Implementation of an anticoagulation practice guideline for COVID 19 via a clinical decision support system in a large academic health system and its RE-AIM evaluation.

Shah, Surbhi; Switzer, Sean; Shippee, Nathan D; Wogensen, Pamela; Kosednar, Kathryn; Jones, Emma; Pestka, Deborah L; Badlani, Sameer; Butler, Mary; Wagner, Brittin; White, Katie; Rhein, Joshua; Benson, Bradley; Reding, Mark; Usher, Michael; Melton, Genevieve B; Tignanelli, Christopher James

BACKGROUND Studies evaluating strategies for the rapid development, implementation and evaluation of clinical decision support(CDS) systems supporting guidelines for diseases with poor knowledge base, such as COVID-19, are limited. OBJECTIVE We developed an anticoagulation clinical practice consensus guideline(CPG) for COVID-19 delivered and scaled via CDS across a 12-hospital Midwest healthcare system. This study represents a pre-planned 6-month post-implementation evaluation guided by the RE-AIM framework. METHODS Implementation outcomes evaluated include reach, adoption, implementation, and maintenance. To evaluate effectiveness, the association of CPG adherence on hospital admission was assessed via multivariable logistic regression and nearest neighbor propensity score matching. A time-to-event analysis was conducted. Sensitivity analyses were also conducted to evaluate the competing risk of death prior to ICU admission. Models were risk adjusted to account for age, gender, race/ethnicity, non-English speaking status, area deprivation index, month of admission, remdesivir, tocilizumab, steroid treatments, body mass index, Elixhauser Comorbidity Index, Oxygen Saturation/FiO2 ratio, systolic blood pressure, respiratory rate, treating hospital, and source of admission. A preplanned subgroup analysis was also conducted in patients that had lab values: D-dimer, C-reactive Protein, Creatinine, and Absolute neutrophil-absolute lymphocyte ratio present. The primary effectiveness endpoint was the need for ICU admission within 48 hours of hospital admission. RESULTS 2,503 patients were included in this study. CDS reach approached 95% during implementation. Adherence achieved a peak of 72% during implementation. Variation was noted in adoption across sites and nursing units. Adoption was best at COVID-19 cohorted hospitals(74-82%) and lowest at academic settings(47-55%). CPG delivery via CDS was associated with improved adherence (OR 1.43, 95%CI 1.2-1.7, p<0.001). Adherence with the anticoagulation CPG was associated with a significant reduction in the need for ICU within 48 hours (OR 0.39, 95%CI 0.30-0.51, p<0.001) on multivariable logistic regression analysis. Similar findings were noted following 1:1 propensity score matching for patients that received adherence vs non-adherent care (21.5% vs 34.3% incidence of ICU admission within 48 hours, log-rank test p < 0.001). CONCLUSIONS CDS are an effective means to rapidly scale a CPG across a heterogeneous healthcare system. Further research is needed to investigate factors associated with adherence at low and high adopting sites and nursing units. CLINICALTRIAL