Multidisciplinary proactive e-consults to improve guideline-directed medical therapies for patients with diabetes and chronic kidney disease: an implementation study.

INTRODUCTION: We hypothesized that multidisciplinary, proactive electronic consultation (MPE) could overcome barriers to prescribing guideline-directed medical therapies (GDMTs) for patients with type 2 diabetes (T2D) and chronic kidney disease (CKD). RESEARCH DESIGN AND METHODS: We conducted an efficacy-implementation pilot study of MPE for T2D and CKD for primary care provider (PCP)-patient dyads at an academic health system. MPE included (1) a dashboard to identify patients without a prescription for sodium-glucose cotransporter-2 inhibitors (SGLT2i) and without a maximum dose prescription for renin-angiotensin-aldosterone system inhibitors (RAASi), (2) a multidisciplinary team of specialists to provide recommendations using e-consult templates, and (3) a workflow to deliver timely e-consult recommendations to PCPs. In-depth interviews were conducted with PCPs and specialists to assess feasibility, acceptability, and appropriateness of MPE and were analyzed using an iterative qualitative analysis approach to identify major themes. Prescription data were extracted from the electronic health record to assess preliminary effectiveness to increase GDMT. RESULTS: 20 PCPs agreed to participate, 18 PCPs received MPEs for one of their patients with T2D and CKD, and 16 PCPs and 2 specialists were interviewed. Major themes were as follows: appropriateness of prioritization of GDMT for T2D and CKD, acceptability of the content of the recommendations, PCP characteristics impact experience with MPE, acceptability and appropriateness of multidisciplinary collaboration, feasibility of MPE to overcome patient-specific barriers to GDMT, and appropriateness of workflow. At 6 months postbaseline, 7/18 (39%) patients were newly prescribed an SGLT2i, and 7/18 (39%) patients were either newly prescribed or had increased dose of RAASi. CONCLUSIONS: MPE was an acceptable and appropriate health system strategy to identify and address gaps in GDMT among patients with T2D and CKD. Adopting MPE could enhance GDMT, though PCPs raised feasibility concerns which could be improved with program enhancements, including follow-up e-consults for reinforcement, and administrative support for navigating system-level barriers.

Effect of health information exchange on recognition of medication discrepancies is interrupted when data charges are introduced: results of a cluster-randomized controlled trial.

OBJECTIVES: To determine the effect of health information exchange (HIE) on medication prescribing for hospital inpatients in a cluster-randomized controlled trial, and to examine the prescribing effect of availability of information from a large pharmacy insurance plan in a natural experiment. METHODS: Patients admitted to an urban hospital received structured medication reconciliation by an intervention pharmacist with (intervention) or without (control) access to a regional HIE. The HIE contained prescribing information from the largest hospitals and pharmacy insurance plan in the region for the first 10 months of the study, but only from the hospitals for the last 21 months, when data charges were imposed by the insurance plan. The primary endpoint was discrepancies between preadmission and inpatient medication regimens, and secondary endpoints included adverse drug events (ADEs) and proportions of rectified discrepancies. RESULTS: Overall, 186 and 195 patients were assigned to intervention and control, respectively. Patients were 60 years old on average and took a mean of 7 medications before admission. There was no difference between intervention and control in number of risk-weighted discrepancies (6.4 vs 5.8, P = .452), discrepancy-associated ADEs (0.102 vs 0.092 per admission, P = .964), or rectification of discrepancies (0.026 vs 0.036 per opportunity, P = .539). However, patients who received medication reconciliation with pharmacy insurance data available had more risk-weighted medication discrepancies identified than those who received usual care (8.0 vs 5.9, P = .038). DISCUSSION AND CONCLUSION: HIE may improve outcomes of medication reconciliation. Charging for access to medication information interrupts this effect. Efforts are needed to understand and increase prescribers' rectification of medication discrepancies.