- Patients whose doctors use computerized alerts to notify them when their care instructions stray from evidence-based guidelines have fewer complications, shorter hospital stays, lower rates of readmission and lower costs, a new study in The American Journal of Managed Care finds.
- Researchers at Cedars-Sinai Health System in Los Angeles analyzed 26,424 inpatient visits to see how outcomes and costs varied when doctors did or did not use automated alerts based on the Choosing Wisely guidance. An alert was triggered if, for instance, a doctor ordered a sedative for a sleepless older patient, which could put them at risk of falls.
- When doctors didn't follow alerts, their patients’ odds of complications rose by 29% and their odds of readmission increased by 14%. Those patients also experienced a 6.2% longer length of stay and 7.3% higher costs — or $944 — after adjusting for severity of illness and case complexity, the study says.
This is the first assessment of the link between adherence to multiple Choosing Wisely guidelines delivered via clinical decision support software and impact on clinical outcomes and cost. Choosing Wisely is an ABIM Foundation campaign that was launched in 2012 to enhance clinical communications between physicians and patients with evidence-supported care.
The researchers point to several limitations in the study, including its strict definition of alert compliance, which excluded visits where doctors followed some but not all of the alerts. In addition, the study doesn’t gauge the impact of specific alerts on costs and outcomes to see if some are more effective than others.
Still, they say the results are statistically and financially significant. “Our findings contribute to the evidence base surrounding the use of CDS and improvements in patient clinical and financial outcomes,” the authors wrote. “Formal prospective cohort studies and randomized CDS intervention trials, perhaps randomizing providers assigned to receive CDS interventions, should be prioritized to help guide future provider strategies in regard to reducing low-value care.”
The study shows that clinical alerts can be a valuable tool in improving patient care, if they are followed regularly. Unfortunately, that’s not always the case. Alert fatigue is a major issue for doctors and hospital support staff, and one that contributes to medical errors. In a national survey, 19 out of 20 hospitals called alert fatigue their chief patient safety concern.
A study by The Doctors Company found that user error, such as data entry mistakes and alert fatigue, played a role in 58% of EHR-related malpractice claims. But the study also cited system failures such as alerts and alarms that failed to sound.
Hospital administrators also need to do a better job of convincing clinicians of the importance of alerts and other CDS tools in clinical care. In a study in the Journal of the American Medical Informatics Association, nearly three-fourths of medication-related clinical decision support alerts in inpatients were overridden — 40% of them inappropriately so.