Ladna Michael, Madhok Ishaan, Bhat Adnan, Ruiz Nicole, Brown Jackson, Wilson Jake, Jiang Peter, Taylor Robert, Radetic Mark, George John, Forsmark Christopher
Department of Internal Medicine, University of Florida, Gainesville, Florida.
Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Florida, Gainesville, Florida.
Gastro Hep Adv. 2024 Aug 30;4(1):100541. doi: 10.1016/j.gastha.2024.08.019. eCollection 2025.
Enzyme insufficiency (EPI) is common in chronic pancreatitis (CP), pancreatic ductal adenocarcinoma (PDAC), and after pancreatic resection. 40%-50% of CP patients and 70%-80% of PDAC patients develop EPI. 1/3rd of these patients are prescribed Pancreatic enzyme replacement therapy (PERT), often at an inadequate dose, with evidence that this leads to increased morbidity and mortality. This study aimed to develop and implement an EPIC-based best practice alert (BPA) and smart set to improve the management of EPI.
A retrospective analysis of all patients with International Classification of Diseases codes for EPI, CP, and PDAC or CPT code for pancreatic resection from Feb-2018 to Feb-2021. Appropriate use of PERT was defined as ≥ 40,000 units of lipase with each meal. The BPA and smart set were implemented into the electronic medical record in Feb-2020. The BPA fired if the patient was already on PERT or if an order for PERT was placed and directed the clinician to the smart set which provided PERT formulations each prefilled to the minimum therapeutic dose of 40,000 units of lipase.
A significant increase in the proportion of patients on minimum therapeutic dose of PERT from 61.9% to 72.9% ( ≤ .001). Ordering of pancreatic elastase, A1c, vitamin D, and dual X-ray absorptiometry increased from 20.4% to 29.9% ( < .001), 54.7%-62.1% ( = .001), 30.9%-48.1% ( < .001) and 10%-18% ( < .001), respectively. The BPA triggered a total of 30,838 times resulting in the smart being opened a total of 624 (2.02%) times over 24 months.
The BPA and smart set were associated with an improvement in the diagnosis and management of EPI and related complications in CP, PDAC, and s/p pancreatic resection.
酶分泌不足（EPI）在慢性胰腺炎（CP）、胰腺导管腺癌（PDAC）以及胰腺切除术后很常见。40%-50%的CP患者和70%-80%的PDAC患者会出现EPI。这些患者中有三分之一接受了胰酶替代疗法（PERT），但剂量往往不足，有证据表明这会导致发病率和死亡率上升。本研究旨在制定并实施基于EPIC的最佳实践警报（BPA）和智能套装，以改善EPI的管理。
对2018年2月至2021年2月期间所有具有EPI、CP和PDAC疾病国际分类代码或胰腺切除CPT代码的患者进行回顾性分析。PERT的合理使用定义为每餐使用≥40000单位脂肪酶。BPA和智能套装于2020年2月实施到电子病历中。如果患者已经在接受PERT治疗，或者下达了PERT治疗医嘱，BPA就会触发，并引导临床医生查看智能套装，其中提供的PERT制剂每种都预先填充至40000单位脂肪酶的最低治疗剂量。
接受最低治疗剂量PERT的患者比例从61.9%显著增加到72.9%（P≤0.001）。胰腺弹性蛋白酶、糖化血红蛋白A1c、维生素D和双能X线吸收测定法的检测医嘱分别从20.4%增加到29.9%（P<0.001）、从54.7%增加到62.1%（P = 0.001）、从30.9%增加到48.1%（P<0.001）以及从10%增加到18%（P<0.001）。BPA总共触发了30838次，导致智能套装在24个月内总共被打开624次（2.02%）。
BPA和智能套装与改善CP、PDAC以及胰腺切除术后EPI及其相关并发症的诊断和管理相关。
