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104. Response to Letter to the Editor, regarding: Observation units as substitutes for hospitalization or home discharge

Author

Blecker, Saul, Gavin, Nicholas P., Ladapo, Joseph A., and Katz, Stuart D.

Subjects
Male, Chest Pain, Surveys and Questionnaires, Critical Pathways, Humans, Female, Middle Aged, Models, Theoretical, Emergency Service, Hospital, Hospital Units, Article, Patient Discharge, United States
Abstract

Observation unit admissions have been increasing, a trend that will likely continue because of recent changes in reimbursement policies. The purpose of this study is to determine the effect of the availability of observation units on hospitalizations and discharges to home for emergency department (ED) patients.We studied ED visits with a final diagnosis of chest pain in the National Hospital Ambulatory Medical Care Survey from 2007 to 2010. ED visits that resulted in an observation unit admission were propensity-score matched to visits at hospitals without an observation unit. We used logistic regression to develop a prediction model for hospitalization versus discharge home for matched patients treated at nonobservation hospitals. The model was applied to matched observation unit patients to determine the likely alternative disposition had the observation unit not been available.There were 1,325 eligible visits that represented 5,079,154 visits in the United States. Two hundred twenty-seven visits resulted in an observation unit admission. The predictive model for hospitalization had a c statistic of 0.91; variables significantly associated with subsequent hospitalization included age, history of coronary atherosclerosis, systolic blood pressure less than 115 beats/min, and administration of antianginal medications. When the model was applied to matched observation unit patients, 49.9% of them were categorized as discharge home likely.In this study, we estimated that half of ED visits for chest pain that resulted in an observation unit admission were made by patients who may have been discharged home had the observation unit not been available. Increased availability of observation units may result in both decreased hospitalizations and decreased discharges to home.

Published
2016

105. Changes in discharge location and readmission rates under bundled payment

Author

Jubelt, Lindsay E., Goldfeld, Keith S., Chung, Wei-yi, Blecker, Saul B., and Horwitz, Leora I.

Subjects
Heart Valve Prosthesis Implantation, Male, Medicare, Home Care Services, Patient Readmission, Rehabilitation Centers, Article, Hospitals, Patient Discharge, Hospitalization, Reimbursement Mechanisms, Spinal Fusion, Humans, Female, Arthroplasty, Replacement, Health Expenditures
Published
2016

109. Revascularization in patients with multivessel coronary artery disease and chronic kidney disease everolimus-eluting stents versus coronary artery bypass graft surgery

Author

Xu, Jinfeng, Bangalore, Sripal, Guo, Yu, Samadashvili, Zaza, Blecker, Saul, and Hannan, Edward L.

Subjects
surgical procedures, operative, percutaneous coronary intervention, cardiovascular diseases, chronic kidney disease, multivessel disease
Abstract

© 2015 American College of Cardiology Foundation. Background Randomized trials of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) routinely exclude patients with chronic kidney disease (CKD). Objectives This study evaluated outcomes of PCI versus CABG in patients with CKD. Methods Patients with CKD who underwent PCI using everolimus-eluting stents were propensity-score matched to patients who underwent isolated CABG for multivessel coronary disease in New York. The primary outcome was all-cause mortality. Secondary outcomes were myocardial infarction (MI), stroke, and repeat revascularization. Results Of 11,305 patients with CKD, 5,920 patients were propensity-score matched. In the short term, PCI was associated with a lower risk of death (hazard ratio [HR]: 0.55; 95% confidence interval [CI]: 0.35 to 0.87), stroke (HR: 0.22; 95% CI: 0.12 to 0.42), and repeat revascularization (HR: 0.48; 95% CI: 0.23 to 0.98) compared with CABG. In the longer term, PCI was associated with a similar risk of death (HR: 1.07; 95% CI: 0.92 to 1.24), higher risk of MI (HR: 1.76; 95% CI: 1.40 to 2.23), a lower risk of stroke (HR: 0.56; 95% CI: 0.41 to 0.76), and a higher risk of repeat revascularization (HR: 2.42; 95% CI: 2.05 to 2.85). In the subgroup with complete revascularization with PCI, the increased risk of MI was no longer statistically significant (HR: 1.18; 95% CI: 0.67 to 2.09). In the 243 matched pairs of patients with end-stage renal disease on hemodialysis, PCI was associated with significantly higher risk of death (HR: 2.02; 95% CI: 1.40 to 2.93) and repeat revascularization (HR: 2.44; 95% CI: 1.50 to 3.96) compared with CABG. Conclusions In patients with CKD, CABG is associated with higher short-term risk of death, stroke, and repeat revascularization, whereas PCI with everolimus-eluting stents is associated with a higher long-term risk of repeat revascularization and perhaps MI, with no long-term mortality difference. In the subgroup on dialysis, the results favored CABG over PCI., Link_to_subscribed_fulltext

Published
2015

110. Electronic health record utilization, intensity of hospital care, and patient outcomes

Author

Blecker, Saul, Goldfeld, Keith, Park, Naeun, Shine, Daniel, Austrian, Jonathan S., Braithwaite, R. Scott, Radford, Martha J., and Gourevitch, Marc N.

Subjects
Adult, Male, Academic Medical Centers, New York, Confounding Factors, Epidemiologic, Length of Stay, Middle Aged, Article, Cohort Studies, Hospitalization, Outcome and Process Assessment, Health Care, Odds Ratio, Electronic Health Records, Humans, Regression Analysis, Female, Health Services Research, Hospital Mortality, Aged
Abstract

Previous studies have suggested that weekend hospital care is inferior to weekday care and that this difference may be related to diminished care intensity. The purpose of this study was to determine whether a metric for measuring intensity of hospital care based on use of the electronic health record was associated with patient-level outcomes.We performed a cohort study of hospitalizations at an academic medical center. Intensity of care was defined as the hourly number of provider accessions of the electronic health record, termed "electronic health record interactions." Hospitalizations were categorized on the basis of the mean difference in electronic health record interactions between the first Friday and the first Saturday of hospitalization. We used regression models to determine the association of these categories with patient outcomes after adjusting for covariates.Electronic health record interactions decreased from Friday to Saturday in 77% of the 9051 hospitalizations included in the study. Compared with hospitalizations with no change in Friday to Saturday electronic health record interactions, the relative lengths of stay for hospitalizations with a small, moderate, and large decrease in electronic health record interactions were 1.05 (95% confidence interval [CI], 1.00-1.10), 1.11 (95% CI, 1.05-1.17), and 1.25 (95% CI, 1.15-1.35), respectively. Although a large decrease in electronic health record interactions was associated with in-hospital mortality, these findings were not significant after risk adjustment (odds ratio 1.74, 95% CI, 0.93-3.25).Intensity of inpatient care, measured by electronic health record interactions, significantly diminished from Friday to Saturday, and this decrease was associated with length of stay. Hospitals should consider monitoring and correcting temporal fluctuations in care intensity.

Published
2013

114. In reply

Author

Blecker, Saul, primary, Katz, Stuart D., additional, Ladapo, Joseph A., additional, and Gavin, Nicholas P., additional

Published
2016
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119. Impact of an emergency department electronic sepsis surveillance system on patient mortality and length of stay.

Author

Austrian, Jonathan S., Jamin, Catherine T., Doty, Glenn R., and Blecker, Saul

Abstract

Objective: The purpose of this study was to determine whether an electronic health record-based sepsis alert system could improve quality of care and clinical outcomes for patients with sepsis.Materials and Methods: We performed a patient-level interrupted time series study of emergency department patients with severe sepsis or septic shock between January 2013 and April 2015. The intervention, introduced in February 2014, was a system of interruptive sepsis alerts triggered by abnormal vital signs or laboratory results. Primary outcomes were length of stay (LOS) and in-hospital mortality; other outcomes included time to first lactate and blood cultures prior to antibiotics. We also assessed sensitivity, positive predictive value (PPV), and clinician response to the alerts.Results: Mean LOS for patients with sepsis decreased from 10.1 to 8.6 days (P < .001) following alert introduction. In adjusted time series analysis, the intervention was associated with a decreased LOS of 16% (95% CI, 5%-25%; P = .007, with significance of α = 0.006) and no change thereafter (0%; 95% CI, -2%, 2%). The sepsis alert system had no effect on mortality or other clinical or process measures. The intervention had a sensitivity of 80.4% and a PPV of 14.6%.Discussion: Alerting based on simple laboratory and vital sign criteria was insufficient to improve sepsis outcomes. Alert fatigue due to the low PPV is likely the primary contributor to these results.Conclusion: A more sophisticated algorithm for sepsis identification is needed to improve outcomes. [ABSTRACT FROM AUTHOR]

Published
2018
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126. Airflow Obstruction, Lung Function, and Incidence of Atrial Fibrillation

Author

Li, Jingjing, primary, Agarwal, Sunil K., additional, Alonso, Alvaro, additional, Blecker, Saul, additional, Chamberlain, Alanna M., additional, London, Stephanie J., additional, Loehr, Laura R., additional, McNeill, Ann Marie, additional, Poole, Charles, additional, Soliman, Elsayed Z., additional, and Heiss, Gerardo, additional

Published
2014
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132. Abstract P108: Association of Forced Expiratory Volume (1 Second) with Incidence of Atrial Fibrillation: The Atherosclerosis Risk in Communities (ARIC) Study

Author

Li, Jingjing, primary, Agarwal, Sunil K, additional, Alonso, Alvaro, additional, Blecker, Saul, additional, Chamberlain, Alanna M, additional, Enright, Paul L, additional, Loehr, Laura R, additional, McNeill, Anne M, additional, Poole, Charles, additional, Soliman, Elsayed Z, additional, and Heiss, Gerardo, additional

Published
2012
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133. Impact of Visit Volume on the Effectiveness of Electronic Tools to Improve Heart Failure Care

Author

Mukhopadhyay, Amrita, Reynolds, Harmony R., King, William C., Phillips, Lawrence M., Nagler, Arielle R., Szerencsy, Adam, Saxena, Archana, Klapheke, Nathan, Katz, Stuart D., Horwitz, Leora I., and Blecker, Saul

Abstract

Electronic health record (EHR) tools can improve prescribing of guideline-recommended therapies for heart failure with reduced ejection fraction (HFrEF), but their effectiveness may vary by physician workload.

Published
2023
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138. Abstract 11295: Design and Rationale for the BETTER CARE-HF Trial: A Pragmatic Cluster-Randomized Controlled Trial Comparing Two Targeted Approaches to Ambulatory Clinical Decision Support for Cardiologists

Author

Mukhopadhyay, Amrita, Reynolds, Harmony, Xia, Yuhe, Phillips, Lawrence M, Aminian, Rod, Diah, Ruth-Ann, Nagler, Arielle, Szerencsy, Adam, Saxena, Archana, Horwitz, Leora, Katz, Stuart D, and Blecker, Saul

Abstract

Introduction:Heart failure with reduced ejection fraction (HFrEF) is a leading cause of morbidity and mortality. However, shortfalls in prescribing of proven therapies, particularly mineralocorticoid receptor antagonist (MRA) therapy, account for several thousand preventable deaths per year nationwide. Electronic clinical decision support (CDS) is a potential low-cost and scalable solution to improve prescribing of therapies. However, the optimal timing and format of CDS tools is unknown. We developed two CDS tools to inform cardiologists of gaps in MRA therapy for patients with HFrEF and without contraindication to MRA therapy: 1) a best practice alert (BPA) that notifies cardiologists at the time of patient visit, and 2) an automated in-basket message that allows for review between visits (Figure).Objective:The BETTER CARE-HF (Building Electronic Tools to Enhance and Reinforce CArdiovascular REcommendations for Heart Failure) trial aims to compare the effectiveness of a BPA vs. in-basket message vs. usual care on the primary outcome of MRA prescribing.Methods:This is a pragmatic, cluster-randomized, three-arm intervention trial. Patients are randomized as a cluster at the level of their cardiologist in a 1:1:1 fashion (180 cardiologists included). The primary outcome is MRA prescription at the end of the study period, and secondary outcomes include prescribing of other GDMT, time to prescription, and provider-level changes in prescribing rates. We will require a total of 1,503 patients (501 per arm) to detect 10% improvement in prescribing with 80% power, and estimate a trial duration of 6 months.Implications:To our knowledge, no study has directly compared the efficacy of a BPA vs. in-basket message. If effective, our findings can be rapidly disseminated to improve morbidity and mortality for patients with HFrEF, and can also inform the development of future CDS interventions for other disease states.Trial registration:NCT05275920

Published
2022
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139. Abstract 10401: Development and Pilot Implementation of Two Targeted Approaches to Ambulatory Clinical Decision Support for Cardiologists to Optimize Medical Therapy for Heart Failure

Author

Mukhopadhyay, Amrita, Reynolds, Harmony, Xia, Yuhe, Phillips, Lawrence M, Aminian, Rod, Diah, Ruth-Ann, Nagler, Arielle, Szerencsy, Adam, Saxena, Archana, Horwitz, Leora, Katz, Stuart D, and Blecker, Saul

Abstract

Introduction:Shortfalls in prescribing of proven therapies for patients with heart failure and reduced ejection fraction (HFrEF), particularly for mineralocorticoid receptor antagonists (MRA), account for several thousand preventable deaths per year nationwide. Electronic clinical decision support (CDS) is a potential low-cost and scalable solution to improve prescribing, but optimal timing and format of CDS tools are unknown.Objective:We developed two CDS interventions to inform cardiologists of gaps in MRA therapy for patients with HFrEF and without contraindication to MRA therapy: 1) a best practice alert (BPA) that notifies cardiologists at the time of patient visit, and 2) an automated in-basket message that allows for review between visits.Methods:We designed CDS tools using an established CDS framework and findings from semi-structured interviews with cardiologists. We then pilot-tested both CDS tools at two cardiology practices for 12 weeks in a cross-over design, and further enhanced them based on additional semi-structured interviews.Results:Based on pilot testing (n=596 patients) and semi-structured interviews (n=11 cardiologists), in-basket messages were modified to reduce the number of patients listed, include future visits, and list date of next visit. The BPA was modified to improve noticeability, reduce extraneous information on guidelines, and include key information on contraindications. Final CDS interventions after incorporation of feedback are depicted in the Figure.Conclusions:Pilot testing and semi-structured interviews were instrumental in the development of CDS interventions and should be employed for other similar studies. We will compare the effectiveness of the BPA vs the in-basket message vs usual care on the primary outcome of MRA prescribing in The BETTER CARE-HF trial (Building Electronic Tools to Enhance and Reinforce CArdiovascular REcommendations for Heart Failure) (Clinicaltrials.gov NCT05275920)

Published
2022
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144. Understanding provider use of a new clinical decision support tool aimed at reducing excess telemetry in an academic health system: A retrospective study.

Author

Hatley, Maya, Korostoff‐Larsson, Olivia, Malik, Tahir, Blecker, Saul, and Eaton, Kevin P.

Subjects
*MEDICAL care use, *ACADEMIC medical centers, *CORONARY care units, *CLINICAL decision support systems, *RETROSPECTIVE studies, *BEHAVIOR, *BIOTELEMETRY, *MEDICAL records, *ACQUISITION of data, *PHYSICIAN practice patterns, *CONFIDENCE intervals, *STROKE, *PHYSICIANS, *PATIENT monitoring, *TIME
Abstract

Rationale: Cardiac monitoring has often been identified as an area of overutilization and remains a limited resource in many hospitals. With the aim of reducing telemetry overuse, we added clinical decision support to our health system's telemetry order with guidance on appropriate indications for monitoring. The new order requires selection of an appropriate clinical indication. Aims and Objectives: In this study, we aimed to understand provider engagement with this tool by assessing concordance between selected indications within the order and the clinical presence of those conditions as documented within the patient chart. Methods: We randomly selected 100 telemetry orders from July to October 2022 across four different hospitals at NYU Langone Health. Two independent, blinded reviewers used a structured protocol to identify documentation of actual indications for telemetry in each selected chart. We calculated the rate of concordance between indications selected in the order and indications that were determined to be clinically present on chart review. Results: There were 30,839 telemetry orders placed during the study timeframe. Overall concordance between the selection within the order and the actual indication was 48% (95% confidence interval [CI], 38.21%−57.79%). We observed especially low concordance rates for vague indications, such as 'Other', and for 'Confirmed Stroke', which was the only indication allowing for indefinite telemetry. Conclusion: The overall low concordance suggests a disconnect between the support tool and clinical practice. Providers are more likely to select an indication that reduces downstream work regardless of a patient's true clinical indication. [ABSTRACT FROM AUTHOR]

Published
2024
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145. Prescription Patterns for Sodium-Glucose Cotransporter 2 Inhibitors in U.S. Health Systems.

Author

Shin, Jung-Im, Xu, Yunwen, Chang, Alexander R., Carrero, Juan J., Flaherty, Carina M., Mukhopadhyay, Amrita, Inker, Lesley A., Blecker, Saul B., Horwitz, Leora I., and Grams, Morgan E.

Subjects
*SODIUM-glucose cotransporter 2 inhibitors, *PEOPLE with diabetes, *TYPE 2 diabetes, *CHRONIC kidney failure, *BUSINESS insurance
Abstract

Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce heart failure (HF) hospitalizations, recurrent cardiovascular events, and chronic kidney disease (CKD) progression, and thus constitute a Class 1a recommendation in people with diabetes and atherosclerotic cardiovascular disease, HF, or CKD and in people with severe albuminuria or HF, regardless of diabetes status. The purpose of this study was to comprehensibly characterize the rate of SGLT2 inhibitor prescriptions among people with a Class 1a recommendation for SGLT2 inhibitor use. Among 3,189,827 adults from 28 U.S. health systems within Optum Labs Data Warehouse between April 1, 2022, and March 31, 2023, we assessed SGLT2 inhibitor prescription rates, stratified by presence of diabetes and Class 1a recommendation. Among 716,387 adults with diabetes, 63.4% had a Class 1a recommendation for SGLT2 inhibitor therapy. There was little difference by Class 1a recommendation status (present: 11.9%; 95% CI: 11.9%-12.0% vs absent: 11.4%; 95% CI: 11.3%-11.6%; standardized mean difference: 1.3%). Among 2,473,440 adults without diabetes, 6.2% had a Class 1a recommendation for SGLT2 inhibitor therapy, and 3.1% (3.0%-3.2%) of those received a prescription. Internists/family practitioners initiated SGLT2 inhibitor prescriptions most commonly among people with diabetes, whereas specialists initiated SGLT2 inhibitor prescriptions most commonly among people without diabetes. No health system had >25% SGLT2 inhibitor prescription rate among people with a Class 1a recommendation. Health systems with higher proportions of patients with commercial insurance and lower proportions with Medicare had higher SGLT2 inhibitor prescription rates. In this analysis of U.S. data from 2022 to 2023, SGLT2 inhibitor prescription among people with a Class 1a recommendation is low. Interventions are needed to increase uptake of guideline-recommended SGLT2 inhibitor use. [ABSTRACT FROM AUTHOR]

Published
2024
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146. Decline in use of high‐risk agents for tight glucose control among older adults with diabetes in New York City: 2017–2022.

Author

Zhang, Jeff, Kanchi, Rania, Conderino, Sarah, Levy, Natalie K., Adhikari, Samrachana, Blecker, Saul, Davis, Nichola, Divers, Jasmin, Rabin, Catherine, Weiner, Mark, Thorpe, Lorna, and Dodson, John A.

Subjects
*OLDER people, *GLYCEMIC control, *TYPE 2 diabetes diagnosis, *TYPE 2 diabetes, *MYOCARDIAL infarction
Abstract

Background Methods Results Conclusions This study aimed to examine the prevalence of inappropriate tight glycemic control in older adults with type 2 diabetes and other chronic conditions in New York City, and to identify factors associated with this practice.We conducted a retrospective cohort study using the INSIGHT Clinical Research Network. The study population included 11,728 and 15,196 older adults in New York City (age ≥ 75 years) with a diagnosis of type 2 diabetes, and at least one other chronic medical condition, in 2017 and 2022, respectively. The main outcome of interest was inappropriate tight glycemic control, defined as HbA1c <7.0% (<53 mmol/mol) with prescription of at least one high‐risk agent (insulin or insulin secretagogue).The proportion of older adults with inappropriate tight glycemic control decreased by nearly 19% over a five‐year period (19.4% in 2017 to 15.8% in 2022). There was a significant decrease in insulin (27.8% in 2017; 24.3% in 2022) and sulfonylurea (29.4% in 2017; 21.7% in 2022) medication prescription, and increase in use of GLP‐1 agonists (1.8% in 2017; 11.4% in 2022) and SGLT‐2 inhibitors (5.8% in 2017; 25.1% in 2022), among the total population. Factors associated with inappropriate tight glycemic control in 2022 included history of heart failure (adjusted odds ratio [aOR] 1.38), chronic kidney disease ([aOR] 1.93), colorectal cancer ([aOR] 1.38), acute myocardial infarction ([aOR] 1.28), “other” ([aOR] 0.72) or “unknown” ([aOR] 0.72) race, and a point increase in BMI ([aOR] 0.98).We found an encouraging trend toward less use of high‐risk medication strategies for older adults with type 2 diabetes and multiple chronic conditions. However, one in six patients in 2022 still had inappropriate tight glycemic control, indicating a need for continued efforts to optimize diabetes management in this population. [ABSTRACT FROM AUTHOR]

Published
2024
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147. Revascularization in Patients With Multivessel Coronary Artery Disease and Chronic Kidney Disease Everolimus-Eluting Stents Versus Coronary Artery Bypass Graft Surgery

Author

Bangalore, Sripal, Guo, Yu, Samadashvili, Zaza, Blecker, Saul, Xu, Jinfeng, and Hannan, Edward L.

Subjects
surgical procedures, operative, percutaneous coronary intervention, cardiovascular diseases, chronic kidney disease, multivessel disease
Abstract

BackgroundRandomized trials of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) routinely exclude patients with chronic kidney disease (CKD).ObjectivesThis study evaluated outcomes of PCI versus CABG in patients with CKD.MethodsPatients with CKD who underwent PCI using everolimus-eluting stents were propensity-score matched to patients who underwent isolated CABG for multivessel coronary disease in New York. The primary outcome was all-cause mortality. Secondary outcomes were myocardial infarction (MI), stroke, and repeat revascularization.ResultsOf 11,305 patients with CKD, 5,920 patients were propensity-score matched. In the short term, PCI was associated with a lower risk of death (hazard ratio [HR]: 0.55; 95% confidence interval [CI]: 0.35 to 0.87), stroke (HR: 0.22; 95% CI: 0.12 to 0.42), and repeat revascularization (HR: 0.48; 95% CI: 0.23 to 0.98) compared with CABG. In the longer term, PCI was associated with a similar risk of death (HR: 1.07; 95% CI: 0.92 to 1.24), higher risk of MI (HR: 1.76; 95% CI: 1.40 to 2.23), a lower risk of stroke (HR: 0.56; 95% CI: 0.41 to 0.76), and a higher risk of repeat revascularization (HR: 2.42; 95% CI: 2.05 to 2.85). In the subgroup with complete revascularization with PCI, the increased risk of MI was no longer statistically significant (HR: 1.18; 95% CI: 0.67 to 2.09). In the 243 matched pairs of patients with end-stage renal disease on hemodialysis, PCI was associated with significantly higher risk of death (HR: 2.02; 95% CI: 1.40 to 2.93) and repeat revascularization (HR: 2.44; 95% CI: 1.50 to 3.96) compared with CABG.ConclusionsIn patients with CKD, CABG is associated with higher short-term risk of death, stroke, and repeat revascularization, whereas PCI with everolimus-eluting stents is associated with a higher long-term risk of repeat revascularization and perhaps MI, with no long-term mortality difference. In the subgroup on dialysis, the results favored CABG over PCI.

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148. Advanced Heart Failure Epidemiology and Outcomes: A Population-Based Study

Author

Dunlay, Shannon M., Roger, Véronique L., Killian, Jill M., Weston, Susan A., Schulte, Philip J., Subramaniam, Anna V., Blecker, Saul B., and Redfield, Margaret M.

Abstract

Some patients with heart failure (HF) progress to advanced HF, characterized by debilitating HF symptoms refractory to therapy. There are limited data on the epidemiology and outcomes of patients with advanced HF.

Published
2021
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149. Abstract 9677: Interrupting Providers With Clinical Decision Support to Improve Heart Failure Care

Author

Blecker, Saul, Austrian, Jonathan, Horwitz, Leora, Shelley, Donna, and Katz, Stuart

Abstract

Background:Evidence-based therapy for heart failure remains underutilized at hospital discharge, particularly for patients with a secondary diagnosis of heart failure. We developed a clinical decision support (CDS) tool to recommend an ACE inhibitor during hospitalization. The CDS was designed to be implemented in both interruptive and non-interruptive versions. The purpose of this study was to compare the effectiveness of the two CDS implementation approaches.Methods:We implemented CDS recommending prescribing an ACE inhibitor for patients with an ejection fraction?40% and no contraindications to therapy. Hospitalizations were pseudo-randomized to the interruptive (pop-up) and non-interruptive (passive checklist) version of the CDS based on even or odd medical record number. We compared discharge prescription of an ACE inhibitor or ARB for these two implementation approaches. We also assessed adoption and implementation fidelity of the CDS.Results:Hospitalizations eligible for the interruptive alert (n=465) had higher rates of ACE inhibitor or ARB use than hospitalizations eligible for the non-interruptive alert (n=493), with rates of 79.6% vs. 74.2%, respectively (p=0.05). ACE inhibitor or ARB prescriptions were higher for patients eligible for the interruptive versus non-interruptive alert among hospitalizations with a secondary diagnosis of heart failure (79.8% vs. 73.4%; p=0.05) but not among those with a principal heart failure diagnosis (p=0.49). As compared to hospitalizations receiving the non-interruptive CDS, those receiving the interruptive alert were more likely to have had: at least one alert that was not dismissed (40.6% vs. 13.1%, p<0.001), contraindications reported (33.1% vs 11.3%, p<0.001), and an inpatient ACE inhibitor ordered within 12 hours of the alert (17.6% vs 10.3%, p<0.01). The response rate for the interruptive alert was 1.7%, and a median (25th, 75thpercentile) of 14 (5,32) alerts were triggered per hospitalization.Conclusions:A CDS implemented as an interruptive alert was associated with improved quality of care for heart failure as compared to the CDS implemented as a passive alert. Whether the comparative benefit was worth the high burden of interruptive alerts deserves further consideration.

Published
2019
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150. Quality of Care for Heart Failure Patients Hospitalized for Any Cause

Author

Coresh, Josef, Blecker, Saul, Chang, Patricia P., Agarwal, Sunil K., Rosamond, Wayne D., Radford, Martha J., Katz, Stuart, Kucharska-Newton, Anna, and Casey, Donald E.

Subjects
3. Good health
Abstract

The study sought to assess the quality of care for heart failure patients who are hospitalized for all causes.

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