Effect of a Default Order vs an Alert in the Electronic Health Record on Hepatitis C Virus Screening Among Hospitalized Patients: A Stepped-Wedge Randomized Clinical Trial

Abstract

Importance: Hepatitis C virus (HCV) screening has been recommended for patients born between 1945 and 1965, but rates remain low.

Objective: To evaluate whether a default order within the admission order set increases HCV screening compared with a preexisting alert within the electronic health record.

Design, setting, and participants: This stepped-wedge randomized clinical trial was conducted from June 23, 2020, to April 10, 2021, at 2 hospitals within an academic medical center. Hospitalized patients born between 1945 and 1965 with no history of screening were included in the analysis.

Interventions: During wedge 1 (a preintervention period), both hospital sites had an electronic alert prompting clinicians to consider HCV screening. During wedge 2, the first intervention wedge, the hospital site randomized to intervention (hospital B) had a default order for HCV screening implemented within the admission order set. During wedge 3, the second intervention wedge, the hospital site randomized to control (hospital A) had the default order set implemented.

Main outcomes and measures: Percentage of eligible patients who received HCV screening during the hospital stay.

Results: The study included 7634 patients (4405 in the control group and 3229 in the intervention group). The mean (SD) age was 65.4 (5.8) years; 4246 patients (55.6%) were men; 2142 (28.1%) were Black and 4625 (60.6%) were White; and 2885 (37.8%) had commercial insurance and 3950 (51.7%) had Medicare. The baseline rate of HCV screening in wedge 1 was 585 of 1560 patients (37.5% [95% CI, 35.1%-40.0%]) in hospital A and 309 of 1003 patients (30.8% [95% CI, 27.9%-33.7%]) in hospital B. The main adjusted model showed an increase of 31.8 (95% CI, 29.7-33.8) percentage points in test completion in the intervention group compared with the control group (P <. 001).

Conclusions and relevance: This stepped-wedge randomized clinical trial found that embedding HCV screening as a default order in the electronic health record substantially increased ordering and completion of testing in the hospital compared with a conventional interruptive alert.

Trial registration: Clinicaltrials.gov: NCT04525690.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Mehta reported receiving grants from the National Cancer Institute outside the submitted work and receiving an honorarium from the American Gastroenterological Association. Dr Patel reported being a founder of Catalyst Health Group, a technology and behavior change consulting firm; and serving on the medical advisory boards for Healthmine, Inc, Life.io, and Holistic Industries. Dr Patel reported receiving personal fees as owner of Catalyst Health Group and serving on the advisory board for Humana Inc outside the submitted work. No other disclosures were reported.

Figures

Figure 1.. Study Flow Diagram

Each hospital participated in 3 wedges: wedge 1 (a preintervention period), wedge 2 (intervention in hospital B vs control in hospital A), and wedge 3 (intervention in both hospitals).

Figure 2.. Hepatitis C Virus Screening Completion by Hospital Site and Study Month

Wedge 1 was a preintervention period. Hospital A (control hospital) received the intervention during wedge 3; hospital B received the intervention during wedges 2 and 3.