Ramirez Magaly, Chen Kimberly, Follett Robert W, Mangione Carol M, Moreno Gerardo, Bell Douglas S
Department of Health Services, School of Public Health, University of Washington, Seattle, WA, United States.
Clinical Informatics, UCLA Health, Los Angeles, CA, United States.
JMIR Med Inform. 2020 Apr 17;8(4):e16421. doi: 10.2196/16421.
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.
加利福尼亚大学洛杉矶分校医疗中心针对糖尿病患者启动血管紧张素转换酶抑制剂（ACEI）或血管紧张素受体阻滞剂（ARB）治疗实施了最佳实践建议（BPA）警报。BPA警报设置了“病历关闭”硬停止条件，要求在关闭病历前做出回应。
本研究旨在评估BPA的实施是否与糖尿病患者初级保健就诊期间ACEI和ARB处方的变化相关。
我们将ACEI和ARB处方机会定义为患者被诊断为糖尿病、近期就诊时血压升高、无现行ACEI或ARB处方且无禁忌症的初级保健就诊。我们使用多变量逻辑回归模型，比较在实施BPA的初级保健机构（n = 30）和未实施BPA的初级保健机构（n = 31）中，BPA实施前后机会性就诊期间ACEI或ARB处方概率的变化。在另一项亚组分析中，我们比较了同时实施了药剂师主导的药物管理项目的BPA实施机构中ACEI和ARB的处方情况。
我们在61个初级保健机构中总共识别出2438次机会性就诊。在BPA实施机构中，BPA实施后机会性就诊期间ACEI或ARB处方的预测概率从11.46%显著增加到22.17%。然而，在亚组分析中，我们仅在同时实施了药剂师主导项目的BPA实施机构中观察到ACEI和ARB处方有显著改善。总体而言，与未实施BPA的机构相比，BPA实施机构中BPA实施前后ACEI或ARB处方预测概率的变化显著更大（差异差值为11.82；P <.001）。
带有“病历关闭”硬停止条件的BPA是治疗合并糖尿病和高血压患者使用ACEI或ARB的一种有前景的工具，特别是在基于团队的护理背景下实施时，临床药剂师可支持初级保健提供者的工作。
