The effect of a computerized best practice alert system in an outpatient setting on metabolic monitoring in patients on second‐generation antipsychotics

Abstract

What is known and objective Metabolic syndrome is a well‐documented adverse effect of second‐generation antipsychotics (SGAs). Patients with metabolic syndrome are at an increased risk of potentially fatal cardiovascular events, including myocardial infarction and stroke. This elevated risk prompted the creation of a national guideline on metabolic monitoring for patients on SGAs in 2004. However, monitoring practices remained low at our clinic. To address this concern, a clinical decision support system was developed to alert providers of monitoring requirements. The purpose of this study is to determine the effect of the best practice alert (BPA), and to assess the impact of provider and patient characteristics on metabolic laboratory (lab) order rates. Methods A retrospective chart review was conducted at a large outpatient psychiatric clinic. Data were collected from all adult patients who were prescribed an SGA and triggered the BPA (indicating lab monitoring is needed for the patient). Data collection included a variety of patient, provider and alert variables. The primary outcome was a composite of fasting blood glucose (FBG), haemoglobin A1c (HbA1c) and/or fasting lipid panel order rates. Secondary outcomes included the rate of valid response, which considered appropriate reasons for not ordering labs (ie monitoring already completed during recent primary care visit), as well as order rates of individual labs. Results and Discussion Data from 1112 patients were collected and analysed. Patients with a thought disorder diagnosis had significantly more labs ordered than those without. No other patient factors affected order rates. Resident psychiatrists and nurse practitioners ordered significantly more labs and had significantly more valid responses than attending psychiatrists. An active alert, which fired during medication order entry, was associated with a higher rate of lab ordering and valid response compared to a passive alert, which fired whenever a prescribing healthcare provider opened the chart. What is new and conclusion Prescribers may associate metabolic syndrome with schizophrenia or with use of SGAs specifically in thought disorders, even though these medications pose a risk for all indications. Higher rates of monitoring by resident physicians may have been due to spending more time with patients during the encounter and in documentation. Lastly, the active BPA was an effective tool to increase metabolic monitoring in patients taking SGAs. Continued education on the importance of regular metabolic monitoring should be implemented for all providers.

Mixed-methods Evaluation of an Expedited Partner Therapy Take-home Medication Program: Pilot Emergency Department Intervention to Improve Sexual Health Equity

“…This study adds to the growing research on clinician acceptability 32 of using BPAs to improve patient care. [33][34][35][36][37][38] A study from an urban ED including 75,901 patients demonstrated that a targeted BPA increased syphilis screening by 124% compared to clinician-initiated testing. 39 However, BPAs are known to contribute to alarm fatigue 40 and must be designed to minimize inappropriate interruptions.…”

Establishing a Care Continuum for Cardiometabolic Conditions for Patients with Serious Mental Illness

“…One benefit of these decision support systems is that they can be implemented within any specialty (e.g., internal medicine, psychiatry), modified according to relevant populations, and used in combination with other interventions, such as team-based care models [ 80 ]. Best practice alerts in other settings have been shown to improve laboratory-based metabolic monitoring while a patient is prescribed antipsychotic medication [ 82 , 83 ]. However, studies note that clinicians may override alerts due to fatigue from overuse of alerts or having alerts that are not well targeted to specific patients [ 84 ].…”

Treatment pearls

“…19 With the majority of healthcare moving to the electronic medical record (EMR), practice alert systems may lead to improvement in the ordering of metabolic monitoring. 20 For example, for patients taking an SGA, the EMR could send an alert to the provider with the recommended screenings for that particular visit. These alerts could be set to follow the monitoring standards discussed earlier for patients taking SGAs.…”