Effect of a Default Order vs an Alert in the Electronic Health Record on Hepatitis C Virus Screening Among Hospitalized Patients

Mehta, Shivan J.; Torgersen, J; Small, Dylan S.; Mallozzi, Colleen P.; McGreevey, John D.; Rareshide, Charles A. L.; Evans, Chalanda N.; Epps, Mika; Stabile, David; Snider, Christopher K.; Patel, Mitesh S.

doi:10.1001/jamanetworkopen.2022.2427

Cited by 10 publications

(9 citation statements)

References 44 publications

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“…Guideline-recommended HCV screening should be implemented in clinical and community-based settings that serve racial and ethnic minority populations such as federally qualified health centers, sexually transmitted infection clinics, emergency departments, safety-net hospitals, correctional facilities, substance use disorder treatment programs, shelters for people experiencing homelessness, syringe service programs, and mobile testing vans (Box 2). Implementation of opt-out HCV testing combined with HIV testing in a Dallas County Jail in Texas was associated with an increase in the acceptance rate of testing from 12.9% (118/915) to 96.4% (3042/3155) .…”

Section: Discussionmentioning

confidence: 99%

“…Compared with White race, Black race was associated with 59% increased odds of being screened (9044/156 288 screened postalert vs 4612/141 955 screened prealert implementation compared with 8698/258 498 postalert vs 4371/217 342 prealert for White patients; aOR, 1.59 [95% CI, 1.53-1.64]) . In a stepped-wedge randomized clinical trial of people born between 1945 and 1965 (28% Black) who were hospitalized at 1 of 2 US academic centers in 2020-2021, a default order for HCV screening resulted in a 69.9% (2257/3229) screening rate compared with 38.1% (1679/4405) using an electronic prompt for HCV screening (OR, 3.18 [95% CI, 2.59-3.89]; P < .001) …”

Section: Discussionmentioning

confidence: 99%

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Hepatitis C in Black Individuals in the US

Falade-Nwulia,

Kelly,

Amanor-Boadu

et al. 2023

JAMA

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ImportanceIn the US, the prevalence of hepatitis C virus (HCV) is 1.8% among people who are Black and 0.8% among people who are not Black. Mortality rates due to HCV are 5.01/100 000 among people who are Black and 2.98/100 000 among people who are White.ObservationsWhile people of all races and ethnicities experienced increased rates of incident HCV between 2015 and 2021, Black individuals experienced the largest percentage increase of 0.3 to 1.4/100 000 (367%) compared with 1.8 to 2.7/100 000 among American Indian/Alaska Native (50%), 0.3 to 0.9/100 000 among Hispanic (200%), and 0.9 to 1.6/100 000 among White (78%) populations. Among 47 687 persons diagnosed with HCV in 2019-2020, including 37 877 (79%) covered by Medicaid (7666 Black and 24 374 White individuals), 23.5% of Black people and 23.7% of White people with Medicaid insurance initiated HCV treatment. Strategies to increase HCV screening include electronic health record prompts for universal HCV screening, which increased screening tests from 2052/month to 4169/month in an outpatient setting. Awareness of HCV status can be increased through point-of-care testing in community-based settings, which was associated with increased likelihood of receiving HCV test results compared with referral for testing off-site (69% on-site vs 19% off-site, P &lt; .001). Access to HCV care can be facilitated by patient navigation, in which an individual is assigned to work with a patient to help them access care and treatments; this was associated with greater likelihood of HCV care access (odds ratio, 3.7 [95% CI, 2.9-4.8]) and treatment initiation within 6 months (odds ratio, 3.2 [95% CI, 2.3-4.2]) in a public health system providing health care to individuals regardless of their insurance status or ability to pay compared with usual care. Eliminating Medicaid’s HCV treatment restrictions, including removal of a requirement for advanced fibrosis or a specialist prescriber, was associated with increased treatment rates from 2.4 persons per month to 72.3 persons per month in a retrospective study of 10 336 adults with HCV with no significant difference by race (526/1388 [37.8%] for Black vs 2706/8277 [32.6%] for White patients; adjusted odds ratio, 1.02 [95% CI, 0.8-1.3]).Conclusions and RelevanceIn the US, the prevalence of HCV is higher in people who are Black than in people who are not Black. Point-of-care HCV tests, patient navigation, electronic health record prompts, and unrestricted access to HCV treatment in community-based settings have potential to increase diagnosis and treatment of HCV and improve outcomes in people who are Black.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Hepatitis C in Black Individuals in the US

Falade-Nwulia,

Kelly,

Amanor-Boadu

et al. 2023

JAMA

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“…They are an attractive strategy to improve guideline adherence due to potential low costs and scalable deployments across institutions. Several CDS systems have been demonstrated in the management of chronic liver diseases, 16 including best practice advisory alerts and clinical dashboards for the treatment of chronic hepatitis B and C, 17 18 workflow support for metabolic dysfunction–associated steatotic liver disease (formerly nonalcoholic fatty liver disease), 19 and medication management. 20 21 Adoptions and implementations of CDS for cirrhosis management, especially inpatient management, have been limited.…”

Section: Introductionmentioning

confidence: 99%

Applying human-centered design to the construction of a cirrhosis management clinical decision support system

Ge,

Buenaventura,

Berrean

et al. 2024

Hepatology Communications

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Background: Electronic health record (EHR)-based clinical decision support is a scalable way to help standardize clinical care. Clinical decision support systems have not been extensively investigated in cirrhosis management. Human-centered design (HCD) is an approach that engages with potential users in intervention development. In this study, we applied HCD to design the features and interface for a clinical decision support system for cirrhosis management, called CirrhosisRx. Methods: We conducted technical feasibility assessments to construct a visual blueprint that outlines the basic features of the interface. We then convened collaborative-design workshops with generalist and specialist clinicians. We elicited current workflows for cirrhosis management, assessed gaps in existing EHR systems, evaluated potential features, and refined the design prototype for CirrhosisRx. At the conclusion of each workshop, we analyzed recordings and transcripts. Results: Workshop feedback showed that the aggregation of relevant clinical data into 6 cirrhosis decompensation domains (defined as common inpatient clinical scenarios) was the most important feature. Automatic inference of clinical events from EHR data, such as gastrointestinal bleeding from hemoglobin changes, was not accepted due to accuracy concerns. Visualizations for risk stratification scores were deemed not necessary. Lastly, the HCD co-design workshops allowed us to identify the target user population (generalists). Conclusions: This is one of the first applications of HCD to design the features and interface for an electronic intervention for cirrhosis management. The HCD process altered features, modified the design interface, and likely improved CirrhosisRx’s overall usability. The finalized design for CirrhosisRx proceeded to development and production and will be tested for effectiveness in a pragmatic randomized controlled trial. This work provides a model for the creation of other EHR-based interventions in hepatology care.

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“…Since 2016, a Pennsylvania law has mandated offering HCV screening to adults born between 1945 and 1965—the target of earlier HCV screening recommendations—in primary care and inpatient settings. To better adhere to Pennsylvania law and increase screening, Mehta et al conducted a stepped-wedge randomized clinical trial in 2 academic Pennsylvania hospitals; results are published elsewhere in JAMA Network Open .…”

mentioning

confidence: 99%

“…The default order was associated with increased ordering, testing, and HCV detection. However, the Pennsylvania law and the default intervention by Mehta et al raise questions about legislating medical practice and the application of defaults.…”

mentioning

confidence: 99%

Default Nudges in Medicine—Designing the Right Choice

Jia

Linder

2022

JAMA Netw Open

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Defaults work. With defaults, a designer or "choice architect" alters the environment and provides a preselected option. 1 An individual must take action to avoid the default occurring. Defaults might be described as making the right choice the easy choice. Although universal agreement on what constitutes "the right choice" is not necessary, defaults should target actions or events about which broad consensus exists. Defaults should preserve individual choice for the target of the action, enable those who do not want to take the action to easily opt out, and occur at a time and setting that make sense for the recipient and the action. Defaults should be transparent or risk being perceived as sneaky and eroding trust.Outside medicine, defaults have been used to increase organ donation, retirement plan enrollment, use of green energy, and healthy food selection. In medicine, defaults-notably those embedded in the electronic health record-have been used to increase vaccinations, increase generic drug prescribing, decrease opioid prescribing amounts, decrease unnecessary imaging, and increase cancer screening. 2What about a default to increase hepatitis C virus (HCV) screening? Hepatitis C virus infection is the leading cause of cirrhosis in the US. Owing to HCV's associated morbidity and mortality, the Centers for Disease Control and Prevention has made recommendations on HCV screening since 1998. The most recent expansion of screening guidelines in 2020 include 1-time HCV screening for all nonpregnant adults. Despite these recommendations, most eligible US residents have not been screened, and effective interventions to improve screening and treatment are needed. 3 To increase screening, some states have implemented laws on HCV screening. Since 2016, a Pennsylvania law has mandated offering HCV screening to adults born between 1945 and 1965-the target of earlier HCV screening recommendations-in primary care and inpatient settings. To better adhere to Pennsylvania law and increase screening, Mehta et al 4 conducted a stepped-wedge randomized clinical trial in 2 academic Pennsylvania hospitals; results are published elsewhere in JAMA Network Open.The intervention embedded a default HCV laboratory order within admission order sets. The order included text reminding clinicians of the state mandate and that positive results would be followed up by a dedicated hepatitis linkage team. The intervention was compared with a pop-up alert that included information about the state mandate and that positive test results would be analogously followed up by the hepatitis linkage team; clinicians were required, in 1 click, to either accept the laboratory order or dismiss the alert and order.With the pop-up alert comparison, HCV tests were ordered for 38.7% of admitted patients, and screening was completed for 34.9%. The default intervention increased laboratory ordering by 38.1 percentage points to 2599 of 3229 patients (80.5%); screening completion increased by 31.8 percentage points to 2257 of 3220 patients (69.9%). The intervent...

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Effect of a Default Order vs an Alert in the Electronic Health Record on Hepatitis C Virus Screening Among Hospitalized Patients

Cited by 10 publications

References 44 publications

Hepatitis C in Black Individuals in the US

Hepatitis C in Black Individuals in the US

Applying human-centered design to the construction of a cirrhosis management clinical decision support system

Default Nudges in Medicine—Designing the Right Choice

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