The Effect of Clinical Decision Support Intervention on Monitoring for Donor Specific Antibodies.

Abstract

Background: Following transplantation, it is recommended that human leukocyte antigen (HLA) donor specific antibody (DSA) monitoring for allograft surveillance be tailored to the patient's antibody-mediated rejection (AMR) risk and immunosuppression needs. However, at our institution, DSA orders were placed more frequently than recommended, with daily duplications due to inconsistent ordering across departments (outpatient, emergency, and inpatient). We evaluated the effectiveness of a non-interruptive clinical decision support (CDS) system integrated with computerized provider order entry (CPOE) in reducing redundant DSA orders.

Methods: CDS included an indication prompt and test status indicator to help providers review test rationale and flag active orders. We then evaluated its impact of this intervention in 5-month periods before and after implementation, using statistical analyses to assess the differences with a t-test.

Results: In the pre-implementation period, 82.5% (1504/1824) of DSA orders from 473 of 792 patients were duplicates, compared to 79.6% (1415/1778) from 463 of 826 patients post-implementation. After excluding cases without reported DSA and overlapping patients, each group had 466 unique patients. Duplicate orders decreased within 50 days post-implementation but increased beyond this period. Among renal transplant recipients, the fraction of duplicate orders within a week significantly dropped (pre-implementation n = 9, post-implementation n = 26, P = 0.009). DSA levels remained stable, suggesting the intervention did not impact detection rates.

Conclusion: The CDS implemented reduced unwarranted duplicate orders within 2 weeks of a prior order without affecting long-term (>50 days) monitoring protocols, demonstrating the effectiveness of non-interruptive CDS-CPOE in improving HLA test ordering.