Download Effect of a standardized order set on adherence to treatment

Effect of a standardized order set on adherence to treatment guidelines in
patients with clostridium difficile infection
Aimee Bower PharmD, MBA; Brian Hodges PharmD, BCPS, BCNSP;
Jessica Robinson PharmD, BCPS; Stephanie Thompson PhD
Purpose: This study retrospectively examines the adherence to national Clostridium difficile treatment
guidelines published by the Infectious Disease Society of America (IDSA) and the American College of
Gastroenterologists (ACG) after the implementation of an order set based on these practice guidelines
within a computerized physician order entry (CPOE) program. In 2013, a retrospective chart review that
was conducted at this institution found that 77.6% of patients did not receive guideline-directed
therapies for C. diff. Thus, this follow-up study was initiated to evaluate whether the implementation of
a guideline-based order set was effective in improving adherence to guidelines, resulting in better
outcomes for both the patient and the institution.
Methods: This study is a retrospective chart review of patients treated for Clostridium difficile infection
(CDI) from January 2014 to January 2015. Patients were randomly selected from a pool of patients
diagnosed with CDI during this time period. These patients were stratified based on disease severity as
outlined in both the IDSA and ACG guidelines. Treatments were then compared to guideline
recommended therapies. The primary endpoint of this study was to compare adherence rates to
guidelines before and after the implementation of the guideline-based order set for patients treated for
CDI. The secondary endpoint was to analyze medication use prior to CDI diagnosis, with a particular
focus on proton pump inhibitors, H2 blockers, and antibiotics, and determine possible correlation to CDI
development.
Results: A total of 123 patient records were reviewed. For the primary endpoint, adherence to IDSA
guidelines was exhibited in 34.1% of patients, while 65.9% of patients did not receive IDSA guidelinedirected therapy. When broken down into disease severity as classified by IDSA, 50.8% of patients in the
mild/moderate category did not receive guideline-directed therapy, as compared to 88.7% of patients in
the severe category (p= <.0001). In the severe, complicated category, 30% of patients did not receive
treatment aligned with guideline recommendations (p=<.0001). When looking at adherence rates to
ACG guidelines, from which the CDI order set was based, 69.1% of patients did not receive treatment
recommended by guidelines. Of the patients in the mild/moderate category, 50% of patients did not
received guideline-directed therapies (p<.0001). Results showed a staggering 94.5% non-adherence rate
of those patients classified as having severe disease, while 79.3% of patients with severe, complicated
disease did not receive treatment recommended by ACG guidelines (p<.0001). For the secondary
endpoint, 69.9% of patients treated for CDI were on a proton pump inhibitor or H2 antagonist at the
time of diagnosis and 56.9% of patients were receiving antibiotics when diagnosed.
Conclusions: Based on these results, the addition of a guideline-based order set for the treatment of CDI
did not appear to influence adherence rates to guideline recommended treatment by health care
providers. In the future, the addition of education coupled with order set implementation may help
increase correct utilization of order sets within a CPOE system.