Low Vision Rehabilitation Service Utilization Before and After Implementation of a Clinical Decision Support System in Ophthalmology

Abstract

Importance: Electronic clinical decision support systems apply clinical guidelines in real time and offer a new approach to improve referral and utilization of low vision rehabilitation (LVR) care.

Objective: To characterize patients and factors associated with LVR service utilization with and without the use of an electronic health record (EHR) clinical decision support system (CDSS) alert.

Design, setting, and participants: Quality improvement study using EHR data to compare patients who did and did not utilize LVR service after referral between November 6, 2017, and October 5, 2019, (primary) and to assess overall service utilization rate from September 1, 2016, to April 2, 2021, regardless of referral status (secondary). Participants in the primary analysis were patients at a large ophthalmology department in an academic medical center in the US who received an LVR referral recommendation from their ophthalmologist according to the CDSS alert. The secondary analysis included patients with best documented visual acuity (BDVA) worse than 20/40 before, during, and after the CDSS implementation. Data were analyzed from August 2021 to April 2022.

Exposures: Number and locations of referral recommendations for LVR service according to the CDSS alert in the primary analysis; active CDSS implementation in the secondary analysis.

Main outcomes and measures: LVR service utilization rate was defined as the number of patients who accessed service among those who were referred (primary) and among those with BDVA worse than 20/40 (secondary). EHR data on patient demographics (age, sex, race, ethnicity) and ophthalmology encounter characteristics (numbers of referral recommendations, encounter location, and BDVA) were extracted.

Results: Of the 429 patients (median [IQR] age, 71 [53 to 83] years; 233 female [54%]) who received a CDSS-based referral recommendation, 184 (42.9%) utilized LVR service. Compared with nonusers of LVR, users were more likely to have received at least 2 referral recommendations (12.5% vs 6.1%; χ21 = 5.29; P = .02) and at an ophthalmology location with onsite LVR service (87.5% vs 78.0%; χ21 = 6.50; P = .01). Onsite LVR service (odds ratio, 2.06; 95% CI, 1.18-3.61) persisted as the only statistically significant factor after adjusting for patient demographics and other referral characteristics. Among patients whose BDVA was worse than 20/40 before, during, and after the CDSS implementation regardless of referral status, the LVR service utilization rate was 6.1%, 13.8%, and 7.5%, respectively.

Conclusions and relevance: In this quality improvement study, ophthalmologist referral recommendations and onsite LVR services at the location where patients receive other ophthalmic care were significantly associated with service utilization. Ophthalmology CDSSs are promising tools to apply clinical guidelines in real time to improve connection to care.

Figure.. Patient Referral Rate and Patient LVR Service Utilization Rate by Ophthalmologist

Referral rate is calculated as the number of patients where the ophthalmologist responded “order referral” divided by the total number of that ophthalmologist’s patients with at least 1 encounter where the CDSS alert appeared. Patient LVR service utilization rate is calculated as the number of patients with an LVR clinic visit at the same institute after the ophthalmologist responded “order referral” within 6 months.