Impact of an electronic medical record best practice alert on expedited partner therapy for chlamydia infection and reinfection

Background Atrius Health implemented a best practice alert (BPA) to encourage clinicians to provide expedited partner therapy (EPT) in October 2014. We assessed the impact of the BPA on EPT provision and chlamydial reinfection; and the impact of EPT on testing for chlamydia reinfection and reinfection rates. Methods We included patients ≥15 years with ≥1 positive chlamydia test between January 2013-March 2019. Tests-of-reinfection were defined as chlamydia tests 28-120 days after initial infection and corresponding positive results were considered evidence of reinfection. We used interrupted time series analyses to identify changes in 1) frequency of EPT; 2) tests-of-reinfection; 3) reinfections after the BPA was released. Log-binomial regression models, with GEE methods, assessed associations between EPT and tests-of-reinfection, and EPT and reinfection. Results Among 7,267 chlamydia infections, EPT was given to 1,475 (20%) patients. EPT frequency increased from 15% to 22% of infections between January 2013-September 2014 (β =0.003, p=0.03). After the BPA was released, EPT frequency declined to 19% of infections by March 2019 (β =-0.004, p=0.008). On average, 35% of chlamydia infections received a test-of-reinfection and 7% were reinfected; there were no significant changes in these percentages after BPA implementation. Patients given EPT were more likely to receive tests-of-reinfection (prevalence ratio (PR) 1.09, 95% CI: 1.01-1.16) but without change in reinfections (PR 0.88, 95% CI: 0.66-1.17). Conclusions BPAs in electronic medical record systems may not be effective at increasing EPT prescribing and decreasing chlamydial reinfection. However, patients given EPT were more likely to receive a test of chlamydia reinfection.

36. Evaluation of a Best Practice Alert (BPA) to Improve Pneumocystis jirovecii Prophylaxis Prescribing in Cancer Patients Receiving High-dose Corticosteroids in an Outpatient Setting

Background In patients (pts) with cancer, the risk of Pneumocystis jirovecii pneumonia (PJP) is a function of dose and duration of corticosteroids (CS), underlying immunodeficiency, and immunosuppressive drugs. Trimethoprim/sulfamethoxazole (TMP/SMX) and atovaquone (ATO) are effective prophylaxis (ppx) agents against PJP. Guidelines recommend PJP ppx for pts on > 20 mg /day of prednisone or its equivalent for ≥ 1 month. A best practice alert (BPA) to identify pts receiving CS may assist with improving PJP ppx prescribing in cancer pts. Methods PJP BPA was created to identify pts on CS (excluding hydrocortisone) with no active prescription for TMP/SMX or ATO ppx in EMR. Dapsone and pentamidine excluded since not preferred agents at our institution. PJP case: positive PJP polymerase chain reaction (PCR) from bronchoalveolar lavage (BAL) > 84 copies or positive PJP direct fluorescent antibody (DFA) or cytology with clinical and radiographic suspicion. PJP PCR from BAL < 84 copies/ml with negative DFA and cytology excluded. Preventable PJP (P-PJP): pts after CS > = 30 days without PJP ppx. Non-preventable PJP (NP-PJP) : pts after CS < 30 consecutive days, or on PJP ppx (non-compliance, failure), or day +1 to +30 post hematopoietic cell transplant (HCT). Pre-intervention (pre-i) PJP pts 3/1/2018 to 7/31/19 (17 months), post-intervention (post-i) PJP pts 8/1/19 to 2/1/20 (18 months) evaluated to assess BPA impact on PJP inpatient (inpt) admissions. Results In the post-i, the BPA fired 3,588 times in 1,302 pts. Pre-i: 20 P-PJP, 13 NP-PJP out of 33 pts. Post-i: 6 P-PJP, 25 NP-PJP out of 31 pts. The BPA fired in 4/31 PJP pts in the post-i period: 2/6 of P-PJP, 2/25 NP-PJP. The number of P-PJP decreased from 20 to 6 in the post-i period (p=0.0097). Conclusion Implementation of a decision support tool significantly decreased the number of P-PJP. The BPA was limited by identifying pts after CS were prescribed after the initial visit leading to periods of CS use without ppx and inability to calculate CS dosing and length of prescription. BPA provided passive education in the outpatient setting and future opportunities include refining the EMR to better identify pts at risk for developing PJP. Disclosures All Authors: No reported disclosures

Implementation of Surprise Question Assessments using the Electronic Health Record in Older Adults with Advanced CKD

Background. The Surprise Question (SQ; "Would you be surprised if this patient died in the next 12 months?") is a validated prognostication tool for mortality and hospitalization among patients with advanced CKD. Barriers in clinical workflow have slowed SQ implementation into practice. Objectives. (1) To evaluate implementation outcomes following use of electronic health record (EHR) decision support to automate collection of the SQ. (2) To assess the prognostic utility of the SQ for mortality and hospitalization/emergency room (ER) visits. Methods. We developed and implemented a best practice alert (BPA) in the electronic health record (EHR) to identify nephrology outpatients > 60 years of age with an eGFR<30 ml/min. At appointment, the BPA prompted the physician to answer the SQ. We assessed the rate and timeliness of provider responses. We conducted a post-hoc open-ended survey to assess physician perceptions of SQ implementation. We assessed the SQ's prognostic utility in survival and time-to-hospital encounter (hospitalization/ER visit) analyses. Results. Among 510 patients for whom the BPA triggered, 95 (18.6%) had the SQ completed by 16 physicians. Among those completed, nearly all (97.9%) were on appointment day, and 61 (64.2%) the first time the BPA fired. Providers answered "No" for 27 (28.4%) and "Yes" for 68 (71.6%) patients. By 12 months, 6 (22.2%) "No" patients died; 3 (4.4%) "Yes" patients died (hazards ratio [HR] 2.86, ref:Yes, 95% CI[1.06, 7.69]). About 35% of "No" patients and 32% of "Yes" patients had a hospital encounter by 12 months (HR 1.85, ref:Yes, 95% CI[0.93, 3.69]). Physicians noted (1) they had goals-of-care conversations unprompted; (2) EHR-based interventions alone for goals-of-care are ineffective; and (3) more robust engagement is necessary. Conclusions. We successfully integrated the SQ into the EHR to aid in clinical practice. Additional implementation efforts are needed to encourage further integration of the SQ in clinical practice.