Adherence to Clinical Care Protocols for Inflammatory Bowel Disease and Evaluation of a Clinical Decision Support System to Improve Adherence

• Author / Creator

  Sutton, Reed T

• Clinical care pathways have been developed with the goal to standardize and improve quality of care. At the University of Alberta, clinical care pathways have been developed, and are currently in use, for inflammatory bowel disease patents experiencing disease flare. However, there is limited literature available regarding the level of adherence of IBD practitioners to the published guidelines or best practices, such as those implemented through these clinical care pathways.

  The first part of this thesis is a retrospective, single-center chart review of 207 inflammatory bowel disease receiving steroid dispensations from inflammatory bowel disease specialists at the University of Alberta. Adherence to best practices for flaring IBD patients were determined by dividing the number of adherent encounters over the total number of encounters. Key gaps in care were found: documenting of clinical scores (33.5%), completion of standard flare lab tests (63.3%), testing for Clostridium difficile toxin (65.5%), testing for fecal calprotectin (17.6%), 2-4 week follow-up (22.2%), documentation of steroid consenting (24.6%), and provision of osteoprotective therapy (29.9%).

  Electronic clinical decision support systems (CDSS) have been shown to have potential to improve adoption of clinical guidelines. The second part of this thesis details the development, two-phase implementation, and evaluation of a CDSS integrated into the electronic medical record system, for inflammatory bowel disease patients suspected of having disease flares. In Phase 1, before-and-after analysis demonstrates an increase in documentation of clinical scores from 3.5% to 24.1% (p<0.001), which also showed a significant level change on interrupted time series analysis (p=0.028). In Phase 2, before-and-after analysis showed increases in ordering of flare lab tests (47.6% to 65.8%, p<0.001), fecal calprotectin (27.9% to 37.3%, p=0.028), and stool culture testing (54.6% to 66.9%, p=0.005). Interrupted time series analyses did not reach statistical significance in Phase 2. The overall system adoption rate was moderate at approximately 25%, with greater adoption by nurse providers than physicians. This study is one of the first to investigate the implementation of an Epic EMR-based CDSS in IBD and prompts many areas for future investigation, such as the effect of CDSS on outcomes, or how to design CDSS that have greater utility for physicians. Future iterations of CDSS for IBD should be evaluated on a larger scale, which can be facilitated by Connect Care, the coming provincial clinical information system for the province of Alberta.

• Subjects / Keywords

  • Electronic Health Record
  • Interrupted Time Series Analysis
  • Decision Support Systems
  • Clinical Care Pathways
  • Inflammatory Bowel Disease

• Graduation date

  Spring 2020

• Type of Item

  Thesis

• Degree

  Master of Science

• DOI

  https://doi.org/10.7939/r3-exjr-bc17

• License

  Permission is hereby granted to the University of Alberta Libraries to reproduce single copies of this thesis and to lend or sell such copies for private, scholarly or scientific research purposes only. Where the thesis is converted to, or otherwise made available in digital form, the University of Alberta will advise potential users of the thesis of these terms. The author reserves all other publication and other rights in association with the copyright in the thesis and, except as herein before provided, neither the thesis nor any substantial portion thereof may be printed or otherwise reproduced in any material form whatsoever without the author's prior written permission.