Impact of a "Chart Closure" Hard Stop Alert on Prescribing for Elevated Blood Pressures Among Patients With Diabetes: Quasi-Experimental Study

Abstract

Background: 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.

Objective: 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.

Methods: 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.

Results: 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).

Conclusions: 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.

Keywords: decision support systems, clinical; diabetes mellitus; drug prescriptions; hypertension.

Figure 1

A “chart closure” hard stop prevents primary care providers from closing a patient’s chart without acting on the Best Practice Advisory alert.

Figure 2

The Best Practice Advisory prompts primary care providers to order an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker or to dismiss the alert by clicking an acknowledge reason. Home BP at goal: Home blood pressure at goal; Pursuing non-Rx treatment: pursuing nonprescription treatment; Will Schedule w PCP: will schedule with primary care provider.

Figure 3

Best Practice Advisory implementation at 30 University of California at Los Angeles Health primary care sites over a 15-month rollout period. The period of interest for this study is from January 2014 to December 2016. BPA: Best Practice Advisory.

Figure 4

Before and after study periods in the difference-in-differences analysis for the 30 primary care sites that implemented the Best Practice Advisory and the 31 primary care sites that did not implement the Best Practice Advisory. BPA: Best Practice Advisory.

Figure 5

Proportion of opportunity encounters with an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker prescription in Best Practice Advisory implementation and nonimplementation sites throughout the study period. ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin-receptor blocker; BPA: Best Practice Advisory.