Impact of Automated Best Practice Advisories on Provider Response to CYP2C19 Genotyping Results for Patients on Clopidogrel

2021 ◽  
pp. 089719002110495
Author(s):  
Natasha J. Petry ◽  
Breanna Curtis ◽  
Erica Feldhege ◽  
Shahjahan Khan ◽  
David D. Leedahl ◽  
...  
Keyword(s):  
Health System ◽  
Antiplatelet Therapy ◽  
Best Practice ◽  
Provider Education ◽  
Study Objective ◽  
Future Design ◽  
Outcome Relationship ◽  
Practice Advisory ◽  
Individual Knowledge ◽  
Study Population

Objective The study objective was to examine provider acceptance and genotyping responses to a best practice advisory (BPA) concerning clopidogrel and CYP2C19 intermediate and poor metabolizers within the context of a new pharmacogenomics program at a Midwestern health system . Other secondary objectives analyzed included appropriate BPA firing, the distribution of alleles in study population, indications for clopidogrel use, and impact of indication on therapy change. Methods: In this study, the progress of this program was assessed by quantifying how providers respond to BPAs generated in the electronic medical record (EMR), in the context of a single representative gene–drug–outcome relationship. Patient data was pulled via reports yielding patients with genotyped information in the EMR and cross-referenced with a report evaluating BPA firing occurrences. Results: By capturing antiplatelet therapy changes in response to CYP2C19 genotyping results, 37 patients were found that had 73 BPAs fire. Nine of those patients had alternative antiplatelet therapy ordered. Of these, 6 alternative antiplatelet therapies were ordered from the BPA. Conclusion: Providers utilized BPAs, but responded differently based on individual knowledge of genotypes and indications. Information obtained from this study can be used for provider education and as reference for future design and wording of BPAs.

Comparison of referral methods into a smoking cessation program

2020 ◽  
Author(s):  
James M Davis ◽  
Leah C Thomas ◽  
Jillian EH Dirkes ◽  
Santanu K Datta ◽  
Paul A Dennis
Keyword(s):  
Smoking Cessation ◽  
Electronic Health Record ◽  
Health System ◽  
Service Utilization ◽  
Best Practice ◽  
Smoking Cessation Program ◽  
Utilization Rate ◽  
Health Record ◽  
Practice Advisory ◽  
Electronic Health

Rational, aims & objectives: The goal of this observational study was to compare three referral methods and determine which led to the highest utilization of the Duke Smoking Cessation Program (DSCP). Materials & methods: We conducted two assessments within the Duke health system: a 12-month assessment of Traditional Referral (a provider refers a patient during a patient visit) and Best Practice Advisory (BPA) (a provider refers a patient after responding to an alert within the electronic health record); and a 30-day assessment of Population Outreach (a list of smokers is generated through the electronic health record and patients are contacted directly). Results: Over the 12-month assessment, a total of 13,586 smokers were seen throughout health system clinics receiving services from the DSCP. During this period, the service utilization rate was significantly higher for Traditional Referral (3.8%) than for BPA (0.6%); p < 0.005. The 30-day pilot assessment of showed a service utilization rate for Population Outreach of 6.3%, significantly higher than Traditional Referral (3.8%); p < 0.005 and BPA (0.6%; p < 0.005). Conclusion: Population Outreach appears to be an effective referral method for increasing utilization of the DSCP.

Impact of an electronic best-practice advisory in combination with prescriber education on antibiotic prescribing for ambulatory adults with acute, uncomplicated bronchitis within a large integrated health system

2019 ◽  
Vol 40 (12) ◽  
pp. 1348-1355 ◽  
Author(s):  
Courtney M. Pagels ◽  
Thomas J. Dilworth ◽  
Lynne Fehrenbacher ◽  
Maharaj Singh ◽  
Charles F. Brummitt
Keyword(s):  
Health System ◽  
Emergency Departments ◽  
Best Practice ◽  
Acute Bronchitis ◽  
Primary Diagnosis ◽  
Urgent Care ◽  
Absolute Difference ◽  
Antibiotic Prescribing ◽  
Practice Advisory ◽  
The Impact

AbstractObjective:To determine the impact of a passive, prescriber-directed, electronic best-practice advisory coupled with prescriber education on the rate of antibiotic prescribing for acute, uncomplicated bronchitis in ambulatory adults across a large health system.Design:This study was a quasi-experiment examining antibiotic prescribing for ambulatory adults with acute bronchitis from January 1, 2016 through December 31, 2018. The intervention was implemented in December 2016 for emergency departments and urgent care clinics followed by ambulatory clinics in September 2017.Setting:Outpatient settings across a health system, including 15 emergency departments, >30 urgent care clinics, and >150 ambulatory clinics.Participants:All adults with a primary diagnosis of acute bronchitis who were seen and discharged from a study site were included.Interventions:A passive, prescriber-directed, best-practice advisory for treatment of acute bronchitis in the electronic health record and an optional, online education module regarding acute bronchitis.Results:The study included 81,975 ambulatory adults with a primary diagnosis of acute bronchitis during the preintervention period (19.8% >65 years of age; 61.9% female) and 89,571 ambulatory adults during the postintervention period (16.5% >65 years of age; 61.1% female). Antibiotic prescribing rates decreased from 60.8% (49,877 of 81,975 patients) preintervention to 51.4% (46,018 of 89,571 patients) postintervention (absolute difference, 9.4%; P < .001). The largest reduction occurred in the emergency departments.Conclusions:An electronic best practice advisory combined with prescriber education was associated with a statistically significant reduction in antibiotic prescribing for adults with acute bronchitis. Future studies should incorporate patient education and address prescriber-reported barriers to appropriate antibiotic prescribing.

scholarly journals Increased Postoperative Bleeding Risk among Patients with Local Flap Surgery under Continued Clopidogrel Therapy

2015 ◽  
Vol 2015 ◽  
pp. 1-5 ◽  
Author(s):  
Wolfgang Eichhorn ◽  
Martina Haase ◽  
Lan Kluwe ◽  
Jürgen Zeuch ◽  
Ralf Smeets ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Univariate Analysis ◽  
Postoperative Bleeding ◽  
Tumor Resection ◽  
Bleeding Risk ◽  
Skin Tumor ◽  
Bleeding Complications ◽  
Skin Grafts ◽  
Clopidogrel Therapy ◽  
Study Population

Purpose. The purpose of the study was to evaluate the influence of a continued antiplatelet therapy with clopidogrel on postoperative bleeding risk in patients undergoing skin tumor resection and reconstruction with local flaps or skin grafts under outpatient conditions.Patients and Methods. The authors designed and implemented a retrospective clinical cohort study at the General Hospital Balingen. The primary endpoint was the bleeding ratio in patients with clopidogrel treatment in comparison to patients without any anticoagulant or antiplatelet therapy. Wound healing was evaluated on days 1, 3, 5, 7, 10, and 14.Results. 650 procedures were performed, 123 of them under continued clopidogrel therapy. There were significantly more postoperative bleeding complications among patients with continued antiplatelet therapy. Regarding the whole study population, malignant lesions, a larger defect size, and skin grafts were accompanied by a higher rate of bleeding incidents. However, there were no significant findings in the univariate analysis of the clopidogrel group. All bleeding incidents were easily manageable.Conclusion. Despite an increased bleeding ratio among patients under continued clopidogrel therapy, the performance of simple surgical procedures can be recommended. However, cautious preparation and careful hemostasis are indispensable.

scholarly journals Health System Implementation of a Tobacco Quitline eReferral

2019 ◽  
Vol 10 (04) ◽  
pp. 735-742 ◽  
Author(s):  
Eve Angeline Hood-Medland ◽  
Susan L. Stewart ◽  
Hien Nguyen ◽  
Mark Avdalovic ◽  
Scott MacDonald ◽  
...  
Keyword(s):  
Electronic Health Record ◽  
Health System ◽  
Best Practice ◽  
Health Record ◽  
System Implementation ◽  
Electronic Health Record Data ◽  
Outpatient Group ◽  
Primary Care Specialty ◽  
Electronic Health ◽  
Order Set

Abstract Background Proactive referrals through electronic orders (eReferrals) can increase patient connection with tobacco quitlines. More information is needed on “real-world” implementation of electronic health record tools to promote tobacco cessation while minimizing provider burden. Objectives This paper examines the health system implementation of an eReferral to a tobacco quitline without best practice alerts in primary care, specialty, and hospital settings in an academic health system. Methods This is a prospective implementation study of a health system tobacco eReferral to a state quitline that was completed with an approach to minimize provider cognitive burden. Data are drawn from electronic health record data at University of California, Davis Health Systems (March 2013–February 2016). Results Over 3 years, 16,083 encounters with smokers resulted in 1,137 eReferral orders (7.1%). Treatment reach was 1.6% for quitline services and 2.3% for outpatient group classes. While the group classes were offered to outpatient smokers, the eReferral order was included in an outpatient order set and eventually an automated inpatient discharge order set; no provider alerts were implemented. Referrals were sustained and doubled after inpatient order set implementation. Among all first time eReferral patients, 12.2% had a 6 to 12 month follow-up visit at which they were documented as nonsmoking. Conclusion This study demonstrates a quitline eReferral order can be successfully implemented and sustained with minimal promotion, without provider alerts and in conjunction with group classes. Reach and effectiveness were similar to previously described literature.

scholarly journals A Successful Strategy to Reduce Hospital-Onset Clostridium difficile

2017 ◽  
Vol 4 (suppl_1) ◽  
pp. S406-S406
Author(s):  
Lou Ann Bruno-Murtha ◽  
Rebecca Osgood ◽  
Casey Alexandre ◽  
Rumel Mahmood
Keyword(s):  
Best Practice ◽  
Teaching Hospitals ◽  
Incentive Payment ◽  
Contact Precautions ◽  
Testing Protocol ◽  
Antigen Assay ◽  
Before And After ◽  
Practice Advisory ◽  
Community Onset ◽  
Community Teaching

Abstract Background Our goal was to reduce the rate of hospital-onset (HO) C. difficile (CD) by prompt testing in patients with diarrhea on hospital day (HD) 1–3 using a nurse-driven testing protocol (NTP) with PCR and improve identification of disease after HD 3 using a combined toxin/antigen assay (TAA). Methods An automated best practice advisory/NTP was developed in Epic, triggered by documentation of diarrhea during HD 1–3, to facilitate prompt stool collection, testing and initiation of contact precautions. Education was provided. The NTP was fully implemented at 2 community-teaching hospitals mid-February 2016. The TAA was adopted 7/27/16 for testing after HD 3. Results In 2016, the standardized infection ratio (SIR) at Cambridge and Everett was 0.43 (P = 0.009) and 0.5 (P = 0.017), respectively, reflecting a 48–61% decrease from 2015. There was a 14–28% improvement in identifying cases as community-onset. The TAA led to a further decline in HO-CD by 10–61%. Refer to the graph for quarterly SIRs before and after implementation. Despite a 26% increase in testing volume, costs are less with the current strategy. Conclusion Prompt identification of CD improves care and prevents inflation of HO-CD. This strategy has enhanced our efforts to reduce our SIR (observed/expected cases) and resulted in a substantial incentive payment for CHA. Disclosures All authors: No reported disclosures.

scholarly journals Regional process redesign of lung cancer care: a learning health system pilot project

2018 ◽  
Vol 25 (1) ◽  
pp. 59 ◽  
Author(s):  
M. Fung-Kee-Fung ◽  
D.E. Maziak ◽  
J.R. Pantarotto ◽  
J. Smylie ◽  
L. Taylor ◽  
...  
Keyword(s):  
Lung Cancer ◽  
Health System ◽  
Cancer Care ◽  
Initial Treatment ◽  
Best Practice ◽  
System Optimization ◽  
Transformation Model ◽  
Patient Journey ◽  
Ottawa Hospital ◽  
Learning Health System

 Background The Ottawa Hospital (toh) defined delay to timely lung cancer care as a system design problem. Recognizing the patient need for an integrated journey and the need for dynamic alignment of providers, toh used a learning health system (lhs) vision to redesign regional diagnostic processes. A lhs is driven by feedback utilizing operational and clinical information to drive system optimization and innovation. An essential component of a lhs is a collaborative platform that provides connectivity across silos, organizations, and professions.Methods To operationalize a lhs, we developed the Ottawa Health Transformation Model (ohtm) as a consensus approach that addresses process barriers, resistance to change, and conflicting priorities. A regional Community of Practice (cop) was established to engage stakeholders, and a dedicated transformation team supported process improvements and implementation.Results The project operationalized the lung cancer diagnostic pathway and optimized patient flow from referral to initiation of treatment. Twelve major processes in referral, review, diagnostics, assessment, triage, and consult were redesigned. The Ottawa Hospital now provides a diagnosis to 80% of referrals within the provincial target of 28 days. The median patient journey from referral to initial treatment decreased by 48% from 92 to 47 days.Conclusions The initiative optimized regional integration from referral to initial treatment. Use of a lhs lens enabled the creation of a system that is standardized to best practice and open to ongoing innovation. Continued transformation initiatives across the continuum of care are needed to incorporate best practice and optimize delivery systems for regional populations.

scholarly journals Multiple chronic conditions at a major urban health system: a retrospective cross-sectional analysis of frequencies, costs and comorbidity patterns

BMJ Open ◽  
2019 ◽  
Vol 9 (10) ◽  
pp. e029340 ◽  
Author(s):  
Usnish B Majumdar ◽  
Christophe Hunt ◽  
Patrick Doupe ◽  
Aaron J Baum ◽  
David J Heller ◽  
...  
Keyword(s):  
New York ◽  
Health System ◽  
Urban Health ◽  
Low Income ◽  
Chronic Conditions ◽  
Cross Sectional Study ◽  
Multiple Chronic Conditions ◽  
Cross Sectional ◽  
Study Population ◽  
Mount Sinai

ObjectiveTo (1) examine the burden of multiple chronic conditions (MCC) in an urban health system, and (2) propose a methodology to identify subpopulations of interest based on diagnosis groups and costs.DesignRetrospective cross-sectional study.SettingMount Sinai Health System, set in all five boroughs of New York City, USA.Participants192 085 adult (18+) plan members of capitated Medicaid contracts between the Healthfirst managed care organisation and the Mount Sinai Health System in the years 2012 to 2014.MethodsWe classified adults as having 0, 1, 2, 3, 4 or 5+ chronic conditions from a list of 69 chronic conditions. After summarising the demographics, geography and prevalence of MCC within this population, we then described groups of patients (segments) using a novel methodology: we combinatorially defined 18 768 potential segments of patients by a pair of chronic conditions, a sex and an age group, and then ranked segments by (1) frequency, (2) cost and (3) ratios of observed to expected frequencies of co-occurring chronic conditions. We then compiled pairs of conditions that occur more frequently together than otherwise expected.Results61.5% of the study population suffers from two or more chronic conditions. The most frequent dyad was hypertension and hyperlipidaemia (19%) and the most frequent triad was diabetes, hypertension and hyperlipidaemia (10%). Women aged 50 to 65 with hypertension and hyperlipidaemia were the leading cost segment in the study population. Costs and prevalence of MCC increase with number of conditions and age. The disease dyads associated with the largest observed/expected ratios were pulmonary disease and myocardial infarction. Inter-borough range MCC prevalence was 16%.ConclusionsIn this low-income, urban population, MCC is more prevalent (61%) than nationally (42%), motivating further research and intervention in this population. By identifying potential target populations in an interpretable manner, this segmenting methodology has utility for health services analysts.

Missed Opportunities for Early Diabetes Screening in Pregnancy

2019 ◽  
Vol 38 (01) ◽  
pp. 023-027
Author(s):  
Ashley N. Battarbee ◽  
Maximiliano Cavallini ◽  
Catherine Keller ◽  
Kim A. Boggess
Keyword(s):  
At Risk ◽  
Early Pregnancy ◽  
Best Practice ◽  
Challenge Test ◽  
Error Variance ◽  
Diabetes Screening ◽  
Provider Education ◽  
Early Screening ◽  
Retrospective Case ◽  
Early Diabetes

Abstract Objective This study aimed to identify characteristics of women at risk of undiagnosed type 2 diabetes mellitus (T2DM) that fail to receive early pregnancy screening. Study Design This was a retrospective case–control study of at-risk women who initiated care at the University of North Carolina at Chapel Hill at <21 weeks from January 2015 to December 2015. In 2013, the American College of Obstetricians and Gynecologists and the American Diabetes Association recommended women with prior GDM, glucose intolerance, or body mass index (BMI) ≥ 30 kg/m2 receive early pregnancy screening for undiagnosed T2DM. We defined early screening as 1-hour 50-g glucose challenge test or hemoglobin A1c at <21 weeks' gestation. Cases were women who did not have early screening, and controls were women who did. Modified Poisson regression with robust error variance estimated relative risks of factors associated with missed early screening. Results Of the 1,932 women who initiated care at <21 weeks, 257 (13%) women were at risk of undiagnosed T2DM and, thus, candidates for early screening. However, 129 (50.2%) women were not screened. Higher BMI and prior GDM were associated with a lower relative risk of missed screening. Conclusion Higher BMI and prior GDM increased the likelihood of early diabetes screening, but only half of at-risk women were screened. Provider education and best practice alert systems are needed to increase screening for undiagnosed T2DM.

scholarly journals 2426 Fostering cross-disciplinary research: Lessons learned from STTEP-UP

2018 ◽  
Vol 2 (S1) ◽  
pp. 56-56 ◽  
Author(s):  
Hannibal Person ◽  
Adjoa R. Smalls-Mantey ◽  
Oluwasheyi Ayeni ◽  
Dagmar Hernandez-Saurez ◽  
Emma K. T. Benn ◽  
...  
Keyword(s):  
Healthcare System ◽  
Lessons Learned ◽  
Virtual Learning Environment ◽  
Provider Education ◽  
Research Strategies ◽  
Web Based ◽  
Protected Time ◽  
Study Population ◽  
Group Brainstorming ◽  
New Research

OBJECTIVES/SPECIFIC AIMS: N/A. METHODS/STUDY POPULATION: N/A. RESULTS/ANTICIPATED RESULTS: N/A. DISCUSSION/SIGNIFICANCE OF IMPACT: There is an increasing need to foster cross-disciplinary research to address complex problems within healthcare. The Sinai Team-based Translational Education Program: the URM Propeller (STTEP-UP) is a NCATS funded program through the Icahn School of Medicine at Mount Sinai. Its goal is to facilitate URM post-doctoral trainees becoming innovative leaders in clinical and translational research. The program includes a team-based research component, where fellows collaborate on a project. This year, disciplines represented by the four fellows include Cardiology, Psychiatry, Neurology, and Pediatrics. Identifying a clinical question and designing an investigation was facilitated by group brainstorming meetings with program mentors. Fellows designed a project to identify medical testing and prescribing that were not clinically indicated throughout the healthcare system, with the goal of exploring whether an intervention, including provider education, could reduce ordering practices. In addition to regular in-person meetings, a licensed virtual learning environment and free web-based sharing platform were used to foster collaboration. Challenges faced throughout this process, included fellows struggling to find protected time, difficulties accessing broad sets of data across the healthcare system, and overcoming administrative barriers between departments. Strengths of this approach, included fellows learning new research strategies and feeling a deeper sense of commonality with their peers. Overall, this experience supports the idea that cross-disciplinary research improves the collaboration and education of emerging researchers. However, addressing logistical and systems-based barriers may better facilitate this education and research.

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