Study: Electronic alerts reduce unnecessary blood testing in elderly

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An electronic message sent to physicians the moment they ordered a blood test for elderly patients reduced unnecessary use of deep-vein thrombosis (DVT) and pulmonary embolism testing that commonly produce false-positive results for the elderly, according to a paper published in the November edition of American Journal of Managed Care.

The D-dimer test, combined with a clinical risking algorithm, can help in the diagnosis of DVT and pulmonary embolism. The risk of developing a blood clot in the venous circulation increases with age, yet the overall accuracy of the D-dimer test worsens as patients get older, and is only 35 percent accurate for patients aged 65 and over, according to lead author Ted E. Palen, MD, PhD, a clinician researcher at Kaiser Permanente’s Institute for Health Research in Denver, and colleagues. “This can result in numerous false-positives and additional, unnecessary testing.”

The study looked at the effectiveness of an electronic alert for a specific condition in a specific patient population. The randomized trial of 223,877 patient visits for patients aged 65 and over, and 564,264 patient visits for patients under 65 years of age, was implemented in eight primary care clinics within the Kaiser Permanente Healthcare System in Colorado; each with at least 3,000 patients aged 65 years or older.

Physicians received an alert in Kaiser Permanente’s HealthConnect EHR when ordering a D-dimer test for patients aged 65 and older. The alert explained the inaccuracy of the test for this age group and suggested using a radiological test as appropriate.

As a result, the researchers found the rate of D-dimer tests for patients over 65 decreased significantly from 5.02 to 1.52 per 1,000 patient visits, a relative reduction of D-dimer orders of 69.7 percent. This decrease was maintained throughout the study period, and the result was similar when the control group later received the alert, according to the authors.

The results indicated that computerized alerts containing alternative diagnostic or treatment strategies to direct clinicians toward more appropriate alternative diagnostic strategies can be more effective in practice than simply providing “negative guidance.”

“Physicians sometimes find it hard to remember to follow evidence-based clinical practice guidelines. Many people have suggested that computer-generated alerts within EMRs may serve as reminders to improve adherence to best practices,” wrote Palen. “However, too many alerts produce alert fatigue, where receiving too many alerts becomes frustrating, leading to ignoring or overriding the messages.”

“Delivering a targeted electronic message for a particular patient profile can result not only in better use of the test in question, it can alter a physician’s ordering behavior and promote improved adherence to a clinical practice guideline,” Palen concluded. “As the healthcare industry moves to widely adopt EMR technology, it is critical that physicians and other caregivers are given specific and relevant data at the point of care to avoid alert fatigue.”