JMIR Publications

ABSTRACT

Background:

UCLA 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:

We evaluated whether 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 pressures in recent encounters, no active ACEI or ARB prescription, and no contraindications. We used a multivariate logistic regression model to compare the change in 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 ACEI or ARB prescription from before to after BPA implementation was significantly greater in BPA implementation sites compared to non-implementation sites (difference-in-differences of 11.82, P <.001).

Conclusions:

A BPA with a “chart closure” hard stop is a promising tool for getting patients with diabetes and hypertension treated 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.