A randomized controlled trial to evaluate the use of a web-based application to manage medications during in vitro fertilization.

OBJECTIVE: To evaluate the use of a web-based application that assists in medication management during in vitro fertilization (IVF) treatment. DESIGN: Multicenter randomized controlled trial. SETTING: University hospitals. PATIENT(S): Women undergoing IVF. INTERVENTION(S): Subjects were recruited to assess quality of life during IVF and were randomly assigned to use either the OnTrack application to assist with medication management or conventional medication management. Surveys were administered at four time points. MAIN OUTCOME MEASURE(S): Medication surplus, incidence of medication errors, amount of patient-initiated communication, and patient satisfaction. RESULT(S): A total of 153 women participated. The average number of portal messages and telephone calls was similar between groups. Twelve patients in the control group (12/69, 17.4%) and 8 patients in the case group (8/72, 11.1%) made medication errors. There were similar amounts of medication surplus in the two groups. The estimated cost of medication waste was $2,578 ± $2,056 in the control group and $2,554 ± $1,855 in the case group. Patient satisfaction was similar between the two groups. CONCLUSION(S): Use of a web-based application did not decrease medication errors, medication surplus, or patient-initiated messages. Many patients had a medication surplus, which can be an area of cost reduction during IVF. CLINICAL TRIAL REGISTRATION NUMBER: Clinicaltrials.gov NCT03383848.

The rise, fall, and future direction of computer-assisted personalized sedation.

PURPOSE OF REVIEW: The first computer-assisted personalized sedation (CAPS) device was developed to address the growing demand for routine endoscopy procedures in the United States in the early 2000s. This review will describe the environment that gave rise to CAPS and summarize the design of that first device. It will then discuss the market forces that led to the fall of CAPS, with sales of the device ending 2 years after commercialization. RECENT FINDINGS: CAPS was initially conceived as a means to enable proceduralists to administer conscious sedation with propofol safely. In the nearly 20 years since its conception, the expectations of patients and proceduralists for endoscopy sedation, have evolved from conscious sedation to deep. Due to the increased risk inherent in deep sedation, future CAPS devices should be tools for anesthesiologists, not proceduralists. SUMMARY: Over $2 billion are spent annually for anesthesia services in routine endoscopic procedures for low-risk patients; a spending rate that is not sustainable. CAPS, in an 'anesthesia oversight' model similar to medical supervision, has a future as a cost-efficient means for anesthesia services to provide sedation in endoscopy and other nonoperating room venues. Anesthesiologists should work with medical device companies and payers to develop a CAPS 'anesthesia oversight' model.

Cost-Effectiveness of Decision Support Strategies in Acute Bronchitis.

BACKGROUND: A recent clinical trial suggests that printed (PDS) and computer decision support (CDS) interventions are safe and effective in reducing antibiotic use in acute bronchitis relative to usual care (UC). OBJECTIVE: Our aim was to evaluate the cost-effectiveness of decision support interventions in reducing antibiotic use in acute bronchitis. DESIGN: We conducted a clinical trial-based cost-effectiveness analysis comparing UC, PDS and CDS for management of acute bronchitis. We assumed a societal perspective, 5-year program duration and 30-day time horizon. PATIENTS: The U.S. population aged 13-64 years presenting with acute bronchitis in the ambulatory setting. INTERVENTIONS: Printed and computer decision support interventions relative to usual care. MAIN MEASURES: Cost per antibiotic prescription safely avoided. KEY RESULTS: In the base case, PDS dominated UC and CDS, with lesser total costs (PDS: $2,574, UC: $2,768, CDS: $2,805) and fewer antibiotic prescriptions (PDS: 3.79, UC: 4.60, CDS: 3.95) per patient over 5 years. In one-way sensitivity analyses, PDS dominated UC across all parameter values, except when antibiotics reduced work loss by ≥ 1.9 days or the probability of hospitalization within 30 days was ≥ 0.9 % in PDS (base case: 0.2 %) or ≤ 0.4 % in UC (base case: 1.0 %). The dominance of PDS over CDS was sensitive both to probability of hospitalization and plausible variation in the adjusted odds of antibiotic use in both strategies. CONCLUSIONS: A PDS strategy to reduce antibiotic use in acute bronchitis is less costly and more effective than both UC and CDS strategies, although results were sensitive to variation in probability of hospitalization and the adjusted odds of antibiotic use. This simple, low-cost, safe, and effective intervention would be an economically reasonable component of a multi-component approach to address antibiotic overuse in acute bronchitis.

Effectiveness of a computerized drug-monitoring program to detect and prevent adverse drug events and medication non-adherence in outpatient ambulatory care: study protocol of a randomized controlled trial.

BACKGROUND: Medications are an effective intervention for managing and preventing health problems but their benefit can be undermined by non-adherence or adverse drug events (ADEs). Since these issues may be interconnected, efforts to improve non-adherence should also include reduction of ADEs. We have developed the ISTOP-ADE system (Information Systems-enabled Outreach for Preventing Adverse Drug Events), which enables timely monitoring and managing of ADEs. The objectives of this study are to determine whether the ISTOP-ADE system, compared to routine care, will reduce: a) the probability of discontinuing the use of prognosis-altering medications; b) the probability of a patient experiencing a severe ADE; c) the proportion of patients experiencing ADEs, preventable ADEs and ameliorable ADEs; and d) health services utilization. METHODS/DESIGN: We will randomly assign 2,200 adult ambulatory patients in the province of Québec who have been prescribed an incident medication for the management or prevention of a chronic health condition, to routine care or the ISTOP-ADE system. The ISTOP-ADE system consists of an interactive voice response system (IVRS) paired with pharmacist support. The IVRS will call patients at 3 and 17 days post-prescription to determine if they are experiencing any problems and connect them with a pharmacist when required or desired by the patient. We will evaluate medication persistence at 180 days and health-care utilization using provincial administrative data. Two blinded physicians will ascertain ADE status through a case review. DISCUSSION: We expect the ISTOP-ADE intervention to be feasible and to improve the quality of patient care through improved medication adherence, reduced ADE duration and reduced number of ADEs resulting in an emergency department or inpatient encounter. This in turn could lower health-care utilization, saving costs and lowering the burden on emergency departments and family practices. The success of ISTOP-ADE would present opportunities to implement this intervention through health systems, health insurance agents and commercial pharmacies. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02059044. Date registered: 10 January 2014.

Advancing medication infusion safety through the clinical integration of technology.

Adverse drug events resulting from errors in prescribing or administering medications are preventable. Within a hospital system, numerous technologies are employed to address the common sources of medication error, including the use of electronic medical records, physician order entry, smart infusion pumps, and barcode medication administration systems. Infusion safety is inherently risky because of the high-risk medications administered and the lack of integration among the stand-alone systems in most institutions. Intravenous clinical integration (IVCI) is a technology that connects electronic medical records, physician order entry, smart infusion pumps, and barcode medication administration systems. It combines the safety features of an automatically programmed infusion pump (drug, concentration, infusion rate, and patient weight, all auto-programmed into the device) with software that provides visibility to real-time clinical infusion data. Our article describes the characteristics of IVCI at WellSpan Health and its impact on patient safety. The integrated infusion system has the capability of reducing medication errors, improving patient care, reducing in-facility costs, and supporting asset management. It can enhance continuous quality improvement efforts and efficiency of clinical work flow. After implementing IVCI, the institution realized a safer patient environment and a more streamlined work flow for pharmacy and nursing.

Effectiveness of medicines review with web-based pharmaceutical treatment algorithms in reducing potentially inappropriate prescribing in older people in primary care: a cluster randomized trial (OPTI-SCRIPT study protocol).

BACKGROUND: Potentially inappropriate prescribing in older people is common in primary care and can result in increased morbidity, adverse drug events, hospitalizations and mortality. In Ireland, 36% of those aged 70 years or over received at least one potentially inappropriate medication, with an associated expenditure of over €45 million.The main objective of this study is to determine the effectiveness and acceptability of a complex, multifaceted intervention in reducing the level of potentially inappropriate prescribing in primary care. METHODS/DESIGN: This study is a pragmatic cluster randomized controlled trial, conducted in primary care (OPTI-SCRIPT trial), involving 22 practices (clusters) and 220 patients. Practices will be allocated to intervention or control arms using minimization, with intervention participants receiving a complex multifaceted intervention incorporating academic detailing, medicines review with web-based pharmaceutical treatment algorithms that provide recommended alternative treatment options, and tailored patient information leaflets. Control practices will deliver usual care and receive simple patient-level feedback on potentially inappropriate prescribing. Routinely collected national prescribing data will also be analyzed for nonparticipating practices, acting as a contemporary national control. The primary outcomes are the proportion of participant patients with potentially inappropriate prescribing and the mean number of potentially inappropriate prescriptions per patient. In addition, economic and qualitative evaluations will be conducted. DISCUSSION: This study will establish the effectiveness of a multifaceted intervention in reducing potentially inappropriate prescribing in older people in Irish primary care that is generalizable to countries with similar prescribing challenges. TRIAL REGISTRATION: Current controlled trials ISRCTN41694007.

Efecto de un sistema automático de dispensación de medicamentos sobre el gasto farmacéutico y el grado de satisfacción del usuario / An automatic dispensing system medications effect in pharmaceutical expenditure and satisfaction user level

Objetivo: Evaluar en términos económicos el efecto de la sustitución de botiquines tradicionales por la implantación de Sistemas Automáticos de Dispensación de Medicamentos en la Unidad de Cuidados Intensivos. Analizar el grado de aceptación de dicho cambio por parte de los usuarios. Método: Para el análisis económico, se consideraron los costes directos e indirectos tangibles, derivados de la implantación: inversión inicial de capital, coste del personal implicado, coste en política de consumo de medicamentos. Todos estos aspectos se evaluaron antes y después de la implantación. El grado de satisfacción de los usuarios se evaluó a través de un cuestionario estandarizado. Resultados: Tras la estimación de los costes, comprobamos que el gasto realizado en la inversión inicial se verá rápidamente compensado fundamentalmente por el coste referido a la política de consumos de medicamentos con una reducción del 24% con respecto al sistema de dispensación anterior. El coste en el capitulo de personal también se ve reducido un 11%, así como el coste/estancia y coste/ingreso que disminuyen un 26% y 30% respectivamente en relación al sistema anterior. La evaluación del cuestionario reveló que los usuarios están satisfechos con la implantación y un 84% del personal de enfermería lo recomendaría a otras unidades. Conclusiones: Los Sistemas Automáticos de Dispensación de Medicamentos constituyen una nueva herramienta tecnológica para el control del gasto farmacéutico, con buena aceptación por parte de los usuarios (AU)

Objective: To evaluate in economic terms, the effect of replacing traditional kits for the implementation of automated dispensing of medications in the Intensive Care Unit. Analyze the degree of acceptance of such changeon the part of users. Method: For the economic analysis is considered tangible direct and indirect costs resulting from the implementation: initial capital investment, cost of staff involved, the political cost of drug consumption. All these aspects were evaluated before and after implantation. The degree of user satisfaction was assessed using a standardized questionnaire. Results: After the estimation of costs, we found that the expenditure incurred on the initial investment will be quickly offset by the cost mainly referred to the politics of consumption of drugs with a reduction of 24% over the previous delivery system. The cost in personal chapter is also reduced by 11%, and the cost per stay and cost / income fell by 26% and 30% respectively over the previous system. The evaluation questionnaire revealed that users are satisfied with the implementation and 84% of nurses would recommend it to other units. Conclusions: Automated Dispensing Systems Drugs are a new technological tool to control drug spending, with good acceptance by users (AU)

The economics of health information technology in medication management: a systematic review of economic evaluations.

OBJECTIVE: To conduct a systematic review and synthesis of the evidence surrounding the cost-effectiveness of health information technology (HIT) in the medication process. MATERIALS AND METHODS: Peer-reviewed electronic databases and gray literature were searched to identify studies on HIT used to assist in the medication management process. Articles including an economic component were reviewed for further screening. For this review, full cost-effectiveness analyses, cost-utility analyses and cost-benefit analyses, as well as cost analyses, were eligible for inclusion and synthesis. RESULTS: The 31 studies included were heterogeneous with respect to the HIT evaluated, setting, and economic methods used. Thus the data could not be synthesized, and a narrative review was conducted. Most studies evaluated computer decision support systems in hospital settings in the USA, and only five of the studied performed full economic evaluations. DISCUSSION: Most studies merely provided cost data; however, useful economic data involves far more input. A full economic evaluation includes a full enumeration of the costs, synthesized with the outcomes of the intervention. CONCLUSION: The quality of the economic literature in this area is poor. A few studies found that HIT may offer cost advantages despite their increased acquisition costs. However, given the uncertainty that surrounds the costs and outcomes data, and limited study designs, it is difficult to reach any definitive conclusion as to whether the additional costs and benefits represent value for money. Sophisticated concurrent prospective economic evaluations need to be conducted to address whether HIT interventions in the medication management process are cost-effective.

Outcomes of a decision support prompt in community pharmacy-dispensing software to promote step-down of proton pump inhibitor therapy.

AIM: To evaluate the effect of a computerized decision support prompt regarding high-dose proton pump inhibitor (PPI) therapy on prescribing and medication costs. METHODS: A prompt activated on dispensing high-dose esomeprazole or pantoprazole was implemented in 73 of 185 pharmacies. Anonymized prescription data and a patient survey were used to determine changes in prescribing and associated medication costs. RESULTS: The pharmacist-recorded PPI intervention rate per 100 high-dose PPI prescriptions was 1.67 for the PPI prompt group and 0.17 for the control group (P < 0.001). During the first 28 days of the trial, 196 interventions resulted in 34 instances of PPI step-down, with 28 of these occurring in PPI prompt pharmacies. Cost savings attributable to the prompt were AUD 7.98 (£4.95) per month per PPI prompt pharmacy compared with AUD 1.05 (£0.65) per control pharmacy. CONCLUSION: The use of electronic decision support prompts in community pharmacy practice can promote the quality use of medicines.

Use of an automated clinical management system improves outpatient immunosuppressive care following liver transplantation.

OBJECTIVE: Immunosuppressive therapy following transplantation, if not managed well, can lead to increased drug toxicity or rejection episodes. We investigated whether use of an automated clinical management system in our liver transplant program would improve clinical outcomes in managing transplant recipients' immunosuppressive medications. DESIGN: We performed a retrospective cohort study of two patient groups receiving liver transplants at our institution. One group of 301 patients transplanted from January 1, 2004 to November 30, 2006 received outpatient immunosuppressive management using a paper charting system. After instituting an automated clinical management system, the following group of 127 patients transplanted from December 12, 2006 to April 1, 2008 received their outpatient immunosuppressive management with that system. Only patients who received tacrolimus therapy, with or without mycophenolate mofetil or prednisone, were studied. MEASUREMENTS: Our endpoints included percentage of patients having rejection and/or tacrolimus toxicity episodes. Various recipient, intraoperative, donor, and postoperative variables, including managing the immunosuppressive therapy with a paper charting system or an automated management system, were studied to determine which factors were associated with our endpoints. RESULTS: Multivariable logistic regression analysis showed the automated system was significantly associated with fewer rejection episodes and fewer tacrolimus toxicity events. Formal cost-effectiveness analysis of the nurses' salaries for 1 year showed the automated system cost US$197 per patient and the paper system cost US$1703 per patient. The automated system improved quality of life years. CONCLUSION: Use of an automated clinical management system for outpatient immunosuppressive management for liver transplant patients has resulted in a decrease in both tacrolimus toxicity and rejection episodes and is cost-effective.

Computer-assisted propofol administration.

The use of propofol for sedation in endoscopy may allow for better quality of sedation, quicker recovery and facilitate greater throughput in endoscopy units. The cost-effectiveness and utility of propofol sedation for endoscopic procedures is contingent on the personnel and resources required to carry out the procedure. Computer-based platforms are based on the patients response to stimulation and physiologic parameters. They offer an appealing means of delivering safe and effective doses of propofol. One such means is the bispectral index where continuous EEG recordings are used to assess the degree of sedation. Another is the closed-loop target-controlled system where a set of physical parameters, such as muscle relaxation and auditory-evoked potential, determine a level of medication appropriate to achieve sedation. Patient-controlled platforms may also be used. These electronic adjuncts may help endoscopists who wish to adopt propofol sedation to change current practices with greater confidence.

A pilot study about the feasibility and cost-effectiveness of electronic compliance monitoring in substitution treatment with buprenorphine-naloxone combination.

OBJECTIVES: The purpose of the study was to investigate whether or not compliance monitoring by microchip could offer a feasible method for reducing abuse and/or diversion of medication from unsupervised substitution treatment for opioid addiction. DESIGN: Naturalistic, 4-week pilot study in out patients. PATIENTS AND INTERVENTIONS: All our patients (N = 12) on buprenorphine-naloxone combination (Suboxone) received their medication for 6 days in a compliance-monitoring device (PharmaDDSi, StoraEnso), which registers date and time of tablet removal. Patients were instructed to take all tablets as one dose. Time cues were displayed and discussed with the patients during their weekly visits for supervised drug administration and counseling. MAIN OUTCOME MEASURES: Regularity of registered time cues, treatment costs in comparison with routine treatment, patients' answers from a questionnaire on acceptability, and effect on drug diversion. RESULTS: Six patients showed good compliance, in two patients irregularities were minor, but in two others lack of adherence to treatment instructions was detected. Patients with several comorbid psychiatric diagnoses showed on an average the longest intervals between removal of first and last tablet of the daily dose. One-fourth of the patients reported that compliance monitoring had helped to avoid diversion. Total cost savings during the 4-week period was a reduction of 39 percent, which was mainly due to fewer visits to the clinic. CONCLUSIONS: Compliance monitoring by PharmaDDSI with weekly feedback was well accepted and subjectively increased compliance with substitution treatment. Future studies will show whether a technical solution for compliance monitoring in real time can help to reduce drug abuse and noncompliance in substitution treatment and other opioid treatments.

[Non-steroidal anti-inflammatory drugs prescription in General Practice setting: 435 does informatics have any influence?]. / Prescrição de anti-inflamatórios não esteróides no ambiente de Medicina Geral e Familiar: a informática influencia?

AIMS: In the ambulatory setting of General Practice/Family Medicine, a retrospective, observational study was carried out to ascertain variation on non-steroidal anti-inflammatory drugs prescription, in an informatics environment where name (brand or chemical), size of package, price and the existence of generic medicines is available. METHODS: Observational transversal study conducted in February 2008 with no prescription study warning given to the doctors in the study period. The differences in volume prescription in Daily Defined Dose (DDD) per registered patient in the middle of 2006 and 2007 two semesters, as well as the value of prescription measured by the price per registered patient were calculated and medicines were studied by the third level of the Portuguese medicines classification very similar to the ATC. The price per DDD was calculated as well. RESULTS: DDD volume and value declined throughout the study comparing entire years or semesters being "Oxicans" the only exception. Even though, the net volume and value decreased between 2006 and 2007 comparing both semesters of 2006 and of 2007. Price per DDD decreased for all medicines except for oxicans with an increase from the first to the second semesters of 2007. CONCLUSIONS: Informatics environment influences the prescription of non-steroidal anti-inflammatory drugs, reducing the number of DDD and the price per registered patient.

User perceptions of in-home medication dispensing devices.

The purpose of this study was to characterize patient and clinician perceptions of programmable medication devices (dispensers and timers) being marketed to consumers to improve medication adherence. Using principles of usability testing, 33 volunteer staff and clinic patients rated seven devices. Raters scored devices on cueing and alarms, storage and dispensing, machine characteristics, potential to improve adherence, and cost. Medication dispensers ranked highest overall. However, even if the Department of Veterans Affairs paid for them, patient participants would be unlikely to use them. No significant differences were found across the devices in the perceived likelihood that the device would improve medication adherence. In this article, we provide a set of criteria for patients who might choose such a device and clinicians who may recommend these kinds of devices. More work is needed in the design and deployment of these devices if they are to be part of a successful medication adherence plan.

Costs associated with developing and implementing a computerized clinical decision support system for medication dosing for patients with renal insufficiency in the long-term care setting.

A team of physicians, pharmacists, and informatics professionals developed a CDSS added to a commercial electronic medical record system to provide prescribers with patient-specific maximum dosing recommendations based on renal function. We tracked the time spent by team members and used US national averages of relevant hourly wages to estimate costs. The team required 924.5 hours and $48,668.57 in estimated costs to develop 94 alerts for 62 drugs. The most time intensive phase of the project was preparing the contents of the CDSS (482.25 hours, $27,455.61). Physicians were the team members with the highest time commitment (414.25 hours, $25,902.04). Estimates under alternative scenarios found lower total cost estimates with the existence of a valid renal dosing database ($34,200.71) or an existing decision support add-on for renal dosing ($23,694.51). Development of a CDSS for a commercial computerized prescriber order entry system requires extensive commitment of personnel, particularly among clinical staff.

Estimating the cost-effectiveness of quality-improving interventions in oral anticoagulation management within general practice.

OBJECTIVES: A clinical trial, "Belgian Improvement Study on Oral Anticoagulation Therapy (BISOAT)," significantly improved the quality after implementing four different quality-improving interventions in four randomly divided groups of general practitioners (GPs). The quality-improving interventions consisted of multifaceted education with or without feedback reports on their performance, international normalized ratio (INR) testing by the GP with a CoaguChek device or computer-assisted advice for adapting oral anticoagulation therapy. The quality improvement in INR control versus baseline was similar in the four groups. The aim of the current study was to calculate the cost-effectiveness and influencing factors of the four quality-improving interventions compared with usual care. METHODS: Activity-based costing techniques with questionnaires were used to determine the global costs per patient per month in the different intervention groups. Effectiveness data were obtained from the BISOAT study. Cost-effectiveness was expressed as cost per additional day within a 0.5 range from INR target. RESULTS: The one-time cost of multifaceted education was 49,997 euro for the whole study. Monthly continuous costs per intervention ranged between 37 euro and 54 euro per patient. Using the CoaguChek in combination with the multifaceted education was associated with net savings and quality improvement, hence dominated usual care. Sensitivity analyses showed improved cost-effectiveness with extended duration and with increased program size. CONCLUSION: Implementation of the combination multifaceted education with the use of the CoaguChek is a cost-effective new organizational model of oral anticoagulation management in general practice.

Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review.

BACKGROUND: Iatrogenic injuries related to medications are common, costly, and clinically significant. Computerized physician order entry (CPOE) and clinical decision support systems (CDSSs) may reduce medication error rates. METHODS: We identified trials that evaluated the effects of CPOE and CDSSs on medication safety by electronically searching MEDLINE and the Cochrane Library and by manually searching the bibliographies of retrieved articles. Studies were included for systematic review if the design was a randomized controlled trial, a nonrandomized controlled trial, or an observational study with controls and if the measured outcomes were clinical (eg, adverse drug events) or surrogate (eg, medication errors) markers. Two reviewers extracted all the data. Discussion resolved any disagreements. RESULTS: Five trials assessing CPOE and 7 assessing isolated CDSSs met the criteria. Of the CPOE studies, 2 demonstrated a marked decrease in the serious medication error rate, 1 an improvement in corollary orders, 1 an improvement in 5 prescribing behaviors, and 1 an improvement in nephrotoxic drug dose and frequency. Of the 7 studies evaluating isolated CDSSs, 3 demonstrated statistically significant improvements in antibiotic-associated medication errors or adverse drug events and 1 an improvement in theophylline-associated medication errors. The remaining 3 studies had nonsignificant results. CONCLUSIONS: Use of CPOE and isolated CDSSs can substantially reduce medication error rates, but most studies have not been powered to detect differences in adverse drug events and have evaluated a small number of "homegrown" systems. Research is needed to evaluate commercial systems, to compare the various applications, to identify key components of applications, and to identify factors related to successful implementation of these systems.

Will decision support in medications order entry save money? A return on investment analysis of the case of the Hong Kong hospital authority.

The computerized medications order entry system currently used in the public hospitals of Hong Kong does not have decision support features. Plans are underway to add decision support to this system to alert physicians on drug-allergy conflicts, drug-lab result conflicts, drug-drug interactions and atypical dosages. A return on investment analysis is done on this enhancement, both as an examination of whether there is a positive return on the investment and as a contribution to the ongoing discussion of the use of return on investment models in health care information technology investments. It is estimated that the addition of decision support will reduce adverse drug events by 4.2 - 8.4%. Based on this estimate, a total net saving of $44,000 - $586,000 is expected over five years. The breakeven period is estimated to be between two to four years.

Computerized management of oral anticoagulant therapy: experience in major joint arthroplasty.

OBJECTIVE: Evaluation of the safety and potential cost savings of a computerized, laboratory-based program to manage inpatient warfarin thromboprophylaxis after major joint arthroplasty. DESIGN: A consecutive-case study of adults. SETTING: A tertiary care orthopedic institution. PATIENTS: Patients requiring joint arthroplasty who had no recent episodes of thromboembolic disease, no mechanical heart valve, atrial fibrillation, severe liver disease or baseline international normalized ratio [INR] greater than 1.3 admitted over a 54-month period (July 1994-December 1998). All patients received a standard regimen of warfarin beginning on the evening after the operation. Four hundred and thirty randomly selected patients managed by the program were followed up by telephone survey 3 months after discharge. Patients exhibiting erratic responses to warfarin were withdrawn from the program and managed individually thereafter. INTERVENTION: Major joint arthroplasty with warfarin therapy administered through the computerized program. MAIN OUTCOME MEASURES: Test results maintained within the desired therapeutic range (INR 2.0-3.0), clinically severe bleeding episodes, readmission rates, clinically symptomatic and venographically proven episodes of venous thrombosis or pulmonary embolism. RESULTS: Over the study period 5629 patients underwent joint arthroplasty; 5,372 patients were considered for the program; 332 patients were ineligible and were managed individually; 311 entered patients did not complete the program. This left 4,729 patients who completed the program. In 2932 (62%) patients test results were maintained in the desired therapeutic range. The major bleeding rate was less than 0.5%, the readmission rate was 3.8%, the deep venous thrombosis rate was 3.7% and the pulmonary embolism rate was 0.2% with no thromboembolic related deaths in the small sample cohort. CONCLUSIONS: The majority of patients requiring warfarin thromboprophylaxis can be safely and effectively managed by this laboratory-based computerized program while in hospital. Significant potential cost savings in nursing time could be achieved.