Impact of a "Chart Closure" Hard Stop Alert on Prescribing for Elevated Blood Pressures Among Patients With Diabetes: Quasi-Experimental Study

Magaly Ramirez; Kimberly Chen; Robert W Follett; Carol M Mangione; Gerardo Moreno; Douglas S Bell

doi:10.2196/16421

Impact of a "Chart Closure" Hard Stop Alert on Prescribing for Elevated Blood Pressures Among Patients With Diabetes: Quasi-Experimental Study

JMIR Med Inform. 2020 Apr 17;8(4):e16421. doi: 10.2196/16421.

Authors

Magaly Ramirez¹, Kimberly Chen², Robert W Follett², Carol M Mangione^{3

4}, Gerardo Moreno⁵, Douglas S Bell³

Affiliations

¹ Department of Health Services, School of Public Health, University of Washington, Seattle, WA, United States.
² Clinical Informatics, UCLA Health, Los Angeles, CA, United States.
³ Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States.
⁴ Department of Health Policy and Management, Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, United States.
⁵ Department of Family Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States.

PMID: 32301741
PMCID: PMC7195665
DOI: 10.2196/16421

Abstract

Background: 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.

Objective: 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.

Methods: 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.

Results: 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).

Conclusions: 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.

Keywords: decision support systems, clinical; diabetes mellitus; drug prescriptions; hypertension.

©Magaly Ramirez, Kimberly Chen, Robert W Follett, Carol M Mangione, Gerardo Moreno, Douglas S Bell. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 17.04.2020.

Abstract

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