An evaluation of clinical decision support tools for Patient Health Questionnaire-9 administration.

INTRODUCTION: Many health care institutions are working to improve depression screening and management with the use of the Patient Health Questionnaire 9 (PHQ-9). Clinical decision support (CDS) within the EHR is one strategy, but little is known about effective approaches to design or implement such CDS. The purpose of this study is to compare implementation outcomes of two versions of a CDS tool to improve PHQ-9 administration for patients with depression. METHODS: This was a retrospective, observational study comparing two versions of a CDS. Version 1 interrupted clinician workflow, and version 2 did not interrupt workflow. Outcomes of interest included reach, adoption, and effectiveness. PHQ-9 administration was determined by chart review. Chi-square tests were used to evaluate associations between PHQ-9 administration with versions 1 and 2. RESULTS: Version 1 resulted in PHQ-9 administration 77 times (15.3% of 504 unique encounters) compared with 49 times (9.8% of 502 unique encounters) with version 2 (P = .011). DISCUSSION: An interruptive CDS tool may be more effective at increasing PHQ-9 administration, but a noninterruptive CDS tool may be preferred to minimize alert fatigue despite a decrease in effectiveness.

Effectiveness of Best Practice Alerts for Potentially Inappropriate Medication Orders in Older Adults in the Ambulatory Setting.

INTRODUCTION: Information is limited about the effectiveness of best practice alerts (BPAs) for potentially inappropriate medications (PIMs) in improving clinical outcomes in older adults. OBJECTIVE: To assess clinical outcomes of 11 BPAs for PIMs in older adults in the ambulatory setting. METHODS: A retrospective cohort study was conducted at an integrated health care delivery system with computerized provider order entry. Patients aged 65 years and older were included if they had a BPA triggered when a prescriber attempted to order a sedating PIM in the ambulatory setting. Patients were categorized into dispensed and nondispensed groups if they did and did not, respectively, have the study PIM for which the BPA was triggered dispensed within 30 days of the alert. Rates of fall, fracture, or other injury and cognitive impairment were measured during 180-day follow-up. RESULTS: A total of 2704 patients were included: 1373 (50.8%) and 1331 (49.2%) in the dispensed and nondispensed groups, respectively. The dispensed group had a lower unadjusted rate of fall/fracture/injury (3.4% vs 5.3%, p = 0.019), but this difference was attenuated with multivariable adjustment (adjusted odds ratio = 0.77, 95% confidence interval = 0.51-1.13). There was no difference in the rate of cognitive impairment between groups (4.6% vs 4.4%, adjusted odds ratio = 1.40, 95% confidence interval = 0.95-2.05). CONCLUSION: No association was identified between PIM dispensing after a prescriber was alerted with a BPA and reduced rates of falls/fractures/injuries and cognitive impairment.

Birth outcomes with prescribed chronic and acute opioid exposure during pregnancy.

OBJECTIVES: To assess the effects of no, any, and acute and chronic prescription opioid exposure for pain during pregnancy on maternal and fetal outcomes. DESIGN: Retrospective cohort study. SETTING: Integrated healthcare delivery system. Information on pregnancies and their outcomes were obtained from administrative data and verified via manual chart review. PARTICIPANTS: Women ≥ 18 years of age who were pregnant between January 1, 2012 and May 31, 2015 and had chronic, acute, and no opioid exposure; defined as an ambulatory dispensing(s) of >30 (with a total of 225 morphine equivalents), 1-29, and 0 days supply of opioid, respectively, during pregnancy. MAIN OUTCOME MEASURE: Non-live birth. RESULTS: A total 13,809 pregnancies for 13,131 women were included. Pregnancies with opioid exposure had higher risk scores and more comorbid conditions. A total of 1,319 (9.6 percent) pregnancies had any documented opioid exposure during pregnancy with 125 (1.0 percent) and 1,194 (8.7 percent) pregnancies having had chronic and acute opioid exposure, respectively. Pregnancies with acute opioid exposure had a higher percentage of non-live births (3.1 percent) compared to pregnancies (1.0 percent) with no opioid exposure (adjusted odds ratio = 3.46, 95% confidence interval 2.33-5.14) but no difference compared to pregnancies with chronic (1.6 percent) opioid exposure (p > 0.05 with adjustment). CONCLUSIONS: While a dose response of opioid exposure was not identified, these results add to existing evidence that opioid exposure during pregnancy is correlated with negative outcomes. Practitioners may better serve pregnant women and their fetuses by encouraging alternate pain relief treatments.

Patient Perspectives on Switching from Infliximab to Infliximab-dyyb in Patients with Rheumatologic Diseases in the United States.

OBJECTIVE: The introduction of biosimilars for rheumatologic diseases (RDs) has provided a potentially lower-cost therapy compared with their bio-originator products; however, adoption of biosimilars may be challenged by patient perceptions. The objective of this study was to describe patients' perspectives of switching from infliximab to infliximab-dyyb. METHODS: This was a survey of adult patients with RDs who qualified for switching from infliximab to infliximab-dyyb therapy between September 1 2017 and January 31 2018. Verbal consent was obtained prior to administration of a telephone survey. Survey questions were focused on the safety, efficacy, and knowledge of biosimilar therapy. RESULTS: A total of 108 patients were identified with 52 (48%) patients consenting to study participation. Forty (77%) and 12 (23%) patients reported switching and not switching, respectively, to infliximab-dyyb. Regarding disease control, most respondents (80%) were satisfied to very satisfied with the switch to infliximab-dyyb. Major concerns reported for switching included not knowing enough about the medication (38%), potential side effects (35%), and loss of disease activity control (35%). CONCLUSION: Overall, patients reported satisfaction with switching from infliximab to infliximab-dyyb, but concerns regarding safety and efficacy were expressed. Patient involvement in the switching decision-making process may allay concerns and enhance biosimilar uptake.