Evaluating Impact of Implementing Order Questions on Appropriate Prescribing of Tolvaptan

BackgroundTolvaptan poses a significant risk to patient safety due to its risk of overcorrection of hyponatremia, and its cost-effectiveness is not well established. Kettering Health implemented order questions into Epic in 2019 to drive appropriate use of tolvaptan. Objective: The primary objective was to determine the impact of implementing order questions on appropriate use of tolvaptan. The secondary objectives were to determine if providers are adhering to the order questions meant to ensure appropriate use, to identify if there is provider variance across the network constituting a higher proportion of use outside of network recommendations, and to look at patients with multiple orders for tolvaptan and discern if dose titration was appropriate based on sodium levels. Methods: This study was a retrospective chart review of all patients who received a dose of tolvaptan from 7/3/2019 to 10/15/2020. Results: From July 2019 to October 2020, 211 patients received tolvaptan for hyponatremia, resulting in 598 administrations. Use of urea powder or fluid restriction preceded 248/586 (42.3%) tolvaptan administrations and the patient's sodium level was < 125 mEq/L or 125-135 mEq/L with documentation of symptoms for 261/586 (44.5%) of the administrations. Medication safety concerns related to monitoring sodium levels were also identified. Conclusions: While tolvaptan use did significantly decrease in Kettering Health since the implementation of order questions, the answers to the questions displayed substantial variability. Further opportunity exists for directing appropriate use of tolvaptan within Kettering Health and additional emphasis should be placed on safe use of this medication.