Utilization of hepatocellular carcinoma surveillance programs in patients with cirrhosis: A systematic review and meta-analaysis.

e16141 Background: Patients with cirrhosis are advised to undergo hepatocellular carcinoma (HCC) surveillance every six months. Routine screening is associated with early tumor detection and improved survival. However, surveillance is underutilized. We aimed to characterize the impact of HCC surveillance interventions on patient uptake and concomitant detection of HCC. Methods: We performed a comprehensive literature search of major databases (from inception to October 2020) to identify studies which assess the impact of HCC surveillance programs in patients with cirrhosis. Our primary endpoint was uptake of screening defined as having an abdominal sonogram every at least every 6 months. Secondary endpoint was the detection of HCC following screening. Pooled data was assessed using a random-effects model expressed in terms of odds ratio (OR) and 95% confidence interval (CI). Results: Nine studies were included for meta-analysis which involved 5,021 patients with cirrhosis. Patients with a history of hepatitis B or C accounted for 40.5% of the study cohort. Comparing both screening and control groups, patients were 5 times more likely to undergo abdominal sonography if they participated in surveillance programs versus usual care (OR 4.69; CI: 2.41 – 9.13, I2: 94%). Overall, the mean difference in patients who did undergo screening versus those who did not participate in surveillance was 30.6% (CI: 19.2% – 41.9%, P < 0.001). Comparing both screening and control groups, patients were 1.5 times more likely to be diagnosed with HCC if they participated in surveillance programs (OR 1.49; CI: 0.57 – 3.89, I2: 65%). On subgroup analysis, comparing type of intervention program, dedicated surveillance programs showed a higher uptake compared to clinical reminders, though not statistically significant (dedicated programs OR 62.6, CI: 1.53 – 2559.5 vs clinical reminders OR 2.63, CI: 1.82 – 3.79). Conclusions: Patient uptake in HCC surveillance remains underutilized. Interventions such as dedicated surveillance programs and clinical reminders systems can significantly increase uptake of abdominal sonography and cancer detection.

Association of Different Interventions to Increase Leukocyte Testing During Treatment With Dimethyl Fumarate

Background: Dimethyl fumarate (DMF), a treatment for multiple sclerosis, may cause leukopenia and infection. Accordingly, periodic white blood cell (WBC) monitoring is recommended. We sought to evaluate the VA Medication Use Evaluation Tracker (MUET) initiative which provides VA facilities with a list of patients prescribed DMF therapy without a documented white blood cell count (WBC).Methods: We identified 118 VA facilities with patients treated with DMF from 1/1/2016 through 9/30/2016. We determined WBC measurements within three months of the first filled prescription. The lead pharmacist at each facility was surveyed asking if any of seven intervention types were used to improve WBC monitoring (academic detailing, provider education without academic detailing, electronic clinical reminders, request for provider action plan, draft orders for WBC monitoring, patient mailings, and patient calls).Results: The facility response rate for the survey was 78% (92 of 118 facilities). For the 92 included facilities (1,115 patients) the mean rate of WBC monitoring was 54%. Use of the at-risk patient lists was noted in 55% (51/92) of facilities. In multivariate analysis, only academic detailing and provider education remained significantly associated with higher WBC monitoring. From a base WBC monitoring rate of 46%, academic detailing increased the rate by 17% (95% CI 4 to 30%, p=0.011) and provider education increased the rate by 9% (95% CI 0.6 to 18%, p=0.037). The WBC monitoring rate increased by 3.8% for each additional intervention used (95% CI 1.2%-6.4%, p=0.005).Conclusions: Interventions focused on the physician, including academic detailing, were associated with improved WBC monitoring for patients at risk for leukopenia from dimethyl fumarate treatment.

Function-specific Design Principles for the Electronic Health Record

This practice-oriented paper provides a collection of design principles that are specific to certain functions within the electronic health record (EHR). Design principles for EHRs tend to be broad rules of thumb rather than specific and actionable because the relevant literature is organized by specific EHR functions. That is, a good amount of research has been conducted on specific functions, rather than EHRs as a whole. Based on the relevant literature, we provide design principles with underlying rationale for progress notes, problem list, consults, clinical reminders, clinical decision support, medication list, medication alerts, and medication reconciliation. This paper is meant to offer a collection of practical guidelines for designers, grounded in the academic literature, that are more actionable than broad usability heuristics. Future work should include refinement of these principles through systematic literature review and the inclusion of additional EHR functions.