Clinical decision support to promote safe prescribing to women of reproductive age: a cluster-randomized trial

Abstract

Background: Potentially teratogenic medications are frequently prescribed without provision of contraceptive counseling.

Objective: To evaluate whether computerized clinical decision support (CDS) can increase primary care providers' (PCPs') provision of family planning services when prescribing potentially teratogenic medications.

Design: Cluster-randomized trial conducted in one academic and one community-based practice between October of 2008 and April of 2010.

Participants/interventions: Forty-one PCPs were randomized to receive one of two types of CDS which alerted them to risks of medication-induced birth defects when ordering potentially teratogenic medications for women who may become pregnant. The 'simple' CDS provided a cautionary alert; the 'multifaceted' CDS provided tailored information and links to a structured order set designed to facilitate safe prescribing. Both CDS systems alerted PCPs about medication risk only once per encounter.

Main measures: We assessed change in documented provision of family planning services using data from 35,110 encounters and mixed-effects models. PCPs completed surveys before and after the CDS systems were implemented, allowing assessment of change in PCP-reported counseling about the risks of medication-induced birth defects and contraception.

Key results: Both CDS systems were associated with slight increases in provision of family planning services when potential teratogens were prescribed, without a significant difference in improvement by CDS complexity (p = 0.87). Because CDS was not repeated, 13% of the times that PCPs received CDS they substituted another potential teratogen. PCPs reported significant improvements in several counseling and prescribing practices. The multifaceted group reported a greater increase in the number of times per month they discussed the risks of medication use during pregnancy (multifaceted: +4.9 ± 7.0 vs. simple: +0.8 ± 3.2, p = 0.03). The simple CDS system was associated with greater clinician satisfaction.

Conclusions: CDS systems hold promise for increasing provision of family planning services when fertile women are prescribed potentially teratogenic medications, but further refinement of these systems is needed.

Trial registration: ClinicalTrials.gov NCT00766207.

Figure 1

CONSORT flow diagram describing physician clusters and patient encounters from the time of recruitment to analysis. CDS indicates clinical decision support. ‘Encounter’ = visit made to a study PCP by a woman aged 18–50 years with no evidence of sterilization, menopause or infertility, whether or not a potential teratogen was prescribed.

Figure 2

Proportion of encounters with documented provision of family planning services at three study time points for three types of visits. ‘Encounter’ = visit made to a study PCP by a woman aged 18–50 years with no evidence of sterilization, menopause or infertility.