Evaluating the prescribing and monitoring of medications associated with QTc-prolongation in the ambulatory care setting.

RATIONALE: Little is known about the prescribing of medications with potential to cause QTc-prolongation in the ambulatory care settings. Understanding real-world prescribing of QTc-prolonging medications and actions taken to mitigate this risk will help guide strategies to optimize safety and appropriate prescribing among ambulatory patients. OBJECTIVE: To evaluate the frequency of clinician action taken to monitor and mitigate modifiable risk factors for QTc-prolongation when indicated. METHODS: This retrospective, cross-sectional study evaluated clinician action at the time of prescribing prespecified medications with potential to prolong QTc in adult patients in primary care. The index date was defined as the date the medication was ordered. Electronic health record (EHR) data were evaluated to assess patient, clinician and visit characteristics. Clinician action was determined if baseline or follow-up monitoring was ordered or if action was taken to mitigate modifiable risk factors (laboratory abnormalities or electrocardiogram [ECG] monitoring) within 48 h of prescribing a medication with QTc-prolonging risk. Descriptive statistics were used to describe current practice. RESULTS: A total of 399 prescriptions were prescribed to 386 patients, with a mean age of 51 ± 18 years, during March 2021 from a single-centre, multisite health system. Of these, 17 (4%) patients had a known history of QTc-prolongation, 170 (44%) did not have a documented history of QTc-prolongation and 199 (52%) had an unknown history (no ECG documented). Thirty-nine patients (10%) had at least one laboratory-related risk factor at the time of prescribing, specifically hypokalemia (16 patients), hypomagnesemia (8 patients) or hypocalcemia (19 patients). Of these 39 patients with laboratory risk factors, only 6 patients (15%) had their risk acknowledged or addressed by a clinician. Additionally, eight patients' most recent QTc was ≥500 ms and none had an ECG checked at the time the prescription was ordered. CONCLUSION: Despite national recommendations, medication monitoring and risk mitigation is infrequent when prescribing QTc-prolonging medications in the ambulatory care setting. These findings call for additional research to better understand this gap, including reasons for the gap and consequences on patient outcomes.

EHR-Integrated Clinical Pathways Promote Education, Confidence, and Save Time for Primary Care Providers.

Computerized clinical decision support tools are increasingly necessary and widespread in primary care due to rapidly evolving evidence and shifting clinical guidelines. Clinical pathways are a subtype of clinical decision support tool which aim to link evidence to practice and which require evaluation of benefits and barriers to use to inform user-centered design. The objective was to describe the use and perceived benefits and barriers to evidence-based, disease-specific electronic health record pathways for clinical decision support. Primary care providers at a large integrated health system were surveyed about their use of clinical pathways using an online questionnaire distributed via email in November 2021. Descriptive statistics were estimated and differences in the characteristics and responses by pathway use were assessed using chi-square or Fisher exact tests. The survey response rate was 26% (153/593). There were differences in the response rates between providers by practice type (42% academic versus 54% community; P < 0.001). No difference was found in the demographics of those that used the pathways versus those that did not according to role, age, or length of time in practice. Providers in the academic practice were more likely than those in community practices to have used the pathways. Among providers who used the pathways, 98% agree they have evidence-based information, 98% agree they allow them to take better care of patients, 88% agree they guide clinical-decisions, and 85% agree they save time. The main barrier for those who had used pathways was that they forget about them. Among those who had not used pathways, 35% were unaware that pathways existed. This analysis demonstrates that primary care providers who adopt clinical pathways perceive benefits in several domains. The largest barriers to adoption were that users forgot about pathways or were unaware of them. Future work should focus on dissemination and education, improving tool accessibility, and content optimization to balance complexity with efficiency.