Impact of Order Set on Exocrine Pancreatic Insufficiency in Chronic Pancreatitis, Pancreatic Cancer, and Pancreatic Resection

Abstract

Background and Aims

Enzyme insufficiency (EPI) is common in chronic pancreatitis (CP), pancreatic ductal adenocarcinoma (PDAC), and after pancreatic resection. 40%–50% of CP patients and 70%–80% of PDAC patients develop EPI. 1/3rd of these patients are prescribed Pancreatic enzyme replacement therapy (PERT), often at an inadequate dose, with evidence that this leads to increased morbidity and mortality. This study aimed to develop and implement an EPIC-based best practice alert (BPA) and smart set to improve the management of EPI.

Methods

A retrospective analysis of all patients with International Classification of Diseases codes for EPI, CP, and PDAC or CPT code for pancreatic resection from Feb-2018 to Feb-2021. Appropriate use of PERT was defined as ≥ 40,000 units of lipase with each meal. The BPA and smart set were implemented into the electronic medical record in Feb-2020. The BPA fired if the patient was already on PERT or if an order for PERT was placed and directed the clinician to the smart set which provided PERT formulations each prefilled to the minimum therapeutic dose of 40,000 units of lipase.

Results

A significant increase in the proportion of patients on minimum therapeutic dose of PERT from 61.9% to 72.9% (P ≤ .001). Ordering of pancreatic elastase, A1c, vitamin D, and dual X-ray absorptiometry increased from 20.4% to 29.9% (P < .001), 54.7%–62.1% (P = .001), 30.9%–48.1% (P < .001) and 10%–18% (P < .001), respectively. The BPA triggered a total of 30,838 times resulting in the smart being opened a total of 624 (2.02%) times over 24 months.

Conclusion

The BPA and smart set were associated with an improvement in the diagnosis and management of EPI and related complications in CP, PDAC, and s/p pancreatic resection.