Introduction: Clinical decision support (CDS) alerts have shown promise in improving health care quality and patient outcomes. Although repeated exposure to alerts may lead to declined responses by physicians, known as “alert fatigue,” little is known about how the introduction of competing alerts may affect uptake over time.

Methods: We examined alert responses over time and identified factors associated with decreased alert effectiveness. We analyzed the audit data from all occurrences of a CDS alert at a single, large academic health system. For patients screening positive for depression during ambulatory visits, a non-interruptive CDS alert is presented to the physician, offering a number of appropriate documentation actions. Alert uptake was defined as the selection of any option offered within the alert during the patient encounter. We assessed the effect of (1) the number of competing clinical guidance alerts presented during the same encounter and (2) the total number of all clinical guidance alerts that the same provider had seen in the prior 90 days, on the probability of depression screen alert uptake, adjusting for physician and patient characteristics.

Results: A total of 55,649 office visits involving 418 physicians and 40,474 patients between September 1, 2017, and February 28, 2021, were included. After adjustment for potential confounders, physicians who had seen the most CDS alerts in the prior 90 days were less likely to utilize the depression alert than those who had seen it the least (adjusted uptake rate, 19.8% at the highest quartile versus 39.3% at the lowest quartile; adjusted odds ratio, 0.38; 95% CI 0.35 to 0.42; p<0.001). The negative impact of competing alerts in the same visit on depression alert uptake was only seen among physicians in the middle two quartiles of alert exposure in the prior 90 days.

Conclusion: Among physicians at a single large academic health care system, the declining use of a non-interruptive depression alert was strongly associated with the provider’s 90-day prior exposure to alerts. Health systems should monitor providers’ recent alert exposure as a measure of potential alert fatigue.

Abstract

Objective: Evaluate provider compliance with guidelines for routine screening of breast cancer before and after the implementation of a targeted “Best Practice Advisory” (BPA) alert, titled CareGaps, embedded in the routine health maintenance module in the UCLA electronic health record (EHR).

Design: The CareGaps BPA was deployed June 2019 in UCLA primary care clinics. We performed a difference-in-differences evaluation using a mixed effects logistic regression model. We compared mammogram order rates between our pre-intervention period and intervention period. These timeframes were broken into four study periods: Jan-May 2018, Jun – Oct 2018, Jan – May 2019 which were all included in our pre-intervention timeframe and Jun – Oct 2019 which was our intervention timeframe. Mammogram orders placed within two weeks of the encounter visit were considered related to the recent encounter and were considered for analysis. Provider characteristics such as specialty and years of practice and patient characteristics such as insurance and race were controlled for in the model.

Primary outcome: Encounter-based mammogram ordering rates were compared between the pre-intervention and intervention groups.

Secondary outcomes: We examined completion rates for breast cancer screening using the health maintenance status of “not due” as a proxy measure. We also examined the CareGaps orderset use between providers and looked at the ordering practices for mammography amongst providers exposed to the BPA.

Results:

The total number of encounters steadily increased over time and ranged from

26,232 to 32,257. Overall the likelihood of placing a mammogram order significantly increased by about 6% between our pre-intervention and intervention groups. (adjusted odds ratio = 1.07, p = 0.036). We did not find a significant impact of the BPA in mammogram completion rates. We did find however that use of the CareGaps orderset increased with deployment of the CareGaps BPA (OR 1.71, CI 1.43 – 2.07, p <.0001). We also found that those providers who were exposed to the BPA and chose to “address” the BPA by interacting with it such as acknowledging it or opening the CareGaps orderset were 25% more likely to place a mammogram order (X2 p<.0001).

Conclusions: Implementation of a targeted BPA for addressing health maintenance topics such as breast cancer screening can be effective for alerting those providers who have not previously addressed these topics with patients.

Objective: Given controversy over use of contact precautions (CP), this study evaluates the impact of discontinuing CP for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) and expansion of chlorhexidine gluconate (CHG) use on the health system.

Design: Retrospective, nonrandomized, observational, quasi-experimental study.

Setting: 2 California hospitals.

Participants: Inpatients.

Methods: We compared hospital-wide LabID clinical culture rates (as a marker of healthcare associated infections) 1 year before and after routine CP for endemic MRSA and VRE were discontinued and CHG bathing was expanded to all units. Culture data from patients and cost data on material utilization were collected. Nursing time spent donning personal protective equipment (PPE) was assessed and quantified using time-driven activity-based costing.

Results: Average positive culture rates before and after discontinuing CP were 0.40 and 0.32 cultures/100 admissions for MRSA (p=0.09), and 0.48 and 0.40 cultures/100 admissions for VRE (p=0.14). When combining isolation gown and CHG costs, the health system saved $643,776 in one year. Prior to the change, 28.5% ICU and 19% Medicine/Surgery beds were on CP for MRSA/VRE. Based on average room entries and donning time, estimated nursing time spent donning PPE for MRSA/VRE before the change was 45,277 hours/year (estimated cost: $4.6 million).

Conclusion: Discontinuing routine CP for endemic MRSA and VRE did not result in increased rates of MRSA or VRE after one year. With cost savings on materials, increased healthcare worker time, and no concomitant increase in possible infections, elimination of routine CP may add substantial value to inpatient care delivery.

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University of California at Los Angeles Health implemented a Best Practice Advisory (BPA) alert for the initiation of an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) for individuals with diabetes. The BPA alert was configured with a “chart closure” hard stop, which demanded a response before closing the chart.

The aim of the study was to evaluate whether the implementation of the BPA was associated with changes in ACEI and ARB prescribing during primary care encounters for patients with diabetes.

We defined ACEI and ARB prescribing opportunities as primary care encounters in which the patient had a diabetes diagnosis, elevated blood pressure in recent encounters, no active ACEI or ARB prescription, and no contraindications. We used a multivariate logistic regression model to compare the change in the probability of an ACEI or ARB prescription during opportunity encounters before and after BPA implementation in primary care sites that did (n=30) and did not (n=31) implement the BPA. In an additional subgroup analysis, we compared ACEI and ARB prescribing in BPA implementation sites that had also implemented a pharmacist-led medication management program.

We identified a total of 2438 opportunity encounters across 61 primary care sites. The predicted probability of an ACEI or ARB prescription increased significantly from 11.46% to 22.17% during opportunity encounters in BPA implementation sites after BPA implementation. However, in the subgroup analysis, we only observed a significant improvement in ACEI and ARB prescribing in BPA implementation sites that had also implemented the pharmacist-led program. Overall, the change in the predicted probability of an ACEI or ARB prescription from before to after BPA implementation was significantly greater in BPA implementation sites compared with nonimplementation sites (difference-in-differences of 11.82; P<.001).

A BPA with a “chart closure” hard stop is a promising tool for the treatment of patients with comorbid diabetes and hypertension with an ACEI or ARB, especially when implemented within the context of team-based care, wherein clinical pharmacists support the work of primary care providers.

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