Effect Of Clinical Decision Support Research Articles

Effect of clinical decision support for severe hypercholesterolemia on low-density lipoprotein cholesterol levels

Severe hypercholesterolemia/possible familial hypercholesterolemia (FH) is relatively common but underdiagnosed and undertreated. We investigated whether implementing clinical decision support (CDS) was associated with lower low-density lipoprotein cholesterol (LDL-C) in patients with severe hypercholesterolemia/possible FH (LDL-C ≥ 190 mg/dL). As part of a pre-post implementation study, a CDS alert was deployed in the electronic health record (EHR) in a large health system comprising 3 main sites, 16 hospitals and 53 clinics. Data were collected for 3 months before (‘silent mode’) and after (‘active mode’) its implementation. Clinicians were only able to view the alert in the EHR during active mode. We matched individuals 1:1 in both modes, based on age, sex, and baseline lipid lowering therapy (LLT). The primary outcome was difference in LDL-C between the two groups and the secondary outcome was initiation/intensification of LLT after alert trigger. We identified 800 matched patients in each mode (mean ± SD age 56.1 ± 11.8 y vs. 55.9 ± 11.8 y; 36.0% male in both groups; mean ± SD initial LDL-C 211.3 ± 27.4 mg/dL vs. 209.8 ± 23.9 mg/dL; 11.2% on LLT at baseline in each group). LDL-C levels were 6.6 mg/dL lower (95% CI, −10.7 to −2.5; P = 0.002) in active vs. silent mode. The odds of high-intensity statin use (OR, 1.78; 95% CI, 1.41–2.23; P < 0.001) and LLT initiation/intensification (OR, 1.30, 95% CI, 1.06–1.58, P = 0.01) were higher in active vs. silent mode. Implementation of a CDS was associated with lowering of LDL-C levels in patients with severe hypercholesterolemia/possible FH, likely due to higher rates of clinician led LLT initiation/intensification.

Sustained Effect of Clinical Decision Support for Heart Failure: A Natural Experiment Using Implementation Science.

In a randomized controlled trial, we found that applying implementation science (IS) methods and best practices in clinical decision support (CDS) design to create a locally customized, "enhanced" CDS significantly improved evidence-based prescribing of β blockers (BB) for heart failure compared with an unmodified commercially available CDS. At trial conclusion, the enhanced CDS was expanded to all sites. The purpose of this study was to evaluate the real-world sustained effect of the enhanced CDS compared with the commercial CDS. In this natural experiment of 28 primary care clinics, we compared clinics exposed to the commercial CDS (preperiod) to clinics exposed to the enhanced CDS (both periods). The primary effectiveness outcome was the proportion of alerts resulting in a BB prescription. Secondary outcomes included patient reach and clinician adoption (dismissals). There were 367 alerts for 183 unique patients and 171 unique clinicians (pre: March 2019-August 2019; post: October 2019-March 2020). The enhanced CDS increased prescribing by 26.1% compared with the commercial (95% confidence interval [CI]: 17.0-35.1%), which is consistent with the 24% increase in the previous study. The odds of adopting the enhanced CDS was 81% compared with 29% with the commercial (odds ratio: 4.17, 95% CI: 1.96-8.85). The enhanced CDS adoption and effectiveness rates were 62 and 14% in the preperiod and 92 and 10% in the postperiod. Applying IS methods with CDS best practices was associated with improved and sustained clinician adoption and effectiveness compared with a commercially available CDS tool.

P610 Donor specific antibodies (DSA) monitoring: The effect of clinical decision support (CDS) intervention on DSA orders

P610 Donor specific antibodies (DSA) monitoring: The effect of clinical decision support (CDS) intervention on DSA orders

Reducing Physical Therapy Consults for Patients With High Functional Mobility in the Acute Medical Inpatient Setting: A Difference-in-Difference Analysis

ObjectiveTo evaluate the effectiveness of clinical decision support for reducing misallocation of physical therapy (PT) consults. DesignA prospective quasi-experimental study. Between October 2018 and November 2021, routinely documented data on functional status and physical therapy referrals were collected from electronic medical records. SettingHospital Medicine and General Internal Medicine service lines at a large quaternary academic medical center. Participants20,810 adult patients hospitalized on any of the included treatment (hospital medicine) or control (general internal medicine) service lines. Main Outcome MeasureThe primary outcome was “change in proportion of misallocated PT consults” measured as likelihood of PT consults for patients admitted with high functional mobility scores. Changes in the primary outcome from the pre-intervention to post-intervention period were compared in the control and treatment groups using propensity score–weighted difference-in-differences multivariable logit regression adjusting for clinically relevant covariates. InterventionThe intervention period was measured for 20 months and consisted of a clinical decision support tool embedded in the daily note templates for hospital medicine providers. The tool provided education on patient mobility scores and their relation to need for PT consult. The tool was rolled out without any further announcements or education. ResultsOur cohort included 20,810 unique admissions (mean age 58.9, 55% women, 83% Black). Post-intervention, the likelihood of PT referrals for patients with high baseline mobility (AM-PAC >18) decreased by 7.3% (P<.001) for the treatment group compared with control, adjusted for age, sex, race, ethnicity, length-of-stay, and mobility change. ConclusionMobility score-based clinical decision support can decrease unneeded PT consults in the inpatient setting. This could help allocate therapy time for at-risk patients while also having a positive effect on health care systems.

RWD127 Mapping the Flow of Biomarker Testing Information, from Test Order through Impact on Treatment Decision-Making: A Case Study in Metastatic NSCLC

The effectiveness of clinical decision support (CDS) tools for selecting therapies in precision oncology is dependent on the flow of biomarker testing information through the electronic health record (EHR). The growth of biomarker-specific cancer treatments has contributed to an increasingly complex environment of testing choices and results for providers to navigate. The purpose of this study was to map biomarker information pathways for cancer treatment within an EHR. Specifically, the study used test reports, structured EHR data, and CDS tool records to measure and visualize the flow of biomarker data relative to critical treatment decisions made by providers.

Reducing Therapeutic Duplication in Inpatient Medication Orders.

Therapeutic duplication, the presence of multiple agents prescribed for the same indication without clarification for when each should be used, can contribute to serious medical errors. Joint Commission standards require that orders contain clarifying information about when each order should be given. In our system, as needed (PRN) acetaminophen and ibuprofen orders are major contributors to therapeutic duplication. Design and evaluate effectiveness of clinical decision support (CDS) to reduce therapeutic duplication with acetaminophen and ibuprofen orders. This study was done in a pediatric health system with 3 freestanding hospitals. We iteratively designed and implemented two CDS strategies aimed at reducing the therapeutic duplication with these agents: (1) interruptive alert prompting clinicians for clarifying PRN comments at order entry and (2) addition of discrete "first line", "second line" PRN reasons to orders. Therapeutic duplications were measured by manual review of orders for 30-day periods before and after each intervention and 6 months later. Therapeutic duplications decreased from 1485 in the 30 days prior to the first alert implementation to 818 in the 30 days after but rose back to 1208 in the 30 days prior to the second intervention. After discrete reasons were added to the order, therapeutic duplication decreased to 336 in the immediate 30 days and 6 months later remained at 277. Alerts firing rates decreased from 76.0 per 1,000 PRN acetaminophen or ibuprofen orders to 42.9 after the second intervention. Interruptive alerts may reduce therapeutic duplication but are associated with high rates of user frustration and alert fatigue. Leveraging discrete PRN reasons for "first line" and "second line" produced a greater reduction in therapeutic duplication as well as fewer interruptive alerts and less manual entry for providers.

Effectiveness of clinical decision support in controlling inappropriate red blood cell and platelet transfusions, speciality specific responses and behavioural change

BackgroundElectronic clinical decision support (CDS) within Electronic Health Records has been used to improve patient safety, including reducing unnecessary blood product transfusions. We assessed the effectiveness of CDS in controlling inappropriate red blood cell (RBC) and platelet transfusion in a large acute hospital and how speciality specific behaviours changed in response.MethodsWe used segmented linear regression of interrupted time series models to analyse the instantaneous and long term effect of introducing blood product electronic warnings to prescribers. We studied the impact on transfusions for patients in critical care (CC), haematology/oncology (HO) and elsewhere.ResultsIn non-CC or HO, there was significant and sustained decrease in the numbers of RBC transfusions after introduction of alerts. In CC the alerts reduced transfusions but this was not sustained, and in HO there was no impact on RBC transfusion. For platelet transfusions outside of CC and HO, the introduction of alerts stopped a rising trend of administration of platelets above recommended targets. In CC, alerts reduced platelet transfusions, but in HO alerts had little impact on clinician prescribing.ConclusionThe findings suggest that CDS can result in immediate change in user behaviour which is more obvious outside specialist settings of CC and HO. It is important that this is then sustained. In CC and HO, blood transfusion practices differ. CDS thus needs to take specific circumstances into account. In this case there are acceptable reasons to transfuse outside of these crude targets and CDS should take these into account.

Effect of Clinical Decision Support With Audit and Feedback on Prevention of Acute Kidney Injury in Patients Undergoing Coronary Angiography

Contrast-associated acute kidney injury (AKI) is a common complication of coronary angiography and percutaneous coronary intervention (PCI) that has been associated with high costs and adverse long-term outcomes. To determine whether a multifaceted intervention is effective for the prevention of AKI after coronary angiography or PCI. A stepped-wedge, cluster randomized clinical trial was conducted in Alberta, Canada, that included all invasive cardiologists at 3 cardiac catheterization laboratories who were randomized to various start dates for the intervention between January 2018 and September 2019. Eligible patients were aged 18 years or older who underwent nonemergency coronary angiography, PCI, or both; who were not undergoing dialysis; and who had a predicted AKI risk of greater than 5%. Thirty-four physicians performed 7820 procedures among 7106 patients who met the inclusion criteria. Participant follow-up ended in November 2020. During the intervention period, cardiologists received educational outreach, computerized clinical decision support on contrast volume and hemodynamic-guided intravenous fluid targets, and audit and feedback. During the control (preintervention) period, cardiologists provided usual care and did not receive the intervention. The primary outcome was AKI. There were 12 secondary outcomes, including contrast volume, intravenous fluid administration, and major adverse cardiovascular and kidney events. The analyses were conducted using time-adjusted models. Of the 34 participating cardiologists who were divided into 8 clusters by practice group and center, the intervention group included 31 who performed 4327 procedures among 4032 patients (mean age, 70.3 [SD, 10.7] years; 1384 were women [32.0%]) and the control group included 34 who performed 3493 procedures among 3251 patients (mean age, 70.2 [SD, 10.8] years; 1151 were women [33.0%]). The incidence of AKI was 7.2% (310 events after 4327 procedures) during the intervention period and 8.6% (299 events after 3493 procedures) during the control period (between-group difference, -2.3% [95% CI, -0.6% to -4.1%]; odds ratio [OR], 0.72 [95% CI, 0.56 to 0.93]; P = .01). Of 12 prespecified secondary outcomes, 8 showed no significant difference. The proportion of procedures in which excessive contrast volumes were used was reduced to 38.1% during the intervention period from 51.7% during the control period (between-group difference, -12.0% [95% CI, -14.4% to -9.4%]; OR, 0.77 [95% CI, 0.65 to 0.90]; P = .002). The proportion of procedures in eligible patients in whom insufficient intravenous fluid was given was reduced to 60.8% during the intervention period from 75.1% during the control period (between-group difference, -15.8% [95% CI, -19.7% to -12.0%]; OR, 0.68 [95% CI, 0.53 to 0.87]; P = .002). There were no significant between-group differences in major adverse cardiovascular events or major adverse kidney events. Among cardiologists randomized to an intervention including clinical decision support with audit and feedback, patients undergoing coronary procedures during the intervention period were less likely to develop AKI compared with those treated during the control period, with a time-adjusted absolute risk reduction of 2.3%. Whether this intervention would show efficacy outside this study setting requires further investigation. ClinicalTrials.gov Identifier: NCT03453996.

Effectiveness of Clinical Decision Support for the California Parkinson’s Disease Registry (P2-11.005)

Effectiveness of Clinical Decision Support for the California Parkinson’s Disease Registry (P2-11.005)

Impact of an electronic health record alert on inappropriate prescribing of high-risk medications to patients with concurrent "do not give" orders.

To evaluate the effectiveness of clinical decision support (CDS) alerts tied to high-risk medications at a Michigan health system by determining the true prescriber action rate in response to select "do not give" (DNG) alerts. A retrospective review of prescriber actions in response to CDS alerts was conducted to evaluate the effectiveness of alerts designed to prevent prescribing of high-risk medications to patients with concurrent DNG orders. The primary endpoint was the overall action rate, determined by totaling orders cancelled within the alert display and orders modified shortly after an alert. The overall action rate was hypothesized to significantly exceed the action rate estimated on the basis of alert overrides alone. Following the initial review, changes were made to the alert format and preset documentation choices ("acknowledgement comments"), and it was hypothesized that these changes would increase the overall action rate. A repeat analysis was conducted to evaluate the impact of these changes. Across a total of 506 CDS alerts over 14 months, 78% resulted in prescribers modifying orders to comply with alert recommendations. Prescribers cancelled orders in response to only 26% of alerts, often overriding alerts prior to modifying orders. Documentation of rationale or approval for overrides was inconsistent, and while requiring acknowledgement comments facilitated documentation of prescriber rationale, it did not consistently improve overall action rates. These findings demonstrate that override rates alone are not good markers for the true effectiveness of CDS alerts and support the need for frequent evaluation of alerts at the institutional level. CDS alerts remain a valuable tool to prevent inappropriate prescribing of high-risk medications and for promoting patient safety.

Effect of Clinical Decision Support on Cardiovascular Risk Among Adults With Bipolar Disorder, Schizoaffective Disorder, or Schizophrenia

Adults with schizophrenia, schizoaffective disorder, or bipolar disorder, collectively termed serious mental illness (SMI), have shortened life spans compared with people without SMI. The leading cause of death is cardiovascular (CV) disease. To assess whether a clinical decision support (CDS) system aimed at primary care clinicians improves CV health for adult primary care patients with SMI. In this cluster randomized clinical trial conducted from March 2, 2016, to September 19, 2018, restricted randomization assigned 76 primary care clinics in 3 Midwestern health care systems to receive or not receive a CDS system aimed at improving CV health among patients with SMI. Eligible clinics had at least 20 patients with SMI; clinicians and their adult patients with SMI with at least 1 modifiable CV risk factor not at the goal set by the American College of Cardiology/American Heart Association guidelines were included. Statistical analysis was conducted on an intention-to-treat basis from January 10, 2019, to December 29, 2021. The CDS system assessed modifiable CV risk factors and provided personalized treatment recommendations to clinicians and patients. Patient-level change in total modifiable CV risk over 12 months, summed from individual modifiable risk factors (smoking, body mass index, low-density lipoprotein cholesterol level, systolic blood pressure, and hemoglobin A1c level). A total of 80 clinics were randomized; 4 clinics were excluded for having fewer than 20 eligible patients, leaving 42 intervention clinics and 34 control clinics. A total of 8937 patients with SMI (4922 women [55.1%]; mean [SD] age, 48.4 [13.5] years) were enrolled. There was a 4% lower rate of increase in total modifiable CV risk among intervention patients relative to control patients (relative rate ratio [RR], 0.96; 95% CI, 0.94-0.98). The intervention favored patients who were 18 to 29 years of age (RR, 0.89; 95% CI, 0.81-0.98) or 50 to 59 years of age (RR, 0.93; 95% CI, 0.90-0.96), Black (RR, 0.93; 95% CI, 0.88-0.98), or White (RR, 0.96; 95% CI, 0.94-0.98). Men (RR, 0.96; 95% CI, 0.94-0.99) and women (RR, 0.95; 95% CI, 0.92-0.97), as well as patients with any SMI subtype (bipolar disorder: RR, 0.96; 95% CI, 0.94-0.99; schizoaffective disorder: RR, 0.94; 95% CI, 0.90-0.98; schizophrenia: RR, 0.92; 95% CI, 0.85-0.99) also benefited from the intervention. Despite treatment effects favoring the intervention, there were no significant differences in individual modifiable risk factors. This CDS intervention resulted in a rate of change in total modifiable CV risk that was 4% lower among intervention patients compared with control patients. Results were driven by the cumulative effects of incremental and mostly nonsignificant changes in individual modifiable risk factors. These findings emphasize the value of using CDS to prompt early primary care intervention for adults with SMI. ClinicalTrials.gov Identifier: NCT02451670.

Effect of Clinical Decision Support at Community Health Centers on the Risk of Cardiovascular Disease

Management of cardiovascular disease (CVD) risk in socioeconomically vulnerable patients is suboptimal; better risk factor control could improve CVD outcomes. To evaluate the impact of a clinical decision support system (CDSS) targeting CVD risk in community health centers (CHCs). This cluster randomized clinical trial included 70 CHC clinics randomized to an intervention group (42 clinics; 8 organizations) or a control group that received no intervention (28 clinics; 7 organizations) from September 20, 2018, to March 15, 2020. Randomization was by CHC organization accounting for organization size. Patients aged 40 to 75 years with (1) diabetes or atherosclerotic CVD and at least 1 uncontrolled major risk factor for CVD or (2) total reversible CVD risk of at least 10% were the population targeted by the CDSS intervention. A point-of-care CDSS displaying real-time CVD risk factor control data and personalized, prioritized evidence-based care recommendations. One-year change in total CVD risk and reversible CVD risk (ie, the reduction in 10-year CVD risk that was considered achievable if 6 key risk factors reached evidence-based levels of control). Among the 18 578 eligible patients (9490 [51.1%] women; mean [SD] age, 58.7 [8.8] years), patients seen in control clinics (n = 7419) had higher mean (SD) baseline CVD risk (16.6% [12.8%]) than patients seen in intervention clinics (n = 11 159) (15.6% [12.3%]; P < .001); baseline reversible CVD risk was similarly higher among patients seen in control clinics. The CDSS was used at 19.8% of 91 988 eligible intervention clinic encounters. No population-level reduction in CVD risk was seen in patients in control or intervention clinics; mean reversible risk improved significantly more among patients in control (-0.1% [95% CI, -0.3% to -0.02%]) than intervention clinics (0.4% [95% CI, 0.3% to 0.5%]; P < .001). However, when the CDSS was used, both risk measures decreased more among patients with high baseline risk in intervention than control clinics; notably, mean reversible risk decreased by an absolute 4.4% (95% CI, -5.2% to -3.7%) among patients in intervention clinics compared with 2.7% (95% CI, -3.4% to -1.9%) among patients in control clinics (P = .001). The CDSS had low use rates and failed to improve CVD risk in the overall population but appeared to have a benefit on CVD risk when it was consistently used for patients with high baseline risk treated in CHCs. Despite some limitations, these results provide preliminary evidence that this technology has the potential to improve clinical care in socioeconomically vulnerable patients with high CVD risk. ClinicalTrials.gov Identifier: NCT03001713.

Effect of Clinical Decision Support with Audit and Feedback for Prevention of AKI in Coronary Angiography and Intervention: Stepped Wedge Cluster Randomized Trial

Effect of Clinical Decision Support with Audit and Feedback for Prevention of AKI in Coronary Angiography and Intervention: Stepped Wedge Cluster Randomized Trial

Effectiveness of Clinical Decision Support for Hypercoagulable Evaluations in One Hospital

Introduction: Venous Thromboembolism (VTE) is a potentially life-threatening disorder that may be provoked by venous stasis, endothelial injury or hypercoagulable states. Workups for hypercoagulable states are frequently undertaken, but tests performed are often either not indicated (if performed in older patients, provoked VTE) or uninterpretable (if functional tests are ordered while patient anticoagulated or with active thrombus). Clinical decision support at point of order entry has the potential to prevent this unnecessary testing. As part of a larger QI project to improve care of VTE patients, we studied the impact of clinical decision support embedded in order sets, measuring the rates of appropriate hypercoagulable evaluations as a primary outcome.Intervention: This study was undertaken from February 2013 - May 2015, and the effects of intervention were subsequently measured until May 2017. Hypercoagulable workups were defined as appropriate when ordered in patients who are < 45 years of age with unprovoked thrombus for all tests (gene and functional tests); and patients without active thrombi or anticoagulants for functional tests. A new order set was developed on the hospital health information system for VTE admissions. The order set provided evidenced-based guidance for ordering work-up. The order set was rolled out in April 2015, after extensive education of health care providers.Outcome: Over the 2 years after the addition of the clinical decision support intervention, there was a reduction of the total number of hypercoagulable state work-ups from 21% pre-intervention to 15.7% post intervention, the average number of inappropriate tests reduced from 33 to 14 per month - a 57% reduction. Cost savings realized per month from the intervention was approximately $4,500 (pre-intervention: $9,050.73, post-intervention $4,569.98; P - 0.0004) and totaled about $117,000 over 26 months post intervention.Conclusion: Clinical decision support interventions may result in a sustained decrease in unnecessary hypercoagulable workups. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Effect of Clinical Decision Support on Diagnostic Imaging for Pediatric Appendicitis

Appendicitis is the most common pediatric surgical emergency. Efforts to improve efficiency and quality of care have increased reliance on computed tomography (CT) and ultrasonography (US) in children with suspected appendicitis. To evaluate the effectiveness of an electronic health record-linked clinical decision support intervention, AppyCDS, on diagnostic imaging, health care costs, and safety outcomes for patients with suspected appendicitis. In this parallel, cluster randomized trial, 17 community-based general emergency departments (EDs) in California, Minnesota, and Wisconsin were randomized to the AppyCDS intervention group or usual care (UC) group. Patients were aged 5 to 20 years, presenting for an ED visit with right-sided or diffuse abdominal pain lasting 5 days or less. We excluded pregnant patients, those with a prior appendectomy, those with selected comorbidities, and those with traumatic injuries. The trial was conducted from October 2016 to July 2019. AppyCDS prompted data entry at the point of care to estimate appendicitis risk using the pediatric appendicitis risk calculator (pARC). Based on pARC estimates, AppyCDS recommended next steps in care. Primary outcomes were CT, US, or any imaging (CT or US) during the index ED visit. Safety outcomes were perforations, negative appendectomies, and missed appendicitis. Costs were a secondary outcome. Ratio of ratios (RORs) for primary and safety outcomes and differences by group in cost were used to evaluate effectiveness of the clinical decision support tool. We enrolled 3161 patients at intervention EDs and 2779 patients at UC EDs. The mean age of patients was 11.9 (4.6) years and 2614 (44.0%) were boys or young men. RORs for CT (0.94; 95% CI, 0.75-1.19), US (0.98; 95% CI, 0.84-1.14), and any imaging (0.96; 95% CI, 0.86-1.07) did not differ by study group. In an exploratory analysis conducted in 1 health system, AppyCDS was associated with a reduction in any imaging (ROR, 0.82; 95% CI, 0.73- 0.93) for patients with pARC score of 15% or less and a reduction in CT (ROR, 0.58; 95% CI, 0.45-0.74) for patients with a pARC score of 16% to 50%. Perforations, negative appendectomies, and cases of missed appendicitis by study phase did not differ significantly by study group. Costs did not differ overall by study group. In this study, AppyCDS was not associated with overall reductions in diagnostic imaging; exploratory analysis revealed more appropriate use of imaging in patients with a low pARC score. ClinicalTrials.gov Identifier: NCT02633735.

114 Effect of Clinical Decision Support on Head Computed Tomography for Children With Minor Head Trauma

114 Effect of Clinical Decision Support on Head Computed Tomography for Children With Minor Head Trauma

Effectiveness of clinical decision support to enhance delivery of family planning services in primary care settings

PurposeThere is a need to improve delivery of family planning services, including preconception and contraception services, in primary care. We assessed whether a clinician-facing clinical decision support implemented in a family medicine staffed primary care network improved provision of family planning services for reproductive-aged female patients, and differed in effect for certain patients or clinical settings. MethodsWe conducted a pragmatic study with difference-in-differences design to estimate, at the visit-level, the clinical decision support’s effect on documenting the provision of family planning services 52 weeks prior to and after implementation. We also used logistic regression with a sample subset to evaluate intervention effect on the patient-level. Results27,817 eligible patients made 91,185 visits during the study period. Overall, unadjusted documentation of family planning services increased by 2.7 percentage points (55.7% pre-intervention to 58.4% intervention). In the adjusted analysis, documentation increased by 3.4 percentage points (95% CI: 2.24, 4.63). The intervention effect varied across sites at the visit-level, ranging from a −1.2 to +6.5 percentage point change. Modification of effect by race, insurance, and site were substantial, but not by age group nor ethnicity. Additionally, patient-level subset analysis showed that those exposed to the intervention had 1.26 times the odds of having family planning services documented after implementation compared to controls (95% CI: 1.17, 1.36). ConclusionsThis clinical decision support modestly improved documentation of family planning services in our primary care network; effect varied across sites. ImplicationsIntegrating a family planning services clinical decision support into the electronic medical record at primary care sites may increase the provision of preconception and/or contraception services for women of reproductive age. Further study should explore intervention effect at sites with lower initial provision of family planning services.

Effect of Electronic Clinical Decision Support on Imaging for the Evaluation of Acute Low Back Pain in the Ambulatory Care Setting

To assess the effectiveness of a clinical decision support tool consisting of an electronic medical record best practice alert (BPA) on the frequency of lumbar imaging in patients with acute low back pain in the ambulatory care setting, and to explore why providers order imaging outside of clinical guidelines. On March 23, 2016, we implemented a BPA pop-up alert that informed the ordering physician of the Choosing Wisely recommendation to not order imaging within the first 6 weeks of low back pain in the absence of red flags. We calculated imaging rates 1 year before and after implementation of the BPA. To override the BPA, providers could ignore the alert or explain their rationale for ordering imaging using either preset options or a free-text submission. We tracked preset options and manually reviewed 125 free-text submissions. Significant decreases in both total imaging rate (9.6% decrease; P= 0.02) and magnetic resonance imaging rate (14.9% decrease; P < 0.01) were observed after implementation of the BPA. No change was found in the rates of X-ray or computed tomography scan orders. Almost two-thirds (64%) of the providers used preset options in overriding the BPA, and 36% of the providers entered a free-text submission. Among those providers using a free-text submission, 56% entered a non-guideline-supported rationale. The present study demonstrates the effectiveness of a simple, low-cost clinical decision support tool in reducing imaging rates for patients with acute low back pain. We also identify reasons why providers order imaging outside of clinical guidelines.

Effect of Clinical Decision Support on Appropriateness of Advanced Imaging Use Among Physicians-in-Training

Clinical decision support (CDS) tools have been shown to reduce inappropriate imaging orders. We hypothesized that CDS may be especially effective for house staff physicians who are prone to overuse of resources. Our hospital implemented CDS for CT and MRI orders in the emergency department with scores based on the American College of Radiology's Appropriateness Criteria (range, 1-9; higher scores represent more-appropriate orders). Data on CT and MRI orders from April 2013 through June 2016 were categorized as pre-CDS or baseline, post-CDS period 1 (i.e., intervention with active feedback for scores of ≤ 4), and post-CDS period 2 (i.e., intervention with active feedback for scores of ≤ 6). Segmented regression analysis with interrupted time series data estimated changes in scores stratified by house staff and non-house staff. Generalized linear models further estimated the modifying effect of the house staff variable. Mean scores were 6.2, 6.2, and 6.7 in the pre-CDS, post-CDS 1, and post-CDS 2 periods, respectively (p < 0.05). In the segmented regression analysis, mean scores significantly (p < 0.05) increased when comparing pre-CDS versus post-CDS 2 periods for both house staff (baseline increase, 0.41; 95% CI, 0.17-0.64) and non-house staff (baseline increase, 0.58; 95% CI, 0.34-0.81), showing no differences in effect between the cohorts. The generalized linear model showed significantly higher scores, particularly in the post-CDS 2 period compared with the pre-CDS period (0.44 increase in scores; p < 0.05). The house staff variable did not significantly change estimates in the post-CDS 2 period. Implementation of active CDS increased overall scores of CT and MRI orders. However, there was no significant difference in effect on scores between house staff and non-house staff.

Effects of clinical decision support and pharmacist prescribing authority on a therapeutic interchange program.

Results of an evaluation of therapeutic interchange (TI) program outcomes with use of prescriber alerts alone or in combination with pharmacist prescribing are reported. A retrospective single-center study was conducted to compare TI outcomes before incorporation of prescriber alerts encouraging formulary agent use into the electronic medical record (period 1), after alert implementation (period 2), and after implementation and expansion of TI protocols including pharmacist prescribing authority (period 3). The evaluation focused on TI orders for 3 drug classes: angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), and 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (HMG-CoA RIs). The primary outcome was formulary medication utilization. In total, 2,881, 2,700, and 3,088 prescriptions for medications in the ACEI, ARB, or HMG-CoA RI class were ordered during periods 1, 2, and 3, respectively. Overall formulary adherence improved from 78.3% in period 1 to 97.6% in period 2 and 99.2% in period 3 (p < 0.001 for both comparisons with period 1). The percentages of inappropriate dosing conversions were 51.6%, 37.2%, and 2.4% in periods 1, 2, and 3, respectively; the corresponding percentages of inappropriate discharge medications were 64.5%, 16.3%, and 2.4%. Percentages of formulary medications in 3 medication classes, considered separately and together, increased with the implementation of TI alerts for prescribers and the addition of TI-related pharmacist prescribing authority. Over the same study periods, percentages of inappropriate dosing conversions and inappropriate discharge medications decreased.