The need for continuous quality assessment for providing optimal comprehensive care for patients with alpha-1 antitrypsin deficiency

Background: Alpha-1-antitrypsin deficiency (AATD) is an orphan disease that mainly affecting the liver and the lung. This creates difficulties to ensure that comprehensive care is administered to both organ systems. Past assessments of care delivered to patients with AATD demonstrated that improvements are needed. For that reason, we reassessed a population of patients with AATD in a large health care system to see if past findings affected present care. Methods: We performed electronic health record (EHR) reviews on all patients with documented AATD and confirmed the diagnosis by evidence of genotyping. We then selected the patients with the ZZ genotype to review comprehensive care. We further compared the findings in patients treated by different specialists (allergy immunology, gastroenterology, and pulmonary). The data were captured and assessed by using a secure web application for building and managing online surveys and data bases. REDCap. Results: We found a total of 329 patients with diagnostic codes for AATD, of these, 203 patients had a confirmed abnormal genotype. Confirmed genotypes were MZ (n = 69), ZZ (n = 48), MS (n = 22), SZ (n = 22). Further focus was applied to the care of the ZZ population secondary to a predisposition to potential severe lung and liver disease. The findings suggest that care can be improved no matter which specialist cares for the patient. Conclusion: Our study demonstrated that all three subspecialty groups had room for improvement in providing care to patients with AATD. Our study further demonstrated the need for recurrent quality-assurance programs that may be aided by care suggestions built into the EHR.

Low Efficacy of Medication Shortage Clinical Decision Support Alerts

Objective We examined clinical decision support (CDS) alerts designed specifically for medication shortages to characterize and assess provider behavior in response to these short-term clinical situations. Materials and Methods We conducted a retrospective analysis of the usage of medication shortage alerts (MSAs) that included at least one alternative medication suggestion and were active for 60 or more days during the 2-year study period, January 1, 2018 to December 31, 2019, in a large health care system. We characterized ordering provider behavior in response to inpatient MSAs. We then developed a linear regression model to predict provider response to alerts using the characteristics of the ordering provider and alert frequency groupings. Results During the study period, there were 67 MSAs in use that focused on 42 distinct medications in shortage. The MSAs suggested an average of 3.9 alternative medications. Adjusting for the different alerts, fellows (p = 0.004), residents (p = 0.03), and physician assistants (p = 0.02) were less likely to accept alerts on average compared with attending physicians. Further, female ordering clinicians (p < 0.001) were more likely to accept alerts on average compared with male ordering clinicians. Conclusion Our findings demonstrate that providers tended to reject MSAs, even those who were sometimes flexible about their responses. The low overall acceptance rate supports the theory that alerts appearing at the time of order entry may have limited value, as they may be presented too late in the decision-making process. Though MSAs are designed to be attention-grabbing and higher impact than traditional CDS, our findings suggest that providers rarely change their clinical decisions when presented with these alerts.