Best Practice Advisory Research Articles

Improving Identification of At-Risk Behaviors in Adolescents with Rheumatic Disease.

Many adolescent patients view their rheumatologist as their primary physician and therefore it is important to screen youth for sexual activity and substance use as recommended by the American Academy of Pediatrics. We implemented an electronic social history questionnaire (SHQ) and alert system to identify at-risk behaviors in adolescents with rheumatic disease. The SHQ was administered to adolescents 14 years and older with a goal to survey patients' sexual activity, and alcohol, tobacco, and drug use. The SHQ was given via tablet at each rheumatology outpatient visit. A positive response triggered a best practice advisory (BPA) alert when the chart was opened to remind the clinician to discuss these results privately. A total of 877 unique patients were surveyed. Ninety patients (12%) reported being sexually active, and sexually active patients were significantly older than those who were not (17.2 vs 15 years, p<0.001). Seventy-two percent of patients were female, and the mean age was 15.8 years. Sexually active patients were more likely to be smokers, drink alcohol, and use other drugs (p<0.001).Strong associations were observed between alcohol use and male sex (p = 0.0227), White race (p = 0.0052), and public insurance (p = 0.0021). Overall, 12% of patients reported being sexually active, underscoring the need to screen adolescents for sexual activity given many rheumatology patients take teratogenic medication. A smaller proportion used substances. Implementing an EMR-based SHQ can help identify patients most at-risk, and the BPA served as a useful tool to remind clinicians to discuss the SHQ privately.

Reimagining fertility preservation guidance for AYA patients: A quality improvement initiative.

283 Background: Infertility can be a devastating consequence for adolescent or young adult (AYA) patients, posing distinct challenges for healthcare providers striving to deliver high-quality, equitable cancer care. The rising incidence of cancer and growing population of AYA cancer survivors necessitates innovative, streamlined, and efficient processes to promote fertility preservation. While guidelines from organizations like American Society of Clinical Oncology (ASCO) and Agency for Healthcare Research and Quality (AHRQ) provide valuable recommendations, ensuring consistent adherence to these standards remains an ongoing challenge. Methods: The aim of this quality improvement project was to increase fertility preservation counseling and documentation, by 20% within 6 months without delaying chemotherapy start for newly diagnoses AYA patients (age 18-39) within a large academic medical center. Utilizing a Define, Measure, Analyze, Improve, Control (DMAIC) methodology, interventions were conducted through a series of Plan-Do-Study-Act (PDSA) cycles that included provider and staff education, referral process standardization, implementation of a best practice advisory (BPA) within the electronic health record (EHR), revision of organizational policy, and establishment of nurse touchpoints to facilitate communication. Results: The percentage of counseling and documentation in AYA cancer patients (n=83) increased by 52%, exceeding the project aim. Statistical significance was calculated using a chi-square test. Contrary to initial concerns of potential delays in beginning chemotherapy while awaiting preservation, the average time to starting chemotherapy decreased by 43%. Conclusions: Fertility preservation counseling is a critical aspect of quality outcomes for AYA cancer patients. Strategic planning of automated methods to facilitate documentation and referral was an ideal method of building quality into a large healthcare system. Establishing methods of process improvement engrained best practices, allowing for enrichment of data collection, while driving continuous quality improvement. Increased utilization of the BPA facilitated tracking of quality metrics, while promoting a patient-centered approach to fertility preservation. Interdisciplinary collaboration between physicians, nurses, and reproductive specialists fosters holistic care to enhance long-term survivorship. Fertility preservation counseling and documentation Results. Month Month Count (%) QuarterlyCount (%) 95% CI Change 95% CI P Mean days to begin chemotherapy Baseline 17 of 41 (41%) 17 of 41 (41%) 0.27 to 0.58 42 October 19 of 20 (95%) November 10 of 12 (83%) December 9 of 14 (64%) 38 of 46 (83%) 0.68 to 0.92 0.41 0.20 to 0.62 &lt;0.001 January 10 of 12 (83%) February 7 of 7 (100%) March 12 of 12 (100%) 29 of 31 (94%) 0.77 to 0.99 0.52 0.32 to 0.72 &lt;0.001 24 April 6 of 6 (100%)

Decreasing adverse events from concurrent Vinca-alkaloid and azole antifungals in a pediatric oncology population: Patient safety improvement process.

297 Background: Azole-antifungals like posaconazole and voriconazole have a documented significant risk of adverse drug events (ADE) when concomitantly administered with vinca-alkaloid chemotherapy (vincristine, vinblastine, vinorelbine) due to inhibition of vinca clearance. Potential ADE’s include paralytic ileus, severe, potentially permanent neuropathies, cranial nerve dysfunction, seizures, etc. Aim: Assess a standardized process to hold azole-antifungal around vinca-alkaloid drug administration to decrease the risk of adverse events associated with this drug-drug interaction in pediatric oncology patients. Intervention: Azole-antifungals (fluconazole*, voriconazole, posaconazole, itraconazole) will be held the day before, day of, and day after the vinca-alkaloid administration (with flexibility given provider discretion*) in the outpatient and inpatient setting at a single site. Methods: Development of a Standard Operating Procedure (SOP), informational technology (IT) processes such as Best Practice Advisory (BPA), nursing orders, Vinca Time-Out order and standard nursing note template for telephone encounter to remind patient/parents. Retrospective data was assessed in three 6-12 month phases, Pre-SOP (Phase 0), Post- SOP and Pre-IT support (Phase 1), and Full implementation (Phase 2). Study Outcomes: 1.Hold the azole-antifungal in 100% of encounters where vinca-alkaloid is due. 2. Decrease number of adverse events by 10%. 3. Maintain adequate fungal prophylaxis (or treatment) with a 0% incidence of breakthrough fungal infections. Results: Average number of concomitant azole/vinca administrations for each Phase was 39. A 97% improvement was seen in the number of vinca administrations dose reduced or held from 28 (Phase 0) to 1 (Phase 2). A 66% improvement in SOP compliance was observed (19 % in Phase 0, and 85% in Phase 2). Significant adverse effects were decreased by 33-50% between Phase 0, and Phase 1 and 2, respectively. Three patients in Phase 2 experienced fungal infection breakthrough; all had documented compliance issues prior to the study period. Conclusions: Implementation of the SOP and IT processes helped achieve a process to hold azole antifungals and led to significant decrease in the need to dose reduce or hold vinca-alkaloids thereby allowing less chemotherapy interruption/dose adjustments. Further modification of the SOP may be developed to exclude those patients on anti-fungal therapy for an active fungal infection.

Improving dihydropyrimidine dehydrogenase genotyping (DPYD) prior to initiation of fluoropyrimidine-based chemotherapy at a community-based hospital: A quality improvement initiative.

347 Background: Dihydropyrimidine dehydrogenase gene (DPYD) testing is crucial in preventing toxicities from fluoropyrimidine chemotherapy. Despite benefits and established guidelines, its adoption within healthcare organizations remains inconsistent and suboptimal. We implemented a quality improvement project to improve DPYD testing prior to fluoropyrimidine chemotherapy at a community-based hospital. We aimed to increase DPYD testing for patients receiving fluoropyrimidine-based chemotherapy from 65% to 95% between July 2023 to July 2024. Balancing measures included DPYD testing turnaround time. Methods: For baseline diagnostics, manual chart review was performed on 126 patients to identify frequency of DPYD testing, and turnaround time (TAT) between May 1, 2023 to August 4, 2023. Patients were excluded if they received fluoropyrimidine-based chemotherapy prior to May 1, 2023. A multidisciplinary team including medical oncology residents and staff, pharmacists, nurses, and clinical informatics specialists worked jointly to identify and address barriers to implementation. Barriers identified included lack of established workflows and awareness of the importance of testing. Diagnostic tools utilized included Ishikawa diagrams and process mapping. The team used Plan-Do-Study-Act (PDSA) cycles to address barriers. A p-chart was used to analyze the results. Results: The baseline DPYD testing rate was 65%. Barriers identified via multidisciplinary sessions included lack of established workflow, awareness and importance of testing. PDSA cycles included education sessions to breast medical oncologists and medical oncology nurses, and development of a best-practice advisory in the electronic medical record. The percentage of eligible patients receiving DPYD testing increased from 65% to 95.8% in the total population. For breast cancer patients, the rate increased from 16.7% to 100%. For gastrointestinal cancer patients, the rate increased from 56.1% to 94.2%. Sustainability was demonstrated two months post-intervention with TAT stable between 7-8 days. Conclusions: Through PDSA cycles, we improved the frequency of DPYD testing for patients receiving fluoropyrimidine chemotherapy from 65% to 95.8%. Future work will assess changes in chemotherapy prescribing behavior in the setting of variant DPYD results, and outcomes of patients with variant DPYD testing.

The Impact of a Methicillin-Resistant Staphylococcus Aureus Nasal Polymerase Chain Reaction Protocol on Vancomycin Length of Therapy Among Patients With Skin and Soft Tissue Infections.

Objective: We evaluated the impact of a methicillin-resistant Staphylococcus aureus (MRSA) nasal polymerase chain reaction (PCR) protocol on the vancomycin length of therapy (LOT) for skin and soft tissue infections (SSTIs). Design: Retrospective quasi-experimental pre- and post- MRSA nasal PCR protocol implementation study. Setting: Tertiary-care academic medical center in Jacksonville, Florida. Patients: Eligible patients received empiric vancomycin for SSTIs from January 1st to September 30th 2020 (pre-implementation group) and from January 1st to September 30th 2022 (post-implementation group). Intervention: The electronic health system software was modified to provide a best-practice advisory (BPA) prompt to the pharmacist upon order verification of vancomycin for patients with SSTIs. Methods: We reviewed patient records to determine the time from vancomycin prescription to de-escalation. The secondary outcomes were incidence of acute kidney injury (AKI), number of vancomycin levels collected, and hospital length of stay (LOS). Results: The study included 131 patients (pre-implementation, n = 86 and post-implementation, n = 45). There was no significant difference in vancomycin length of therapy (LOT) between implementation groups: mean LOT in days and standard deviation (SD) were 2.7 (1.9) and 2.6 (1.3), respectively, p-value 0.493. Of significance, in the post-implementation group, vancomycin LOT between patients with a negative and positive MRSA PCR were 2.3 (1.1) and 3.9 (1.6), p-value 0.006. There was no difference in secondary outcomes. Conclusion: The utilization of the MRSA nasal PCR to guide vancomycin de-escalation did not significantly change the vancomycin LOT, however in the post-implementation group there was a significant difference in vancomycin LOT between negative and positive MRSA PCRs.

Reduction in Unindicated Cervical Cancer Screening in Adolescents in a Large Health Care System.

Evidence-based guidelines recommend against screening for cervical cancer (Pap testing) in average-risk adolescents <21 years old. Despite this, many still undergo unindicated screenings with subsequent detrimental reproductive health and economic consequences. Our aim was to reduce unindicated cervical cancer screening in individuals <21 years old in a large health care system by utilizing an electronic provider notification. Starting in July 2020, a Best Practice Advisory (BPA) appeared in the electronic medical record (EMR) if providers ordered Pap testing on individuals <21 years old. This BPA reiterated that screening was not indicated for average-risk adolescents and prompted users to choose an indication if they wanted to proceed.A retrospective chart review, pre/post intervention study was performed comparing individuals <21 years old with Pap testing performed before and after intervention (January 2019-June 2020 and July 2020-June 2021, respectively). Patient characteristics were extracted from the EMR and analyzed using Fisher exact tests, Kruskal-Wallis tests, and logistic regression. There were 140 subjects included: 106 preintervention and 34 postintervention. There were no differences in baseline characteristics. Neither Pap nor human papillomavirus testing results differed between the groups. Preintervention, 6.6% of cytology tests were indicated compared to 20.6% postintervention ( p = .042). The proportion of indicated human papillomavirus testing did not differ preintervention and postintervention at 65% and 45%, respectively ( p = .295). The overall reduction in unindicated cervical cancer screening postintervention was 13.9% (95% CI = 4.0-23.7). We demonstrated that incorporating a BPA to the EMR reduces unindicated cervical cancer screening.

Impact of a new state law and electronic health record prompt on naloxone prescribing in an academic medical center.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. To evaluate the impact of a best-practice advisory (BPA) and South Carolina legislation on naloxone prescribing patterns. The primary objective was to assess the change in naloxone prescription rates following BPA implementation. The secondary objective was to analyze the performance of the BPA. Naloxone prescriptions generated before (July 28, 2020, through July 27, 2021) and after (July 28, 2021, through July 28, 2022) BPA implementation were analyzed via retrospective chart review. Lists of patients at risk for opioid overdose and patients for whom the BPA fired were generated for March 2022. The BPA's effectiveness was evaluated based on the proportion of at-risk patients missed by the alert, the frequency with which the BPA resulted in a naloxone prescription, and the reasons for not prescribing naloxone when the BPA fired. Following BPA implementation, there was a significant increase in the average monthly naloxone prescribing rate from 66.1 to 625.5 prescriptions per month. Overall, 2,086 patients were considered at risk for opioid overdose and 1,101 had a BPA alert during March 2022, with 32.7% of BPA alerts resulting in naloxone prescribing. The most common reasons selected for not prescribing naloxone were "patient refusal" and "criteria not met." Only 354 patients (17.1%) at risk for opioid overdose also had a BPA alert. State legislation and implementation of the BPA significantly increased naloxone prescribing rates. However, a significant proportion of patients identified as being at risk did not have a BPA alert and most BPA alerts did not result in naloxone prescribing, suggesting a need for improvement of the BPA.

Using a Built-in Clinical Decision Support to Improve Phosphate Repletion Practice: A Quasi-Experimental Study

BackgroundInpatient serum phosphate replacement is common, but there is great variability in replacement practice, which leads to overuse. Electronic medical record (EMR) interventions with clinical decision support (CDS) can be effective tools to guide clinicians towards best clinical practices. Our objective was to utilize CDS tools to reduce overuse of hypophosphatemia corrections at a large safety-net healthcare system. MethodsOur first intervention involved enhancing an existing order set for phosphate repletion by incorporating CDS to guide appropriate repletion orders based on deficit severity and simplifying ordering. The second intervention was a best practice advisory (BPA) that triggered when an intravenous (IV) phosphate repletion was ordered for a patient with mild to moderate phosphate deficiency without an existing nil per os (NPO) order. The primary outcome measure was the number of patients with mild and moderate hypophosphatemia receiving IV replacement without NPO orders per 1000 patient days. ResultsAcross all hospitals, rate of IV replacement in patients with mild to moderate hypophosphatemia (1.0 to 1.9 mg/dL) without NPO orders decreased from 7.22 to 3.40 per 1000 patient days (53.0% reduction, p<0.001), while the oral replacements in this population increased from 6.39 to 8.87 (38.8% increase, p<0.001). For patients with phosphate levels ≥2.0, IV replacements decreased from 10.66 to 5.36 (49.8% reduction, p<0.001) and oral replacements decreased 19.78 to 16.69 (15.6% reduction, p<0.01). ConclusionsOur intervention successfully reduced inpatient IV phosphate replacements by 53% in patients with mild to moderate hypophosphatemia using a two-pronged electronic health record intervention across a large safety net setting.

Factors Associated With Tobacco Cessation Advice Recall and Quit Rates in Vascular Surgery Patients. A Single Center Study.

Smoking is an important modifiable risk factor in all vascular diseases and verbal advice from providers has been shown to increase rates of tobacco cessation. We sought to identify factors that will improve tobacco cessation and recall of receiving verbal cessation advice in vascular surgery patients at a single institution. The study is a retrospective cohort study. Patients seen in outpatient vascular surgery clinic who triggered a tobacco Best Practice Advisory (BPA) during their office visits over a 10-month period were contacted post-clinic and administered surveys detailing smoking status, cessation advice recall, and validated scales for nicotine dependence and willingness to quit smoking. This BPA is a "hard stop" that requires providers to document actions taken. Charts were reviewed for tobacco cessation documentation. Nine-digit zip-codes identified the area deprivation index, a measure of socioeconomic status. Univariate analysis was used to identify factors associated with cessation and advice recall. One hundred out of 318 (31.4%) patients responded to the survey. Epic Slicer Dicer found 97 BPA responses. To dismiss the BPA, 89 providers (91.8%) selected "advised tobacco cessation" and "Unable to Advise" otherwise. Of the 318 patients, 115 (36.1%) had cessation intervention documented in their provider notes and 151 (47.5%) received written tobacco cessation advice. Of survey respondents, 70 recalled receiving verbal advice, 27 recalled receiving written advice, 28 reported receiving offers of medication/therapy for cessation. 55 patients reported having tobacco cessation plans, and among those 17 reported having quit tobacco. Recall of receiving written advice (P < .001) and recall of receiving medication/therapy (P = .008) were associated with recall of receiving verbal cessation advice. Providing patients with tobacco cessation medication/therapy and written tobacco cessation education during office visits is associated with increased patients' recall of tobacco cessation advice. Vascular surgeons should continue to provide directed tobacco cessation advice.

1044-P: A Best Practice Advisory (BPA) Alert within the EHR Reduces Hypoglycemia Related to Insulin Administration in a Real-World Hospital Setting

1044-P: A Best Practice Advisory (BPA) Alert within the EHR Reduces Hypoglycemia Related to Insulin Administration in a Real-World Hospital Setting

Pathways for provider initiated genetic testing to bridge the gap in germline genetic testing for metastatic breast cancer.

e23239 Background: Genetic testing for BRCA 1/2 in breast cancer patients have important implications on systemic therapy options, particularly for qualification of PARP inhibitor therapy. NCCN guidelines currently recommend genetic testing for all patients with metastatic or recurrent breast cancer, triple negative breast cancer, as well as high-risk HER2-negative breast cancer. Despite these recommendations, germline genetic testing in these populations remain suboptimal in part due to limited access to genetic counselors. Introducing pathways to identify patients who qualify for genetic testing through nurse navigator screening and increasing provider ordered testing can help bridge the gap to expedite genetic testing. Methods: A retrospective review of metastatic breast cancer patients who were seen at MD Anderson Cancer Center (MDA) between 01/01/2021 and 12/31/2021 was performed to determine a baseline rate at which this population met with genetic counselors. A new protocol was established to aid nurse navigators in identifying patients establishing care at MDA who qualify for testing and guide providers on ordering genetic testing at initial appointment. Nurse navigators and providers underwent a formal training session on protocol with guidelines on patient qualification. Additionally, a best practice advisory (BPA) was implemented into the electronic medical record to alert providers to patients who should be tested. Results: At baseline, 29.6% of patients with metastatic breast cancer had met with genetic counselors at our institution in 2021. Based on this finding, the provider initiated genetic testing process was implemented, where providers order genetic testing at the initial appointment. Initial uptake of this process was low with less than 10 tests ordered in the first three months of intervention. Therefore, a nurse navigator pathway was implemented as well as a BPA within our electronic medical records to alert providers on patients who qualify for testing. This BPA flags patients with stage IV breast cancer that have not seen genetic counselors at our institution and guides providers to either order genetic testing, place a referral for genetic counseling, or dismiss the BPA due to specified reasons. Conclusions: It is imperative that patients with metastatic breast cancer have access to genetic testing at diagnosis to determine optimal therapy. With the expansion of genetic testing recommendations, moving toward a provider driven testing model may expedite and increase access to genetic testing. By implementing additional screening through our nurse navigators and BPA advisories, we hope to increase provider driven testing at our institution. Additionally, we aim to expand these interventions to other subgroups of breast cancer who would qualify for adjuvant PARP therapy in the next phase of intervention.

Integration of a machine learning model-generated surgical risk score into the EHR and preoperative workflow.

11163 Background: We previously developed a machine learning model (MLM) that accurately predicts postoperative complications (POC) for cancer inpatients. As laborious manual entry of patient data is a barrier for risk calculator use, and risk constantly changes depending on clinical status, we sought to integrate our MLM into the electronic health record (EHR) and preoperative workflow as a readily available surgical risk score (SRS) that is generated using real-time data. Here, we report on the integration process and survey results regarding its functionality and impact on patient care. Methods: A MLM that predicts severe POC (CD Grade ≥3) for cancer inpatients undergoing same-hospitalization operations was previously developed using EHR data. To integrate our MLM into the Epic EHR, we developed a real-time infrastructure (RTI) using the cloud-based platform Azure. EHR data is inputted to RTI and processed in real-time to generate model outputs. These outputs are then sent back to the EHR through the Epic Cognitive Computing Platform to generate each patient’s specific SRS. The SRS is dichotomized as “high” or “low” risk based upon a previously determined threshold and is displayed as a “Best Practice Advisory (BPA)” when a surgical case request is entered. In addition to the automated BPA, the SRS is sent to the primary surgeon as an InBasket Case Message. To elicit feedback of our EHR-integrated SRS, a survey was distributed to surgical providers at our institution. Results: After integration of our MLM into the EHR preoperative workflow, 185 surgeries were completed between November 16, 2021 to July 31, 2023. The 30-day severe POC rate was 27.6%, and our MLM had precision of 44.7% and recall of 74.5%, resulting in AUROC of 0.78 and AUPRC of 0.53. 35 surgical providers (40% primary surgeons, 34% surgical fellows, 26% advanced practice providers) from the divisions of surgical oncology, colorectal surgery, and gynecologic oncology completed our survey in July 2022 and July 2023. 28 (80%) of providers stated that they have interacted with the SRS through either BPA or InBasket Case Messages. Of these providers, 21 (75%) strongly agreed or agreed that the SRS was visible at appropriate times, and 18 (64%) strongly agreed or agreed that the SRS contains relevant information to assess surgical risk. 8 (29%) strongly agreed or agreed that the SRS was used to facilitate preoperative discussion. The 2023 survey additionally asked whether the SRS impacted the decision to operate; among providers who had interacted with the SRS, 4 (36%) strongly agreed or agreed with this statement. Conclusions: Integration of a real-time, MLM-generated SRS into the EHR and preoperative workflow can be successfully performed. While our integrated SRS is visible to surgeons and contains risk assessment felt relevant to the operation, the impact of the SRS on clinical care and decision making remains unclear.

Development of a routine bedside CYP2C19 genotype assessment programfor antiplatelet therapy guidance in a community hospital catheterization laboratory.

Genotype based personalized antiplatelet therapy in the setting of percutaneous coronary intervention (PCI) has been studied in clinical trials. Despite the demonstrated risk associated with CYP2C19 loss-of-function (LoF) carriage in clopidogrel-treated PCI patients, real-world implementation of genotyping for PCI has been low. The goal of the current study was to provide CYP2C19 genotype information to the interventionalist prior to the completion of the catheterization to facilitate immediate personalized antiplatelet therapy. Routine personalization of P2Y12 inhibitor therapy for PCI in a community hospital cardiac catheterization laboratory by POC genotyping with the SpartanRx system was first offered in February 2017. A best practice advisory (BPA) based on the Clinical Pharmacogenetics Implementation Consortium Guideline for CYP2C19 genotype and clopidogrel therapy was placed in the electronic health record prescription medication ordering system. By December 2019, 1,052 patients had CYP2C19 genotype testing, 429 patients underwent PCI with genotype guided antiplatelet therapy, and 250 patients underwent PCI without genotype testing and received antiplatelet therapy at the discretion of the treating physician. BPA compliance was 93. 87% of LoF allele carriers were prescribed ticagrelor or prasugrel whereas 96% of non-LoF allele carriers were prescribed clopidogrel. The genotyping results were available within 1h and made immediately available for decision making by the interventional cardiologist. POC CYP2C19 genotyping is feasible in a community hospital catheterization laboratory and is associated with high rate of best practice compliance.Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03040622.

Randomized Comparison of Electronic Health Record Alert Types in Eliciting Responses about Prognosis in Gynecologic Oncology Patients.

To compare the ability of different electronic health record alert types to elicit responses from users caring for cancer patients benefiting from goals of care (GOC) conversations. A validated question asking if the user would be surprised by the patient's 6-month mortality was built as an Epic BestPractice Advisory (BPA) alert in three versions-(1) Required on Open chart (pop-up BPA), (2) Required on Close chart (navigator BPA), and (3) Optional Persistent (Storyboard BPA)-randomized using patient medical record number. Meaningful responses were defined as "Yes" or "No," rather than deferral. Data were extracted over 6 months. Alerts appeared for 685 patients during 1,786 outpatient encounters. Measuring encounters where a meaningful response was elicited, rates were highest for Required on Open (94.8% of encounters), compared with Required on Close (90.1%) and Optional Persistent (19.7%) (p < 0.001). Measuring individual alerts to which responses were given, they were most likely meaningful with Optional Persistent (98.3% of responses) and least likely with Required on Open (68.0%) (p < 0.001). Responses of "No," suggesting poor prognosis and prompting GOC, were more likely with Optional Persistent (13.6%) and Required on Open (10.3%) than with Required on Close (7.0%) (p = 0.028). Required alerts had response rates almost five times higher than optional alerts. Timing of alerts affects rates of meaningful responses and possibly the response itself. The alert with the most meaningful responses was also associated with the most interruptions and deferral responses. Considering tradeoffs in these metrics is important in designing clinical decision support to maximize success.

An automated best practice advisory increases both routine HIV screening and HIV cotesting with sexually transmitted infections in the emergency department

There is increasing interest in improving routine HIV screening in emergency departments and increasing HIV cotesting rates among patients tested for sexually transmitted infections (STIs), who are considered at elevated risk of acquiring HIV. This is a retrospective review of all ED encounters at a large, urban emergency departments with an existing HIV screening program for seven months before (November 1, 2018, to May 30, 2019) and after (June 1 to December 31, 2019) the implementation of a best practice advisory prompting universal HIV and syphilis screening. The study included 14,767 unique encounters, with 3,982 pre-implementation encounters and 10,785 post-implementation. After implementation, HIV testing increased 242%, from 2,851 tests to 9,757, and syphilis testing increased 326%, from 2,191 tests to 9,330. The proportion of encounters for urogenital STI testing without HIV cotesting decreased by 10.3%, from 43.6% to 33.3%. An automated electronic medical record (EMR) prompt can have a huge impact on both HIV and syphilis testing rates, as well as the rate of missed opportunities for cotesting among patients undergoing STI testing. Hospitals should support screening with automated alerts to help meet quality metrics, improve screening rates, and reduce missed opportunities for screening in vulnerable patients.

De-implementation of Fecal Occult Blood Testing in the Emergency Department and Hospital Units: A Quality Improvement Project.

Fecal occult blood tests (FOBT) are inappropriately used in patients with melena, hematochezia, coffee ground emesis, iron deficiency anemia, and diarrhea. The use of FOBT for reasons other than screening for colorectal cancer is considered low-value and unnecessary. Quality Improvement Project that utilized education, Best Practice Advisory (BPA) and modification of order sets in the electronic health record (EHR). The interventions were done in a sequential order based on the Plan-Do-Study-Act (PDSA) method. An annotated run chart was used to analyze the collected data. Education and Best Practice Advisory within the EHR led to significant reduction in the use of FOBT in the ED. The interventions eventually led to a consensus and removal of FOBT from the order set of the EHR for patients in the ED and hospital units. The use of electronic BPA, education and modification of order sets in the EHR can be effective at de-implementing unnecessary tests and procedures like FOBT in the ED and hospital units.

Evaluation of a Best-Practice Advisory for Primary Aldosteronism Screening

Primary aldosteronism (PA) is a common cause of secondary hypertension and an independent risk factor for cardiovascular morbidity and mortality. Fewer than 2% to 4% of patients at risk are evaluated for PA. To develop and evaluate an electronic health record best-practice advisory (BPA) that assists with PA screening. This prospective quality improvement study was conducted at academic center outpatient clinics. Data analysis was performed between February and June 2023 and included adults with hypertension and at least 1 of the following: 4 or more current antihypertensive medications; hypokalemia; age younger than 35 years; or adrenal nodule(s). Patients previously tested for PA were excluded. A noninterruptive BPA was developed to trigger for PA screening candidates seen in outpatient setting by clinicians who treat hypertension. The BPA included an order set for PA screening and a link to results interpretation guidance. (1) The number of PA screening candidates identified by the BPA between October 1, 2021, and December 31, 2022; (2) the rates of PA screening; and (3) the BPA use patterns, stratified by physician specialty were assessed. Over 15 months, the BPA identified 14 603 unique candidates (mean [SD] age, 65.5 [16.9] years; 7300 women [49.9%]; 371 [2.5%] Asian, 2383 [16.3%] Black, and 11 225 [76.9%] White individuals) for PA screening, including 7028 (48.1%) with treatment-resistant hypertension, 6351 (43.5%) with hypokalemia, 1537 (10.5%) younger than 35 years, and 445 (3.1%) with adrenal nodule(s). In total, 2040 patients (14.0%) received orders for PA screening. Of these, 1439 patients (70.5%) completed the recommended screening within the system, and 250 (17.4%) had positive screening results. Most screening orders were placed by internists (40.0%) and family medicine physicians (28.1%). Family practitioners (80.3%) and internists (68.9%) placed most orders via the embedded order set, while specialists placed most orders (83.0%-95.4%) outside the BPA. Patients who received screening were younger and included more women and Black patients than those not screened. The likelihood of screening was higher among patients with obesity and dyslipidemia and lower in those with chronic kidney disease and established cardiovascular complications. The study results suggest that noninterruptive BPAs are potentially promising PA screening-assistance tools, particularly among primary care physicians. Combined with artificial intelligence algorithms that optimize the detection yield, refined BPAs may contribute to personalized hypertension care.

PROMOTING PROVIDER ADHERENCE TO THE MEDICATION M OF THE AGE-FRIENDLY 4MS FRAMEWORK

Abstract BACKGROUND The Age Friendly Health Systems (AFHS) initiative promotes use of the 4Ms Framework: We sought to evaluate provider adherence to protocols addressing the medication M of the framework. METHODS The project was conducted among patients &amp;gt; 65years treated in the inpatient (IP), outpatient (OP) and emergency departments (ED) of Grady Memorial Hospital (GMH). We implemented 2 approaches to improve provider prescribing among older adults 1) Using a clinical decision support tool via the electronic health record Epic Systems®, a best practice advisory (BPA) offered individual provider feedback regarding potentially inappropriate medications (PIMs) ordered and offered safer alternative medications. 2)A pharmacist-led daily medication review with provider feedback on PIMs in the Acute Care for Elderly (ACE) Unit. Primary outcome: Percentage of PIMs discontinued. Secondary outcomes: Percentage of BPA vs pharmacist recommendations accepted, discharge PIMs, Length of Stay (LOS), mobility, delirium and Katz scores, 30-day readmission rate. RESULTS: 8270 BPA alerts fired for 3291 patients, mean age 73.7, with 5709 BPAs in IP, 1462 in ED &amp; 1083 in OP settings. Providers responded to alerts by overriding BPA (10.2%), canceling BPA (60.4%), removing alerted PIM (20.6%), ordering alternative medication (3.5%).. With the pharmacist led intervention, ACE Unit providers accepted 47.2% recommendations, discontinued 17.9% PIMs . 19% of ACE and 1.1% of GMU patients were discharged without PIMs. 30-day readmission rate was 19.1% (ACE) vs 27% (GMU) (P = 0.31). Conclusion There was a higher provider acceptance rate with the pharmacist led intervention but no significant difference in PIM discontinuation rate

Effect of best practice advisory on the administration of contraindicated medications to hospitalized patients with Parkinson's disease and related disorders.

To determine the effect of a Best Practice Advisory (BPA) on the ordering and administration of contraindicated dopamine blocking agents (DBA) to hospitalized patients with Parkinson's disease (PD) and related disorders. Patients with PD are more likely to require hospitalization and are at increased risk of complications. Administration of contraindicated DBA contributes to worsened outcomes in this patient population. Electronic medical record (EMR) warnings (also referred to as BPA) have been proposed as a way to prevent the administration of contraindicated medications. A BPA was launched in January 2020 within the University of Rochester EMR system, which alerts the provider when a contraindicated DBA is ordered in hospitalized patients with PD and related disorders. Patients with PD and related disorders hospitalized at two hospitals affiliated to the University of Rochester during a time period before (t1: 1/1/2019-1/1/2020) and after (t2: 1/8/2020-1/8/2021) the implementation of the BPA were included in this study. Epic SliderDicer was used to collect the data from the University of Rochester EMR. The number of patients who had contraindicated DBA orders and administrations in both time periods, and the number of patients who had the BPA triggered during t2 were obtained. We compared the results before and after the implementation of the BPA. 306 patients with PD and related disorders were hospitalized during t1 and 273 during t2. There was significantly less percentage of patients who had contraindicated DBA orders (41.5% in t1 vs. 17.6% in t2) and patients who had contraindicated DBA administrations (16% in t1 vs. 8.8% in t2) during t2 (p < 0.05 for both comparisons). There was no significant difference between the percentage of patients who had contraindicated DBA orders in t1 and patients with attempted orders (BPA triggered) in t2 (p = 0.27). The results of this study increase the evidence of the potential benefit of EMR warnings for the optimization of inpatient medication management in patients with PD and related disorders. In particular, our results suggest that EMR warnings help reduce the administration of contraindicated medications, which is a known contributing factor for hospital complications in this patient population.

Initiative to reduce unnecessary routine daily testing of complete blood counts across 11 safety net hospitals.

National societies recommend against performing routine daily laboratory testing without a specific indication. Unnecessary testing can lead to patient harm, such as hospital-acquired anemia. The objective of this study was to reduce repeat complete blood counts (CBCs) after initial testing. This was a quality improvement initiative implemented across 11 safety net hospitals in New York City. A best practice advisory (BPA) was implemented that asked the user to remove a CBC if the last 2 CBCs within 72 hours had normal white blood cell and platelet counts and unchanged hemoglobin levels. The outcome measure was the rate of CBCs per 1000 patient days preintervention (January 8, 2020, to December 22, 2020) to postintervention (December 23, 2020, to December 7, 2021). The process measure was the acceptance rate of the BPA, defined as the number of times the repeat CBC order was removed through the BPA divided by the total number of times the BPA triggered. Across 11 hospitals, repeat CBC testing decreased by 12.3% (73.05 to 64.04 per 1000 patient days, P < .001). Six of the 11 hospitals exhibited statistically significant decreases, ranging from a 10% to 48.9% decrease of repeat CBCs. The overall BPA action rate was 20.0% (24,029 of 119,944 repeat CBCs). This low-effort, electronic health record-based intervention can effectively reduce unnecessary laboratory testing.