Clinical Decision Support to Promote Safe Prescribing to Women of Reproductive Age: A Cluster-Randomized Trial
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Potentially teratogenic medications are frequently prescribed without provision of contraceptive counseling.
To evaluate whether computerized clinical decision support (CDS) can increase primary care providers’ (PCPs’) provision of family planning services when prescribing potentially teratogenic medications.
Cluster-randomized trial conducted in one academic and one community-based practice between October of 2008 and April of 2010.
Forty-one PCPs were randomized to receive one of two types of CDS which alerted them to risks of medication-induced birth defects when ordering potentially teratogenic medications for women who may become pregnant. The ‘simple’ CDS provided a cautionary alert; the ‘multifaceted’ CDS provided tailored information and links to a structured order set designed to facilitate safe prescribing. Both CDS systems alerted PCPs about medication risk only once per encounter.
We assessed change in documented provision of family planning services using data from 35,110 encounters and mixed-effects models. PCPs completed surveys before and after the CDS systems were implemented, allowing assessment of change in PCP-reported counseling about the risks of medication-induced birth defects and contraception.
Both CDS systems were associated with slight increases in provision of family planning services when potential teratogens were prescribed, without a significant difference in improvement by CDS complexity (p = 0.87). Because CDS was not repeated, 13% of the times that PCPs received CDS they substituted another potential teratogen. PCPs reported significant improvements in several counseling and prescribing practices. The multifaceted group reported a greater increase in the number of times per month they discussed the risks of medication use during pregnancy (multifaceted: +4.9 ± 7.0 vs. simple: +0.8 ± 3.2, p = 0.03). The simple CDS system was associated with greater clinician satisfaction.
CDS systems hold promise for increasing provision of family planning services when fertile women are prescribed potentially teratogenic medications, but further refinement of these systems is needed.
KEY WORDSpreconception care contraceptive counseling health IT decision support birth defects
This investigator-initiated study was funded by the Agency for Healthcare Research and Quality (AHRQ R18HS017093). Further support was received from NICHD K23 funds (Dr. Schwarz) and grants from the NIH and The Roadmap/NCRR/University of Pittsburgh Multidisciplinary Clinical Research Career Development Award (Dr. Handler). Many thanks to Wishwa Kapoor, MD, MPH for help with project implementation and Doug Landsittel, PhD for statistical guidance. An abstract on the physician survey data was presented at the AHRQ Health IT grantee meeting, Washington DC, June 2, 2010. An abstract on the EMR data was presented at the 1st European Congress on Preconception Care and Health, Brussels, Belgium, October 8, 2010. This work was also presented at the Epic Users’ Group Meeting, Madison, Wisconsin, September 21, 2011.
Conflict of Interest
The authors declare that they do not have a conflict of interest.
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