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DOI: 10.1055/s-0041-1740484
Pediatric Provider Utilization of a Clinical Decision Support Alert and Association with HIV Pre-exposure Prophylaxis Prescription Rates
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Abstract
Objectives An electronic clinical decision support (CDS) alert can provide real-time provider support to offer pre-exposure prophylaxis (PrEP) to youth at risk for human immunodeficiency virus (HIV). The purpose of this study was to evaluate provider utilization of a PrEP CDS alert in a large academic-community pediatric network and assess the association of the alert with PrEP prescribing rates.
Methods HIV test orders were altered for patients 13 years and older to include a hard-stop prompt asking if the patient would benefit from PrEP. If providers answered “Yes” or “Not Sure,” the CDS alert launched with options to open a standardized order set, refer to an internal PrEP specialist, and/or receive an education module. We analyzed provider utilization using a frequency analysis. The rate of new PrEP prescriptions for 1 year after CDS alert implementation was compared with the year prior using Fisher's exact test.
Results Of the 56 providers exposed to the CDS alert, 70% (n = 39) responded “Not sure” to the alert prompt asking if their patient would benefit from PrEP, and 54% (n = 30) chose at least one clinical support tool. The PrEP prescribing rate increased from 2.3 prescriptions per 10,000 patients to 6.6 prescriptions per 10,000 patients in the year post-intervention (p = 0.02).
Conclusion Our findings suggest a knowledge gap among pediatric providers in identifying patients who would benefit from PrEP. A hard-stop prompt within an HIV test order that offers CDS and provider education might be an effective tool to increase PrEP prescribing among pediatric providers.
Keywords
clinical decision support - electronic health records - adolescents - CDS alert - order set - health care systemProtection of Human and Animal Subjects
The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects, and was reviewed by Stanford University Institutional Review Board.
Publication History
Received: 22 July 2021
Accepted: 01 November 2021
Article published online:
12 January 2022
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References
- 1 Centers for Disease Control and Prevention. HIV Surveillance Report, 2018 (Preliminary); vol. 30. November 2019. Accessed April 14, 2020 at: http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html
- 2 California Department of Public Health, Office of AIDS, California. HIV Surveillance Report—2018. February 2020. Accessed April 14, 2020 at: https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/California_HIV_Surveillance_Report2018.pdf
- 3 Pre-Exposure Prophylaxis (PrEP) | HIV Risk and Prevention | HIV/AIDS | CDC. Accessed April 14, 2020 at: https://www.cdc.gov/hiv/risk/prep/index.html
- 4 PrEP use linked to fewer new HIV infections in US states | aidsmap. Accessed April 14, 2020 at https://www.aidsmap.com/news/jul-2018/prep-use-linked-fewer-new-hiv-infections-us-states
- 5 Gilead Sciences Inc. U.S. Food and Drug Administration Approves Expanded Indication for Truvada® (Emtricitabine and Tenofovir Disoproxil Fumarate) for Reducing the Risk of Acquiring HIV-1 in Adolescents. Published 2018. Accessed September 15, 2021 at: https://www.gilead.com/news-and-press/press-room/press-releases/2018/5/us-food-and-drug-administration-approves-expanded-indication-for-truvada-emtricitabine-and-tenofovir-disoproxil-fumarate-for-reducing-the-risk-of
- 6 California—AIDSVu. Accessed April 14, 2020 at: https://aidsvu.org/local-data/united-states/west/california/
- 7 Harris NS, Johnson AS, Huang YA. et al. Vital signs: status of human immunodeficiency virus testing, viral suppression, and HIV preexposure prophylaxis—United States, 2013-2018. Morb Mortal Wkly Rep 2019; 68 (48) 1117-1123
- 8 Henny KD, Duke CC, Geter A. et al. HIV-related training and correlates of knowledge, HIV screening and prescribing of nPEP and PrEP among primary care providers in Southeast United States, 2017. AIDS Behav 2019; 23 (11) 2926-2935
- 9 Liu A, Cohen S, Follansbee S. et al. Early experiences implementing pre-exposure prophylaxis (PrEP) for HIV prevention in San Francisco. PLoS Med 2014; 11 (03) e1001613
- 10 Mullins TLK, Idoine CR, Zimet GD, Kahn JA. Primary care physician attitudes and intentions toward the use of HIV pre-exposure prophylaxis in adolescents in one metropolitan region. J Adolesc Health 2019; 64 (05) 581-588
- 11 Zhang C, McMahon J, Fiscella K. et al. HIV pre-exposure prophylaxis implementation cascade among health care professionals in the United States: implications from a systematic review and meta-analysis. AIDS Patient Care STDS 2019; 33 (12) 507-527
- 12 Sales JM, Cwiak C, Haddad LB. et al. Brief report: impact of PrEP training for family planning providers on HIV prevention counseling and patient interest in PrEP in Atlanta, Georgia. J Acquir Immune Defic Syndr 2019; 81 (04) 414-418
- 13 Pinto RM, Witte SS, Filippone P, Choi CJ, Wall M. Interprofessional collaboration and on-the-job training improve access to HIV testing, HIV primary care, and pre-exposure prophylaxis (PREP). AIDS Educ Prev 2018; 30 (06) 474-489
- 14 Schedlbauer A, Prasad V, Mulvaney C. et al. What evidence supports the use of computerized alerts and prompts to improve clinicians' prescribing behavior?. J Am Med Inform Assoc 2009; 16 (04) 531-538
- 15 Hansen MJ, Carson PJ, Leedahl DD, Leedahl ND. Failure of a best practice alert to reduce antibiotic prescribing rates for acute sinusitis across an integrated health system in the midwest. J Manag Care Spec Pharm 2018; 24 (02) 154-159
- 16 Devries J, Rafie S, Polston G. Implementing an overdose education and naloxone distribution program in a health system. J Am Pharm Assoc (2003) 2017; 57 (2S): S154-S160
- 17 Malte CA, Berger D, Saxon AJ. et al. Electronic medical record alert associated with reduced opioid and benzodiazepine coprescribing in high-risk veteran patients. Med Care 2018; 56 (02) 171-178
- 18 Strom BL, Schinnar R, Aberra F. et al. Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial. Arch Intern Med 2010; 170 (17) 1578-1583
- 19 Jaspers MWM, Smeulers M, Vermeulen H, Peute LW. Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings. J Am Med Inform Assoc 2011; 18 (03) 327-334
- 20 Kwan JL, Lo L, Ferguson J. et al. Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials. BMJ 2020; 370: m3216
- 21 Ostropolets A, Zhang L, Hripcsak G. A scoping review of clinical decision support tools that generate new knowledge to support decision making in real time. J Am Med Inform Assoc 2020; 27 (12) 1968-1976
- 22 Oluoch T, Santas X, Kwaro D. et al. The effect of electronic medical record-based clinical decision support on HIV care in resource-constrained settings: a systematic review. Int J Med Inform 2012; 81 (10) e83-e92
- 23 Gibbs KD, Shi Y, Sanders N. et al. Evaluation of a Sepsis Alert in the Pediatric Acute Care Setting. Appl Clin Inform 2021; 12 (03) 469-478
- 24 Friebe MP, LeGrand JR, Shepherd BE, Breeden EA, Nelson SD. Reducing inappropriate outpatient medication prescribing in older adults across electronic health record systems. Appl Clin Inform 2020; 11 (05) 865-872
- 25 Lin J, Mauntel-Medici C, Heinert S, Baghikar S. Harnessing the power of the electronic medical record to facilitate an opt-out HIV screening program in an urban academic Emergency Department. J Public Health Manag Pract 2017; 23 (03) 264-268
- 26 Marcelin JR, Tan EM, Marcelin A. et al. Assessment and improvement of HIV screening rates in a Midwest primary care practice using an electronic clinical decision support system: a quality improvement study. BMC Med Inform Decis Mak 2016; 16 (01) 76
- 27 Ridgway JP, Lee A, Devlin S, Kerman J, Mayampurath A. Machine learning and clinical informatics for improving HIV care continuum outcomes. Curr HIV/AIDS Rep 2021; 18 (03) 229-236
- 28 van den Berg P, Powell VE, Wilson IB, Klompas M, Mayer K, Krakower DS. Primary care providers' perspectives on using automated HIV risk prediction models to identify potential candidates for pre-exposure prophylaxis. AIDS Behav 2021; 25 (11) 3651-3657
- 29 Epic [Computer software]. . Verona, WI: Epic Systems Corporation; 2021
- 30 Hart-Cooper GD, Allen I, Irwin Jr CE, Scott H. Adolescent health providers' willingness to prescribe pre-exposure prophylaxis (PrEP) to youth at risk of HIV infection in the United States. J Adolesc Health 2018; 63 (02) 242-244
- 31 Weingart SN, Toth M, Sands DZ, Aronson MD, Davis RB, Phillips RS. Physicians' decisions to override computerized drug alerts in primary care. Arch Intern Med 2003; 163 (21) 2625-2631
- 32 Payne TH, Nichol WP, Hoey P, Savarino J. Characteristics and override rates of order checks in a practitioner order entry system. Proc AMIA Symp 2002; 602-606
- 33 Isaac T, Weissman JS, Davis RB. et al. Overrides of medication alerts in ambulatory care. Arch Intern Med 2009; 169 (03) 305-311
- 34 Gadhiya K, Zamora E, Saiyed SM, Friedlander D, Kaelber DC. Drug alert experience and salience during medical residency at two healthcare institutions. Appl Clin Inform 2021; 12 (02) 355-361
- 35 Krakower D, Solleveld P, Levine K. et al. Impact of COVID-19 on HIV preexposure prophylaxis care at a Boston community health center. Paper presented at: 23rd International AIDS Conference; virtual; 2020: 176-177