Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Department of Ophthalmology, Massachusetts Eye and Ear and Harvard Medical School, Boston.
JAMA Netw Open. 2023 Feb 1;6(2):e2254006. doi: 10.1001/jamanetworkopen.2022.54006.
Electronic clinical decision support systems apply clinical guidelines in real time and offer a new approach to improve referral and utilization of low vision rehabilitation (LVR) care.
To characterize patients and factors associated with LVR service utilization with and without the use of an electronic health record (EHR) clinical decision support system (CDSS) alert.
DESIGN, SETTING, AND PARTICIPANTS: Quality improvement study using EHR data to compare patients who did and did not utilize LVR service after referral between November 6, 2017, and October 5, 2019, (primary) and to assess overall service utilization rate from September 1, 2016, to April 2, 2021, regardless of referral status (secondary). Participants in the primary analysis were patients at a large ophthalmology department in an academic medical center in the US who received an LVR referral recommendation from their ophthalmologist according to the CDSS alert. The secondary analysis included patients with best documented visual acuity (BDVA) worse than 20/40 before, during, and after the CDSS implementation. Data were analyzed from August 2021 to April 2022.
Number and locations of referral recommendations for LVR service according to the CDSS alert in the primary analysis; active CDSS implementation in the secondary analysis.
LVR service utilization rate was defined as the number of patients who accessed service among those who were referred (primary) and among those with BDVA worse than 20/40 (secondary). EHR data on patient demographics (age, sex, race, ethnicity) and ophthalmology encounter characteristics (numbers of referral recommendations, encounter location, and BDVA) were extracted.
Of the 429 patients (median [IQR] age, 71 [53 to 83] years; 233 female [54%]) who received a CDSS-based referral recommendation, 184 (42.9%) utilized LVR service. Compared with nonusers of LVR, users were more likely to have received at least 2 referral recommendations (12.5% vs 6.1%; χ21 = 5.29; P = .02) and at an ophthalmology location with onsite LVR service (87.5% vs 78.0%; χ21 = 6.50; P = .01). Onsite LVR service (odds ratio, 2.06; 95% CI, 1.18-3.61) persisted as the only statistically significant factor after adjusting for patient demographics and other referral characteristics. Among patients whose BDVA was worse than 20/40 before, during, and after the CDSS implementation regardless of referral status, the LVR service utilization rate was 6.1%, 13.8%, and 7.5%, respectively.
In this quality improvement study, ophthalmologist referral recommendations and onsite LVR services at the location where patients receive other ophthalmic care were significantly associated with service utilization. Ophthalmology CDSSs are promising tools to apply clinical guidelines in real time to improve connection to care.
电子临床决策支持系统实时应用临床指南，并提供了一种新方法来改善低视力康复（LVR）服务的转诊和利用。
描述患者特征和与 LVR 服务利用相关的因素，包括使用电子健康记录（EHR）临床决策支持系统（CDSS）警报和不使用 EHR CDSS 警报的情况。
设计、设置和参与者：这是一项质量改进研究，使用 EHR 数据比较了 2017 年 11 月 6 日至 2019 年 10 月 5 日之间接受眼科医生转诊推荐后利用和未利用 LVR 服务的患者（主要分析），并评估了 2016 年 9 月 1 日至 2021 年 4 月 2 日期间无论转诊状态如何的整体服务利用率（次要分析）。主要分析中的参与者是在美国一家学术医疗中心的大型眼科部门接受 LVR 转诊推荐的患者，这些推荐是根据 CDSS 警报做出的。次要分析包括在 CDSS 实施前后最佳记录视力（BDVA）差于 20/40 的患者。数据分析于 2021 年 8 月至 2022 年 4 月进行。
根据 CDSS 警报，主要分析中 LVR 服务转诊推荐的数量和位置；次要分析中 CDSS 的实际实施情况。
LVR 服务利用率的定义是在接受转诊的患者（主要分析）和 BDVA 差于 20/40 的患者（次要分析）中接受服务的患者数量。提取了患者人口统计学特征（年龄、性别、种族、民族）和眼科就诊特征（转诊推荐次数、就诊地点和 BDVA）的 EHR 数据。
在 429 名（中位数[IQR]年龄，71[53 至 83]岁；233 名女性[54%]）接受基于 CDSS 的转诊推荐的患者中，184 名（42.9%）利用了 LVR 服务。与未使用 LVR 的患者相比，使用者更有可能接受至少 2 次转诊推荐（12.5%比 6.1%；χ21=5.29；P=0.02），并且在有现场 LVR 服务的眼科就诊地点（87.5%比 78.0%；χ21=6.50；P=0.01）。调整患者人口统计学特征和其他转诊特征后，现场 LVR 服务（比值比，2.06；95%CI，1.18-3.61）仍然是唯一具有统计学意义的因素。在 CDSS 实施前后，无论转诊状态如何，BDVA 差于 20/40 的患者中，LVR 服务利用率分别为 6.1%、13.8%和 7.5%。
在这项质量改进研究中，眼科医生的转诊推荐和患者接受其他眼科护理的就诊地点的现场 LVR 服务与服务利用率显著相关。眼科 CDSS 是实时应用临床指南以改善患者与医疗服务连接的有前途的工具。
