Abstract
BackgroundUniversity of California at Los Angeles Health implemented a Best Practice Advisory (BPA) alert for the initiation of an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) for individuals with diabetes. The BPA alert was configured with a “chart closure” hard stop, which demanded a response before closing the chart.ObjectiveThe aim of the study was to evaluate whether the implementation of the BPA was associated with changes in ACEI and ARB prescribing during primary care encounters for patients with diabetes.MethodsWe defined ACEI and ARB prescribing opportunities as primary care encounters in which the patient had a diabetes diagnosis, elevated blood pressure in recent encounters, no active ACEI or ARB prescription, and no contraindications. We used a multivariate logistic regression model to compare the change in the probability of an ACEI or ARB prescription during opportunity encounters before and after BPA implementation in primary care sites that did (n=30) and did not (n=31) implement the BPA. In an additional subgroup analysis, we compared ACEI and ARB prescribing in BPA implementation sites that had also implemented a pharmacist-led medication management program.ResultsWe identified a total of 2438 opportunity encounters across 61 primary care sites. The predicted probability of an ACEI or ARB prescription increased significantly from 11.46% to 22.17% during opportunity encounters in BPA implementation sites after BPA implementation. However, in the subgroup analysis, we only observed a significant improvement in ACEI and ARB prescribing in BPA implementation sites that had also implemented the pharmacist-led program. Overall, the change in the predicted probability of an ACEI or ARB prescription from before to after BPA implementation was significantly greater in BPA implementation sites compared with nonimplementation sites (difference-in-differences of 11.82; P<.001).ConclusionsA BPA with a “chart closure” hard stop is a promising tool for the treatment of patients with comorbid diabetes and hypertension with an ACEI or ARB, especially when implemented within the context of team-based care, wherein clinical pharmacists support the work of primary care providers.
Highlights
BackgroundGiven the increasing interest in using health information technology to enhance diabetes care, it is critically important to examine the impact of these interventions on quality of care [1,2]
In this study, using a quasi-experimental difference-in-differences design, we found that patient encounters at University of California at Los Angeles (UCLA) Health primary care sites that implemented the Best Practice Advisory (BPA) with a “chart closure” hard stop were significantly more likely to result in an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) prescription for patients with diabetes compared with encounters in nonimplementation sites
In contrast to our findings that the BPA with a “chart closure” hard stop was associated with improvements in primary care provider (PCP) ordering an ACEI or ARB, Schnipper et al [26] found that a smart form documentation tool with Clinical decision support (CDS) capability was not associated with improvements in ACEI and ARB prescribing for patients with diabetes
Summary
BackgroundGiven the increasing interest in using health information technology to enhance diabetes care, it is critically important to examine the impact of these interventions on quality of care [1,2]. There is limited research examining the impact of EHR-based CDS systems on the initiation of antihypertensive therapies for patients with comorbid diabetes and hypertension [3]. The standards of diabetes care developed by the American Diabetes Association urge the timely treatment of hypertension using an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB), as these medications decrease the risk for microvascular and macrovascular complications [8]. At University of California at Los Angeles (UCLA) Health, we implemented a CDS system that alerted PCPs of any patient with diabetes who was missing one of these medications and had no contraindications. University of California at Los Angeles Health implemented a Best Practice Advisory (BPA) alert for the initiation of an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) for individuals with diabetes. The BPA alert was configured with a “chart closure” hard stop, which demanded a response before closing the chart
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