg (4.1±1.3mg/kg/day) post-DST (P<0.001). Only 0.2% prescriptions exceeded mean 400mg daily, and 0.1% prescriptions were indicated for COVID-19. In multivariable analysis, a rheumatologist prescriber (in comparison to all other specialties, OR 0.66 [99% CI 0.54-0.80]) and greater weight (OR 0.94 [99% CI 0.93-0.95], equivalent to -0.062 log odds per 1 kg increase in weight) were associated with reduced odds of excessive dosing.
Conclusions :
Implementation of a DST significantly improved prescriber adherence with 2016 AAO ophthalmic safety recommendations for hydroxychloroquine dosing. As daily dosage is a strong predictor of retinopathy risk, an electronic DST demonstrates potential to reduce ophthalmic morbidity associated with chronic hydroxychloroquine use.
This is a 2021 ARVO Annual Meeting abstract.