Clinical decision support for gastrointestinal panel testing

Abstract

Objective: This study aimed to assess the impact of clinical decision support (CDS) to improve ordering of multiplex gastrointestinal polymerase chain reaction (PCR) testing panel ("GI panel").

Design: Single-center, retrospective, before-after study.

Setting: Tertiary care Veteran's Affairs (VA) Medical Center provides inpatient, outpatient, and residential care.

Patients: All patients tested with a GI panel between June 22, 2022 and April 20, 2023.

Intervention: We designed a CDS questionnaire in the electronic medical record (EMR) to guide appropriate ordering of the GI panel. A "soft stop" reminder at the point of ordering prompted providers to confirm five appropriateness criteria: 1) documented diarrhea, 2) no recent receipt of laxatives, 3) C. difficile is not the leading suspected cause of diarrhea, 4) time period since a prior test is >14 days or prior positive test is >4 weeks and 5) duration of hospitalization <72 hours. The CDS was implemented in November 2022.

Results: Compared to the pre-implementation period (n = 136), fewer tests were performed post-implementation (n = 92) with an IRR of 0.61 (p = 0.003). Inappropriate ordering based on laxative use or undocumented diarrhea decreased (IRR 0.37, p = 0.012 and IRR 0.25, p = 0.08, respectively). However, overall inappropriate ordering and outcome measures did not significantly differ before and after the intervention.

Conclusions: Implementation of CDS in the EMR decreased testing and inappropriate ordering based on use of laxatives or undocumented diarrhea. However, inappropriate ordering of tests overall remained high post-intervention, signaling the need for continued diagnostic stewardship efforts.

Figure 1.

GI panel ordering questionnaire.

Figure 2.

Chart of gastrointestinal polymerase chain reaction (PCR) panel ordering during study period, June 2022 to April 2023.