“I've spent my entire medical career striving to reduce readmissions for hepatic encephalopathy, which is one of the worst things that can happen to somebody with cirrhosis, and causes a very high readmission rate, somewhere around 35% over 30 days,” said Elliot Tapper, MD, assistant professor of gastroenterology at the University of Michigan.
Rifaximin is authorized by the FDA to reduce the risk for readmission in patients who are taking lactulose and have breakthrough episodes of hepatic encephalopathy, but it's not widely used for this, according to Dr. Tapper. “Most people don't know about it, or they don't know when it is indicated,” he said.
In a previous effort to address this issue, Dr. Tapper had put rifaximin on a checklist, without much success. “A checklist—not only does it have to be easy to do within the flow of care, but you have to do constant education, constantly reminding people about the importance of it and how to do it. And what that causes is friction, anger, resentment for the person that's constantly emailing you, or showing up unannounced and saying, ‘Why aren't you doing this checklist?’”
Rather than being that person again, he decided to build an alert into the electronic prescribing system.
How it works
First on the GI and hospitalist services, and later throughout the hospital, clinicians treating a patient with hepatic encephalopathy and a prescription for lactulose would get a best-practice advisory alert on two occasions: when opening the chart after lactulose was ordered (if rifaximin was not previously ordered) and when discharge planning.
“We targeted the alert to the patient who could benefit from this medication at the time that the provider is ordering medications, so it was right within their workflow,” said Dr. Tapper. “They're ordering medicine, then they're asked by the computer, ‘Do you want to order this medication?’, and boom, it's very easy for them.”
Appropriate use of rifaximin rose after the alert was put in place, according to study results published in the March American Journal of Gastroenterology. Use was already fairly high on the GI and hospitalist services (at 73.5% before the intervention and 74.5% after), but on other services, it increased significantly, from 52.6% to 71.1% (adjusted odds ratio, 1.20; 95% CI, 1.09 to 1.31). (Dr. Tapper notes that he has previously consulted for and received unrestricted research grants from Valeant/Bausch. Bausch played no role in the funding, concept, design, analysis, or writing of the study.)*
“We were able to see an increase in appropriate prescriptions of rifaximin particularly on services that are not directly staffed by liver specialists,” said Dr. Tapper. “People with cirrhosis and hepatic encephalopathy can wind up on the surgery service or the cardiology service for another problem, and that hepatic encephalopathy will complicate their care.”
There was also a slight reduction in readmissions, although Dr. Tapper noted that proving the improvement was caused by the alert, not any other factors, would be difficult.
The Michigan researchers are now trying to use the same methodology to improve other aspects of GI care. “Our next step was to create a bundle of new alerts to target different conditions … more rare, but they're very serious,” said Dr. Tapper. “I will soon examine our results and figure out if we made an impact.”
“The biggest challenge for people interested in improving the outcomes of people who have cirrhosis is getting buy-in from the institution about the importance of our patients' well-being. They tend to fly under the radar,” he said.
His solution was to gather data showing that patients with cirrhosis are readmitted for financially penalized conditions, including pneumonia and heart failure. “All of a sudden, our interests were aligned. The key thing is getting buy-in from stakeholders who may not be familiar with the specific needs of patients with cirrhosis,” he said.
Words of wisdom
Physicians at other hospitals could easily add a similar alert to their own electronic health records, but they should make sure to include a method for collecting feedback on it, he advised. “I put my email in the alert, so if people were upset about it, they would tell me,” said Dr. Tapper. “I didn't get any hate mail.”